Usefulness of Left Atrial Strain to Predict End Stage Renal Failure in Patients With Chronic Kidney Disease

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Left atrial (LA) enlargement predicts adverse cardiovascular events in patients with chronic kidney disease (CKD). The aim of our study was to evaluate the value of LA reservoir strain, a novel measure of LA function, as a prognostic marker for adverse renal outcomes. A total of 280 patients (65.8 ± 12.2years, 63% male) with stable Stage 3 and 4 CKD without prior cardiac history were evaluated with transthoracic echocardiography and prospectively followed for up to 5 years. The primary end point was progressive renal failure, which was the composite of death from renal cause, end-stage renal failure and/or doubling of serum creatinine. Over a mean follow up of 3.9 ± 2.7years, 56 patients reached the composite endpoint. By log rank test, older age, lower baseline eGFR, anemia, diabetes mellitus, higher urinary albumin/creatinine ratio, number of antihypertensive medications, higher indexed left ventricular mass, larger LA volumes, and impaired LA reservoir strain were significant predictors of the composite outcome (p <0.01 for all). Multi-variable Cox regression analysis found LA reservoir strain, eGFR, number of antihypertensive medications and urinary albumin/creatinine ratio were independent predictors for progressive renal failure (p <0.01 for all). Impaired LA reservoir strain was associated with a 2.5-fold higher risk of the composite outcome (HR 2.51, 95% CI 1.19 to 5.30, p = 0.02) and was the only echocardiographic parameter that predicted progressive renal failure independent of established clinical risk factors for end-stage renal failure. Its utility requires validation in high risk CKD patients with cardiac disease.

Section snippets

Methods

This was a prospective multicenter cohort study with longitudinal outcome evaluation. CKD patients with Stage 3 (eGFR 30 to 59 mL/min/1.73 m2) and Stage 4 (eGFR 15 to 29 mL/min/1.73m2) disease attending outpatient nephrology clinics across 2 tertiary hospitals in Western Sydney between 2011 and 2017 were prospectively screened for eligibility. Inclusion criteria were stable renal function, defined as an average change in eGFR of < 5% over the 3 months prior to enrolment, and absent cardiac

Results

A total of 1989 consecutive CKD patients attending the outpatient nephrology clinics were screened of which 792 met the inclusion criteria. Exclusions included 498 patients with previous cardiac history apparent at screening, and an additional 14 patients were excluded following their initial cardiac assessment (Figure 1). Of the 280 patients that comprised the study cohort, 71% of patients had Stage 3 and 29% had Stage 4 CKD. The mean age was 65.8 ± 12.2 years and 63% were male.

Vascular risk

Discussion

Our study demonstrates the prognostic value of LA strain as an independent predictor of progression of renal dysfunction in stable Stage 3/4 CKD patients without previous cardiac history and stable renal function. LA strain was the only echocardiographic parameter that predicted progressive renal failure and was independent of traditional clinical determinants including baseline eGFR, number of anti-hypertensive agents, and urinary albumin/creatinine ratio on multivariate analysis. Other

Authors’ Contribution

Gary C.H. Gan: conceptualization, methodology, investigation, formal analysis, validation, writing – original draft, writing – review and editing, funding acquisition. Aditya Bhat: investigation, formal analysis, validation, writing – original draft, writing – review and editing. Krishna K. Kadappu: investigation, writing – review and editing. Fernando Fernandez: investigation, resources. Kennith H. Gu: investigation. Henry H.L. Chen: investigation, writing – original draft, visualisation.

Disclosures

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgment

We would like to acknowledge Dr. S. T. Spicer, Dr. G Suryanarayanan and A/Prof L. Kairaitis from the nephrology departments of Liverpool Hospital, Blacktown Hospital and Westmead Hospital for their support and assistance with recruitment of subjects. We would also like to thank Dr. Karen Byth from the Biostatistics Unit of the Research and Education Network of the Western Sydney Local Health District for her advice and input with our statistical analysis. Lastly, our study would also not have

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  • Funding: Dr. Gary C.H. Gan is supported byUniversity of New South Wales Postgraduate Award (UNSW3080080) and the Research and Education Network of the Western Sydney Local Health District Early Investigator Grant (REN 368010)

    Data Availability Statement: The data underlying this article will be shared on reasonable request to the corresponding author.

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