It's not always a case of a broken heart...
One the left is a case from our second year resident Dr. Anthony Piche, one of on the right a case from our ultrasound extraordinaire and associate program director Dr. Noonan. Both of these patients have the same chronic, non-cardiac disease… can you guess what it is?
Scroll down for the answer!
End stage renal disease is characterized by four principle echocardiographic features: LVH, diastolic dysfunction, pericardial effusion, and valvular calcification.(1)
LVH and diastolic dysfunction result from the combined effects of chronic hypertension, microvascular disease, and intramyocardial fibrosis. (2,3)
Pericardial effusion is typically transudative and associated with volume overload or uremic pericarditis. Calcific valvular disease is multifactorial in etiology with metabolic as well as mechanical contributors.
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But why should you care about LVH or diastolic dysfunction in the ED?
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In LVH, the myocardium becomes noncompliant and fibrotic— increasingly high filling pressures are needed to obtain the same end diastolic volume. With elevated left atrial pressure at baseline, a relatively small increase in fluid load can lead to pulmonary edema. Conversely, a relatively small decrease in fluid load can lead to diastolic underfilling and decreased cardiac output. (2) Thus, diastolic dysfunction is one of the primary substrates for the hemodynamic volatility we encounter in ESRD patients!
In patients on dialysis, LVH is the most common structural cardiac defect and LV diastolic dysfunction is the most common functional defect (seen in up to 85% of patients). (4,5)
Pericardial effusion is present to varying degrees in approximately 1/3 of ESRD patients, however progression to tamponade is notably rare. (6)
Valvular heart disease can be found in up to 14% of ESRD patients with calcific aortic stenosis the most common lesion. (7)
A normal EF does not guarantee a normal cardiac output or dry lung fields; ESRD patients are often the exemplar of heart failure with preserved ejection fraction.
References
(1) Ito T, Akamatsu K. Echocardiographic manifestations in end-stage renal disease. Heart Fail Rev. 2024;29(2):465-478. doi:10.1007/s10741-023-10376-5
(2) Chiu DY, Green D, Abidin N, Sinha S, Kalra PA. Echocardiography in hemodialysis patients: uses and challenges. Am J Kidney Dis. 2014;64(5):804-816. doi:10.1053/j.ajkd.2014.01.450
(3) Bornstein AB, Rao SS, Marwaha K. Left Ventricular Hypertrophy. In: StatPearls. Treasure Island (FL): StatPearls Publishing; August 8, 2023.
(4) Farshid, A., Pathak, R., Shadbolt, B. et al. Diastolic function is a strong predictor of mortality in patients with chronic kidney disease. BMC Nephrol 14, 280 (2013). https://doi.org/10.1186/1471-2369-14-280
(5) Jameel FA, Junejo AM, Khan QUA, et al. Echocardiographic Changes in Chronic Kidney Disease Patients on Maintenance Hemodialysis. Cureus. 2020;12(7):e8969. Published 2020 Jul 2. doi:10.7759/cureus.8969
(6) Chang KW, Aisenberg GM. Pericardial Effusion in Patients with End-Stage Renal Disease. Tex Heart Inst J. 2015 Dec 1;42(6):596. doi: 10.14503/THIJ-15-5584. PMID: 26664323; PMCID: PMC4665297.
(7) Elewa M, Mitra S, Jayanti A. Left-sided valvular heart disease in dialysis recipients: a single-centre observational study. Clin Kidney J. 2023;16(7):1092-1101. Published 2023 Jan 30. doi:10.1093/ckj/sfad020