assessment of cardiac function in relation to the effect of a newly

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AL-AZHAR ASSIUT MEDICAL JOURNAL

VOL 13 , NO 1 , JANUREY 2015 SUPPL-2

ASSESSMENT OF CARDIAC FUNCTION IN RELATION TO THE EFFECT OF A NEWLY CREATED ARTERIOVENOUS FISTULA IN CHRONIC KIDNEY DISEASE PATIENTS Tarek Elsayed1, Ahmed Alashker1, Abdelrahman Ali2, Nagwa Abdelghafar3 and Tarek Elbaz1 Internal medicine & nephrology1 and cardiology2 departments, faculty of medicine Al-Azhar University Clinical and chemical pathology3 national research center

‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬ ABSTRACT Background: Few studies, including limited number of patients, examined the effect AVF creation on heart function. It is important to determine early changes in cardiovascular system after fistula creation in an attempt to fully understand its pathophysiological consequences on the heart. We aimed to study the association between AVF creation and cardiac function in chronic kidney disease patients .Patient and Methods: Forty patients with end stage renal disease who were prepared for hemodialysis therapy were included. All patients underwent history taking, clinical examination. An echocardiographic assessment was done before and 2 weeks after the creation of the AVF. Plasma atrial natriuretic peptide (ANP) at the same time periods was measured. Results: There was a highly significant increment in patients' heart rate. On the other hand, there was a highly significant descent in Patients' diastolic blood pressure, mean arterial pressure and peripheral vascular resistance. In contrary to the above results we did not detect a significant difference as regard Patients' weight or systolic blood pressure. As regard laboratory data, there was no statistical change in hemoglobin, serum urea or creatinine readings after the access operation. As regard the echocardiographic findings, we observed a highly significant increment of left ventricular end diastolic diameter and volume as well as inferior vena caval diameter. Furthermore, there was a significant elevation of left atrial diameter, left ventricular shortening fraction, ejection fraction, stroke volume, cardiac output, and cardiac index. Furthermore, we found appositive correlation between ANP level and cardiac output as well as left atrial diameter .Conclusion: This study showed that following creation of arteriovenous fistula, state of volume overload ensued, which was alleviated by the unloading effect of the new low set level of peripheral vascular resistance and increased level of ANP secretion in response to atrial fibers stretching. Key words: arteriovenous fistula; atrial natriuretic peptide; cardiac function Correspondence To: Ahmed Mohamed Alashker, MD; 26; 298; Almaadi, Cairo Tel: 01116980000; E-Mail: [email protected] chronic hemodialysis treatment. Patients with INTRODUCTION Native arteriovenous fistulae (AVF) are the one or more of the following criteria were vascular access of choice for hemodialysis [1]. excluded: valvular heart diseases, ischemic The contribution of the AVF to cardiac heart disease (IHD) patients, cardiomyopathy, performance in this group of patients has been a uncontrolled hypertension, congenital heart matter of concern for nephrologist especially diseases, or regional wall motion abnormalities after the recent reports that incriminated AVF in on echocardiography. deteriorating cardiac function [2]. Most All patients were subjected to the following previous studies assessed the effect of AVF on before and two weeks after creation of cardiac function while a short manual arteriovenous fistula. compression over the access attempted to Firstly, history taking and clinical examination compare cardiac function before and after which included patients' weight, and height, temporary fistula closure [3]. Other studies body surface area, sitting blood pressure and compare patients’cardiac function before and heart rate, history of diabetes mellitus, after fistula closure after they have undergone a medications and finally calculating mean successful renal transplant [4]. Very few studies arterial pressure by the following equation: investigated this issue in a prospective design MAP = 1/3 (SBP – DBP) + DBP [6]. The but they included limited number of patients [5]. peripheral vascular resistance was calculated by In the present study we aimed to determine the the following equation 80 x mean arterial effect of AVF creation on cardiovascular pressure / cardiac output [7]. function Then the following laboratory investigations were done: complete blood count, creatinine, SUBJECTS AND METHODS 40 chronic kidney disease patients were urea, and plasma level of atrial natriuretic included in the study. They were candidates for peptide (ANP) as an indicator of volume 19 | P a g e

VOL 13 , NO 1 , JANUREY 2015 SUPPL-2

Tarek elsayed et al

overload. To measure the plasma levels of ANP, arteriovenous fistula as they didn’t have an blood was collected with 1.0 mg/mL EDTA acute indication to start dialysis via central then Plasma was obtained by centrifugation at venous hemodialysis catheter. Of these 40 3000 rpm for 10 min at 4 °C and stored at patients, 22 (55%) patients were males and 18 −80 °C until the end of the study to be assayed (45%) were females, 25 (65%) were diabetics, blindly. Immuno-radiometric assays were used 23 (57%) were hypertensive with the means and to measure levels of ANP [8]. Mean plasma standered deviations of age and body surface immunoreactive ANP in normal subjects area were 63.25± 3.5 years, 22.54± 3.15 consuming a normal salt intake is 14 +/- 1 pico respectively. As regard cause of renal failure, 13 mol/liter [9]. patients had diabetic nephropathy, 11 patients All patients had a comprehensive M-mode, had hypertensive nephropathy, six patients had two-dimensional, echocardiogram performed by obstructive uropathy, five patients had chronic a single experienced sonographer using glomerulonephritis and five patients had commercially available ultrasound transducer analgesic nephropathy. Types of fistulae done and equipment (X5 adult probe, A Philips IE 33 were as following: 17 radiocephalic fistulas, 13 phased array system). The images were digitally brachiocephalic fistulas, and 10 brachiobasilic stored for off-line analysis. All the measures fistula. were recorded as the average of three During the study period no one of them changed consecutive cardiac cycles. Studies were his medications. All patients had hemodialysis performed and quantitated in accordance with started shortly after 25 .2±4.5 days of the second guidelines of the American Society of step of our study protocol utilizing wellEchocardiography [10]. functioning vascular accesses that allowed The study data were organized, tabulated, and blood flow rates of 250-350 ml/min. analyzed using statistical package for social To study the effect of AVF creation on sciences (SPSS) version 17 for windows. Data cardiovascular parameters, we compared our were presented as the Mean ± standard patients with themselves at the time of operation deviation (SD), frequency, and percentage. and two weeks after. Categorical data were statistically analyzed Clinically, on comparing patients before and using the chi-square (χ2). Continuous data were after fistula creation, there was a highly analyzed by the Student t test (two-tailed) and significant increment in patients' heart rate. On one – way ANOVA test for parametric data. the other hand, there was a highly significant Correlation between parameters was performed, descent in Patients' diastolic blood pressure, using a Pearson’s correlation for normally mean arterial pressure and peripheral vascular distributed samples. The level of significance resistance. In contrary to the above results we was accepted if the P value was below 0.05. did not detect a significant difference as regard Patients' weight or systolic blood pressure. As RESULTS In this study, we included 40 patients with stage regard laboratory data, there was no statistical five chronic kidney disease with a glomerular change in hemoglobin, serum urea and 2 filtration rate of 11 ± 1.5 ml/min/1.7m . They creatinine readings after the access operation as were prepared for hemodialysis by creation of shown in table (1). Table (1): clinical and laboratory parameters before and after arteriovenous access creation variables Weight kg Heart rate 60-100 beat/minute Systolic blood pressure (90-140 mmHg) Diastolic blood pressure (60-90 mmHg) Mean arterial pressure 65 -110 mmHg Systemic vascular resistance 800 - 1200 dynes · sec/cm5 Hemoglobin 10.5-11.5 g/dL Serum urea 20-40mg|d Creatinine 0.5-1.5 mg|dl Atrial natriuretic peptide (13-15 pg/L)

Pre-operation

Post-operation

P value

Sig

69.7 ± 10.87

69.35 ± 10.55

>0.05

NS

76.15 ±6.434

81.500±7.030

0.05

NS

87.25 ±4.44

73.250±6.129

0.05

NS

39.7± 3.58

82.18±6.34

0.05 >0.05