https://doi.org/10.1007/s00392-025-02625-4
1Universitätsmedizin Göttingen Herzzentrum, Klinik für Kardiologie und Pneumologie Göttingen, Deutschland; 2Forum Medizin GbR Kardiologie Rosdorf, Deutschland; 3Universitätsmedizin Göttingen Nephrologie und Rheumatologie Göttingen, Deutschland
Background
Chronic kidney disease (CKD) is an established risk factor for cardiac diastolic dysfunction and heart failure with preserved ejection fraction (HFpEF). However, diastolic dysfunction is often detected only after development of symptomatic heart failure in more advanced stages of HFpEF. As left atrial (LA) function is a pivotal element in the emergence of HFpEF, we hypothesized that echocardiographic LA speckle-tracking detects initial changes of diastolic cardiac function in otherwise asymptomatic patients with CKD.
Methods
Asymptomatic patients (NYHA≤I) with preserved left ventricular ejection fraction (LVEF)≥50%, absence of cardiomyopathies and severe valve disease but at risk for HFpEF (age≥60 years, arterial hypertension (RR≥140/90 mmHg or ≥two antihypertensives), diabetes mellitus, history of atrial fibrillation, obesity (body mass index≥30 kg/m2), chronic kidney disease) were prospectively enrolled from internal medicine outpatient departments. Patients with an established diagnosis of HFpEF were excluded. All patients underwent structured clinical assessments including anamnesis, transthoracic echocardiography and laboratory testing. LA strain analyses were conducted via Philips Q-Station (Version 3.8.5) on apical two- and four-chamber views (Fig. 1). LA strain values were manually derived from strain curves. Renal function was calculated using the 2021 CKD-EPI equation to estimate glomerular filtration rate (eGFR). CKD was defined as an eGFR<60 ml/min/1.73m2 or urinary albumin/creatinine ratio (uACR) ≥30mg/g.
Results
A total of 120 patients (52 years (49;55), 32% female) were eligible for participation. The cohort comprised 71 patients with CKD, and a control group of 49 patients without CKD.
Patients in both groups were of similar age (54years (37;62) vs. 53years (36;67); p=0.559) and had similar proportions of female sex (32.4% vs. 30.6%; p=0.837). No differences were observed in the presence of cardiovascular risk factors including body mass index, presence of hypertension, hyperlipidemia and diabetes mellitus across both groups.
Echocardiographic assessments revealed similar LVEF (62% vs. 63%; p=0.162), LV global longitudinal strain (-19.5% vs. -19.3%; p=0.624), E/e’ (7.1 vs. 7.5; p=0.777), LA volume index (25.2 ml/min2 vs. 25.5ml/min2; p=0.612) and left ventricular mass index (84g/m2 vs. 79g/m2; p=0.554) in patients with and without CKD.
However, patients with CKD had decreased LA booster pump strain (Ɛa) and reservoir strain (Ɛs) compared to patients without CKD. (Ɛa: 8.0% (4.8;11.8) vs. 9.5% (7.0;13.0), p=0.042 and Ɛs: 24.6% (19.9;30.8) vs. 30.0% (23.3;34.5), p=0.041) (Fig. 1).
Conclusion
Asymptomatic patients with CKD show impaired LA reservoir and booster pump strain but normal conventional measures of diastolic dysfunction. Impaired LA strain may emerge as an early sign of evolving cardiac diastolic deterioration in patients with CKD.
Fig. 1: Comparison of LA strain in patients with and without CKD. (A) Example of LA strain analysis in apical four- and two-chamber view. (B) Resulting LA strain curve including reservoir, conduit and booster pump strain. (C) Boxplots (median with interquartile ranges (IQR) and whiskers defining 95% Confidence Interval) of booster pump and reservoir strain in patients with and without CKD. A p<0.05 indicates statistical significance. CKD – chronic kidney disease, LA – left atrium.