Echocardiography to Screen for Pulmonary Hypertension in CKD

Abstract

Introduction Pulmonary hypertension (PH) is a common yet incompletely understood complication of chronic kidney disease (CKD). Although transthoracic echocardiogram is commonly used to noninvasively estimate PH, it has not been validated in a CKD population. We investigated the utility of this diagnostic tool for CKD-associated PH in a large right heart catheterization (RHC) cohort. Methods We reviewed RHC and echocardiography data in 4036 patients (1714 with CKD) obtained between 2011 and 2014 at a single center. We used multivariate regression to determine the associations of echocardiography measurements with PH, and evaluated whether estimated glomerular filtration rate (eGFR) modified these associations. Using internal validation, we sequentially added measurements to predictive models and analyzed the incremental predictive performance using the change in the area under the receiver operating characteristic curve (ΔAUC) and net reclassification improvement. Results The echocardiography measurements most strongly associated with the diagnosis of PH included tricuspid regurgitant velocity (TRV), tricuspid annular plane systolic excursion (TAPSE), right atrial pressure, diastolic dysfunction, and right ventricular function. Among these measurements, eGFR significantly modified the associations of TAPSE and diastolic dysfunction with the diagnosis of PH. The model consisting of a combination of TRV, right atrial pressure, and TAPSE most accurately predicted the diagnosis of PH in a CKD population (AUC 0.82). Conclusions The optimal model to predict PH diagnosis included TRV, right atrial pressure, and TAPSE. Since TAPSE more strongly associated with PH in the CKD population, these findings support a CKD-specific approach to the development of noninvasive screening algorithms for PH.

Chronic Kidney Disease and Heart Failure–Everyday Diagnostic Challenges

“…In contrast, among patients with CKD, the combined pre-and post-capillary and isolated extra-capillary subtypes dominated [17]. The multifactorial nature of pulmonary hypertension in the course of CKD suggests that the cause may be, among others, pulmonary congestion, due to reduced LV compliance and LV diastolic dysfunction [17,50]. The coincidence of CKD and pulmonary hypertension is associated with a significant increase in patient mortality; therefore, it is important to understand the pathological mechanisms underlying pulmonary hypertension.…”

“…Edmonston et al showed that, among patients without CKD, the pre-capillary subtype was dominant, and was associated with the highest risk of death. In contrast, among patients with CKD, the combined pre-and post-capillary and isolated extra-capillary subtypes dominated [17]. The multifactorial nature of pulmonary hypertension in the course of CKD suggests that the cause may be, among others, pulmonary congestion, due to reduced LV compliance and LV diastolic dysfunction [17,50].…”

“…However, for patients with previously diagnosed CKD, the usefulness of the HF diagnostic algorithm currently proposed may be considered questionable [1] (Figure 2). [1,[10][11][12][13][14][15][16][17]. The HF diagnostic algorithm (left) includes symptoms that are common in patients with CKD, with or without HF (center).…”

“…However, for patients with advanced renal failure, including those on dialysis, the pathophysiology of pulmonary hypertension is multifactorial. The pathophysiological mechanisms include: increased CO in the course of anemia, due to the presence of an AVF [17,50].…”

“…During right heart catheterization the pulmonary capillary wedge pressure, pulmonary arterial pressure, and pulmonary vascular resistance are determined. Based on these results, three pulmonary hypertension subtypes are distinguished: (1) pre-capillary, (2) post-capillary, and (3) combined pre-and post-capillary [17].…”