Systolic Dysfunction in
children with ESRD
Conventional Echo
Tissue doppler
Speckle Tracking Echo
Systolic Dysfunction
• Children with ESRD: LVH and diastolic dysfunction
Systolic dysfunction (SD)?
• Adults + CKD: SD
clinical signs of cardiac failure and decreased survival1
• Systolic function is thought to be preserved in children2
(measured by conventional US and TDI)
• New: Speckle Tracking Echocardiography (STE) may unmask
more subtle changes in systolic function
1.
Parfrey NDT 1996
2.
Johnstone. Kidney Int 1996
Systolic Dysfunction
Conventional Echo
Tissue Doppler Imaging (TDI)
Speckle Tracking Echo (STE)
Systolic Dysfunction
Conventional Echo
SF= Shortening fraction= change in diameter of
LV (%)
Tissue Doppler Imaging
Speckle Tracking Echo (STE)
SF (%)
Systolic Dysfunction
Conventional Echo
Tissue Doppler Imaging
S= Peak systolic velocity of myocard (cm/s)
Speckle Tracking Echo (STE)
TDI
S
Systolic Dysfunction
Conventional Echo
Tissue Doppler Imaging
Speckle Tracking Echo (STE)
Longitudinal strain: myocardial LV deformation (%)
Speckle Tracking Echo
Healthy
adults
Adults with
hypertension
Literature
Adults:
- STE is accurate (compared to MRI and TDI) 2
- STE and hypertension: SD before LVH3
- STE and ESRD: CKD associated with a reduction of
systolic function quantified by STE 4
- Advantage: Load and angle indepenent 5
Children:
- STE is accurate & reproducible in healthy
children 6
- STE and ESRD: no previous studies
2. Geyer et al. JASE 2010
3. Imbalzano et al. Echocardiography 2010
4. Liu et al. Am. J. Nephrol 2011
5. Burns et al, Euro J. echocardio. 2010
6. Singh et al JASE 2010
Methods
1. STE
ESRD (n=47) vs controls (n=26) Children from Amsterdam, Nijmegen and
Leuven
2. STE vs conventional US and TDI:
ESRD (n=27) vs controls (n=21)
all from Amsterdam
3. Intra-observer reproducibility
ESRD (n=15) and controls (n=10)
4. SD and ESRD related outcomes (n=47)
Results 1
• ESRD children were sign. older than controls (p=0.030),
matched for BSA
• Problem: more girls in the control group (p=0.004) (still
measuring healthy boys)
• After adjustement for age and gender by lineair regression:
Mean strain
(%)
ESRD
n=47
mean (sd)
Healthy
n= 26
mean (sd)
Mean
difference
(95%CI)
P value
17.5 (3.2)
20.6 (2.1)
2.7 (1.2-4.2)
0.001
2. STE vs US and TDI
Controls
n=21
mean (sd)
1.3 (0.4)
P value
BSA (m2)
ESRD
n=27
mean (sd)
1.3 (0.3)
Age (years)
13.3 (4.4)
11.1 (4.3)
0.099
Male n (%)
17 (63%)
6 (29%)
0.018
US
SF (%)
38.4 (5.2)
38.1 (4.6)
0.692*
TDI
Septum S’ (cm/s)
7.9 (1.5)
8.0 (1.2)
0.230*
LV S’ (cm/s)
8.8 (2.8)
9.6 (3.0)
0.211*
17.3 (2.7)
20.7 (2.2)
0.016*
Speckle Mean strain (%)
0.775
* Adjusted for age and gender
3. Reproducibility (n=25)
Mean long.
strain (%)
Measurement
1
mean (sd)
Measurement
2
mean (sd)
Limits of
Agreement
CV
18.5 (3.1)
18.7 (2.9)
-2.2-2.6
3%
Cv: coefficient of variation measures variability
in relation to the mean
4. Association between
SD and ….
• ESRD children with SD* : 31/47 (66%)
• Children with SD were sign. older, mean (sd) age:
14.3 (3.3) vs 9.5 (4.3) years (p<0.001)
• No significant associations were found with duration
RRT/ Tx/ dialysis or bloodpressure, iPTH, Hb and
phosphate
• The associations with FGF 23 and Klotho has to be
evaluated
*SD= systolic dysfunction defined as mean long strain < p 5 for age.
Marcus et al. JASE 2011
Conclusions
• Measured by STE children with ESRD have
significantly decreased LV systolic function
compared to healthy matched controls
• STE is more sensitive in detection of SD than
conventional echocardiography and TDI
• Longitudinal studies are necessary to evaluate the
progression of cardiac dysfunction in these children
Questions
Correlation DD and SD