A prospective echocardiographic evaluation of pulmonary hypertension in chronic hemodialysis patients in the United States: prevalence and clinical significance

Figures & data

Table 1 Baseline clinical characteristics

	All n = 90	<2.5 m/s n = 48	2.5–3.0 m/s n = 24	>3.0 m/s n = 18	P-value
Age (years)	58.3 ± 15.4	54.5 ± 14.3	62.5 ± 13.6	62.4 ± 18.3	0.05
Gender (% male)	59M (66%)	30M (63%)	20M (83%)	9M (50%)	0.06
Ethnicity
AA	58 (64%)	35 (73%)	13 (54%)	10 (56%)
C	16 (18%)	7 (15%)	3 (13%)	6 (33%)	0.07
H	16 (18%)	6 (13%)	8 (33%)	2 (11%)
BMI	27.2 ± 6.0	29.6 ± 5.9	25.1 ± 4.3	24.0 ± 5.7	<0.02
Dialysis access
AVF	35 (40%)	20 (43%)	12 (52%)	3 (17%)
AVG	39 (44%)	20 (43%)	8 (35%)	11 (61%)	0.23
Ca	14 (16%)	7 (15%)	3 (13%)	4 (22%)
Years on dialysis	3.6 ± 2.9	3.8 ± 2.7	3.1 ± 2.8	3.6 ± 3.3	0.67

Abbreviations: F, female; M, male; AA, African American; C, Caucasian; H, Hispanic; BMI, body mass index; AVF, arteriovenous fistula; AVG, arteriovenous graft; Ca, catheter.

Table 2 Echocardiographic parameters

TR velocity	<2.5 m/s n = 48	2.5–3.0 m/s n = 24	>3.0 m/s n = 18	P-value
Right heart echo parameters
RA volume (mL)	41.6 ± 20.3	51 ± 20.3	70.1 ± 27.9	<0.02
RV apical diameter (cm)	3.5 ± 0.7	3.6 ± 0.5	4.2 ± 0.7	0.003
RV Tei	0.14 ± 0.2	0.19 ± 0.19	0.28 ± 0.17	0.053
Annular descent (cm)	1.9 ± 0.6	1.8 ± 0.4	1.6 ± 0.7	0.29
RV fractional shortening	40.8 ± 6.3	41 ± 8.7	35.4 ± 9.5	0.1
RAP (mmHg)	7.4 ± 3.4	9.6 ± 4.1	12.8 ± 4.6	<0.02
Left heart echo parameters
LVID (cm)	4.5 ± 0.7	4.7 ± 0.6	4.6 ± 0.7	0.534
LVEF (%)	61.1 ± 7.4	56.9 ± 11.2	53.2 ± 14.7	0.017
LA volume (mL)	60.7 ± 22.1	62.5 ± 19.4	74.8 ± 26.5	0.085
PCWP (mmHg)	15.6 ± 5.3	19.5 ± 7.7	24.9 ± 7.9	<0.02
LVHa (cm)	1.4 ± 0.6	1.5 ± 0.6	1.9 ± 0.6	0.1

a Note: average wall thickness of interventricular septum and posterior wall measured in the parasternal long axis view.

Abbreviations: TR, tricuspid regurgitant; RA, right atrial; RV, right ventricular; RAP, right atrial pressure; LVID, left ventricular internal dimension; LVEF, left ventricular ejection fraction; LA, left atrial; PCWP, pulmonary capillary wedge pressure.

Figure 1 Kaplan Meier survival estimates based on presence, absence, and degree of PH by TR jet: group 1 = no TR, and TR < 2.5 m/s; group 2 = TR 2.5–3.0 m/s; group 3 = TR > 3.0 m/s (P = 0.0004). At 12 months, mortality was 44% (8/18) in group 3 versus 6% (3/48) and 12.5% (3/24) in groups 1 and 2, respectively (P = 0.001). The P = 0.0004 is based on the time to event analysis and signifies an overall difference between the 3 curves/groups. P = 0.001 is based on a chi-square test for the number of deaths by 12 months between the 3 groups.

Abbreviation: TR, tricuspid regurgitant.

Table 3 Analysis by survivors and non-survivors

	Survivors n = 76	Non-survivors n = 14	P-value
Age	57.4 ± 15	62.79 ± 16.8	0.23
Race	49AA, 14C, 13H	9AA, 2C, 3H	0.89
Gender	52M, 24F	7M, 7F	0.18
BMI	27.549 ± 6	25.55 ± 5.8	0.27
Access	33AVF, 32AVG, 10Ca	6AVF, 3AVG, 4Ca	0.2
Years on HD	3.4 ± 2.6	5.4 ± 3.4	0.02
RA volume	47.4 ± 23.4	63.4 ± 25.2	0.03
RA fractional shortening	38.8 ± 9.4	28.7 ± 15.7	0.008
RV apical diameter	3.6 ± 0.7	4.0 ± 0.6	0.07
RV function	1.1 ± 0.4	1.7 ± 0.9	0.001
Annular descent	1.8 ± 0.6	1.5 ± 0.7	0.06
RV fractional shortening	40.5 ± 7.2	35 ± 10.9	0.07
TR severity	1.4 ± 0.7	1.9 ± 1.0	0.01
RAP	8.7 ± 3.9	12.3 ± 5.6	0.006
PAP	39.4 ± 10.5	56.9 ± 19.7	<0.02
LVID	4.6 ± 0.6	4.6 ± 0.8	0.87
LVEF	59.1 ± 9.7	54.7 ± 14.5	0.16
PCWP	17.3 ± 6.6	23.9 ± 8.8	0.01

Abbreviations: F, female; M, male; AA, African American; C, Caucasian; H, Hispanic; AVF, arteriovenous fistula; AVG, arteriovenous graft; Ca, Catheter; BMI, body mass index; HD, hemodialysis; RA, right atrial; RV, right ventricular; TR, tricuspid regurgitant; RAP, right atrial pressure; PAP, pulmonary artery pressure; LVID, left ventricular internal dimension; LVEF, left ventricular ejection fraction; PCWP, pulmonary capillary wedge pressure.

Table 4 Review of studies evaluating pulmonary hypertension in patients with end stage renal disease

	Country of study	Number of patients	Mean age	Male/female	Incidence of PH	Reason for HD	Factors associated with PH	Long-term outcome	Notes
Abdelwhab et al^Citation3	Egypt	45	50.8 ± 8	58%/42%	44.4%
Mazdeh et al^Citation21	Iran	62	51.1 ± 17.3	18/14	52%	Dm and HTN
Tarrass et al^Citation22	Morocco	86	45.4 ± 14.4	40/46	26.7%	GN>>HTN			Excluded COPD, collagen vascular disease, SLE, LVEF < 50%, significant valvular disease
Yigla et al^Citation2	Israel	58			40%	Dm>HTN>GN	High CO, lower hemoglogin, shorter duration of HF	At 24–60 months follow-up, mortality was 30 versus 8.5% in patients with and without PH	After HD in 9 patients, PAP decreased in 3 patients, increased in 4 patients and remained same in 2 patients In 4/5 HD patients, PAP normalized after renal transplantation In 4 patients, CO and PAP decreased with access compression
Yigla et al^Citation23	Israel	127a	No PH: 61.2 ± 13.4 PH before HD: 63.3 ± 14.0 PH after HD: 62.9 ± 17.4	No PH: 56/34 PH before HD: 10/7 PH after HD: 12/8	29%	Dm>Pyelonephritis> HTN> Nephrolithiasis> Polycystic kidney disease>GN		1-, 3-, and 5-year mortality in patients with and without PH were 21.4% vs 3.5%, 57.1% vs 21.2%, and 74.8% vs 33.6%	Predictors of mortality: Univariate analysis – age at onset of HD, valvular diseases, PH prevalence before HD, PH incidence after HD Multivariate analysis – development of PH before and after HD initiation
Amin et al^Citation20	Egypt	51	PH: 44 ± 10 No PH: 41 ± 11	PH: 4/11 No PH: 24/12	29%	HTN> Pyelonephritis = GN >Dm			No significant difference in Tc 99m diphosphate scintigraphy, PTH, Ca, phosphorus between PH and no PH patients – Higher incidence of PH in women
Havlucu et al^Citation14	Turkey	25	60.1 ± 15.6	40%/60%	56%	HTN/GN/Dm	Higher CO, longer duration of CRI, higher PTH+Ca/PO4 product, higher probability of having AVF		Excluded cardiac etiology (diastolic/systolic dysfunction)

a Note: This included patients from Yigla².

Abbreviations: PH, pulmonary hypertension; HD, hemodialysis; Dm, diabetes mellitus; HTN, hypertension; GN, glomerulonephritis; CO, cardiac output; HF, heart failure; COPD, chronic obstructive pulmonary disease; SLE, systemic lupus erythematosus; LVEF, left ventricular ejection fraction; PAP, pulmonary artery pressure; CRI, chronic renal insufficiency; PTH, parathyroid hormone; AVF, arteriovenous fistula.

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