Original Investigation
Left ventricular mass index increase in early renal disease: Impact of decline in hemoglobin

https://doi.org/10.1016/S0272-6386(99)70118-6Get rights and content

Abstract

Cardiovascular disease occurs in patients with progressive renal disease both before and after the initiation of dialysis. Left ventricular hypertrophy (LVH) is an independent predictor of morbidity and mortality in dialysis populations and is common in the renal insufficiency population. LVH is associated with numerous modifiable risk factors, but little is known about LV growth (LVG) in mild-to-moderate renal insufficiency. This prospective multicenter Canadian cohort study identifies factors associated with LVG, measured using two-dimensional–targeted M-mode echocardiography. Eight centers enrolled 446 patients, 318 of whom had protocol-mandated clinical, laboratory, and echocardiographic measurements recorded. We report 246 patients with assessable echocardiograms at both baseline and 12 months with an overall prevalence of LVH of 36%. LV mass index (LVMI) increased significantly (>20% of baseline or >20 g/m2) from baseline to 12 months in 25% of the population. Other than baseline LVMI, no differences in baseline variables were noted between patients with and without LVG. However, there were significant differences in decline of Hgb level (−0.854 v −0.108 g/dL; P = 0.0001) and change in systolic blood pressure (+6.50 v −1.09 mm Hg; P = 0.03) between the groups with and without LVG. Multivariate analysis showed the independent contribution of decrease in Hgb level (odds ratio [OR], 1.32 for each 0.5-g/dL decrease; P = 0.004), increase in systolic blood pressure (OR, 1.11 for each 5-mm Hg increase; P = 0.01), and lower baseline LVMI (OR, 0.85 for each 10-g/m2; P = 0.011) in predicting LVG. Thus, after adjusting for baseline LVMI, Hgb level and systolic blood pressure remain independently important predictors of LVG. We defined the important modifiable risk factors. There remains a critical need to establish optimal therapeutic strategies and targets to improve clinical outcomes.

Section snippets

Patients and methods

This Canadian multicenter prospective cohort study enrolled 446 patients with renal insufficiency. Consecutive patients seen by nephrologists in eight academic centers were enrolled onto the study if they met eligibility criteria. Eligible patients were those who had impaired renal function, defined as calculated creatinine clearance (using the Gault-Cockroft formula14) between 25 and 75 mL/min; clinically established chronicity by biopsy or clinical course; and/or renal ultrasound showing

Demographics

Of the 446 patients enrolled, 318 (71% of the original cohort) completed 12 months of follow-up. Of the remaining 128 patients without a 12-month follow-up, 43 patients were lost or refused further follow-up, 45 patients started dialysis, 17 patients died, 1 patient received a transplant, and 22 patients had protocol deviations consisting of collection of follow-up data outside the 3 month grace period (ie, >15 months or <9 months).

Two assessable echocardiograms were available in 246 of the 318

Discussion

This large, multicenter, cohort study shows that patients with mild to moderately impaired renal function who do not have arteriovenous fistulae and are not yet undergoing dialysis have a high prevalence of LVH early in the course of their renal disease. Furthermore, a substantial proportion of the cohort show a significant increase in LVMI. LVG occurs in association with potentially modifiable risk factors; decrease in Hgb level and increase in systolic blood pressure.

This study extends

Acknowledgements

Acknowledgment: The authors thank the Kidney Foundation of Canada for grant support for this study, the many research nurses across the country who helped in data collection and validation, and the expert technical support of the cardiac sonographers, especially Roz Gillis.

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    Received February 20, 1998; accepted in revised form December 18, 1998.

    Supported in part by a grant from the Kidney Foundation of Canada, Montreal, Canada, 1994-1998 (A.L., C.R.T., and J.S.).

    Address reprint requests to Adeera Levin, MD, Director, Renal Insufficiency Clinic, St Paul's Hospital, Room 6010 A Providence Wing, 1081 Burrard St, Vancouver BC, V6Z 1Y8, Canada. E-mail: [email protected]

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