Features of renal dysfunction in patients with chronic heart failure

Chronic heart failure is one of the most important factors leading to a malfunction of the glomerular apparatus of the kidney. Every fourth patient with chronic heart failure, have decreasing in GFR of less 60ml / min / 1, 73m2 s. Deviation of eсhogeometry parameters of mitral valve from normal values occurred twice as often in patients with chronic heart failure with a lower glomerular filtration rate.

Keywords: chronic heart failure, chronic kidney disease

Поражение клубочкового аппарата почек является одним из мультифокальных факторов развития хронической сердечной недостаточности. Каждый четвёртый больной с хронической сердечной недостаточностью имеет СКФ ниже 60 мл / мин / 1, 73м² с. EУ больных ХСН отклонение эхогеометрических параметров митрального клапана от нормальных показателей в 2 раза чаще приводит к снижению клубочковой фильтрации.

Ключевые слова: хроническая сердечная недостаточность, хроническая болезнь почек

Numerous studies have shown that chronic heart failure (CHF) is an actual problem of the XXI century. According to epidemiological studies, the prevalence of heart failure in Europe and the United States ranges from 0.4 to 2.5 % and significantly increases with age, reaching 10 % in people older than 60 years [6]. In the European part of the Russian Federation, according to a study AGE-CHF, this disease affects 8.9 % of the total population and 54 % of those over 80 years of age [3]. The Forecasts for patients with CHF is extremely unfavorable. [5] According to MHC, in 2005, in the world from cardiovascular disease (CVD) dead more than 17.5 million people (30 % of deaths) [3, 7]. According to forecasts, by 2030, coronary heart disease (CHD) and stroke remain the main causes of disability and death, and the mortality rate will increase to 23.4 million people [3.7]. It is known that the chronic heart failure affects to various organs and tissues, which leads to disruption of their function sometimes so significant that becomes the immediate cause of death of patients.

One of the muscular organs is the kidney. Scientists have found similarities between the risk factors of SSB and predictors of progression of renal dysfunction: age, sex, hypertension, dyslipidemia [1, 2, 4, 5]. With aim designation of identified links between cardiovascular events and renal dysfunction has been suggested the term «cardiorenal continuum» [4, 3]. Early renoprotective and cardioprotective strategy in the patients with chronic heart failure improves clinical and occupational patient prognosis, reduce the number of complications and mortality, as well as to reduce the economic costs of the state for treatment, this is achieved by reducing the cost and duration of hospitalization of patients, reducing the need for emergency dialysis, successful the formation of vascular access. There is evidence that the degenerative changes of the mitral valve, such as its calcification or mitral regurgitation are more significant predictors of mortality than the ejection fraction in CHF [1]. At the same time insufficiently clear, is the connection of mitral regurgitation with renal dysfunction in patients with CHF.

Aim: to determine the possible relationship between the state of the mitral valve of the heart and kidney dysfunction in patients with chronic heart failure in the outcome of coronary heart disease (CHD) and hypertension.

The study included 72 patients with CHF, including 35 women and 37 men. The age of patients ranged from 56, 9 ± 5, 1 years. All patients were hospitalized in the Republican Scientific and Practical Center of Nephrology.

Table 1

Distribution of patients in functional class (FC) of CHF and the sex.

Diagnosis is determined on the basis of Russian recommendations and GFCF PRAS 3^rd review on the diagnosis and treatment of chronic heart failure (2009) [3]. Diagnosis is based on subjective, objective symptoms, clinical-laboratory and instrumental examinations (including echocardiography echocardiography). Glomerular filtration rate was calculated on the basis of the concentration of serum creatinine according to MDRD formula. Depending on the glomerular filtration rate the patients with CHF were divided into two groups. To the first group was selected patients with GFR over 60 ml / min / 1,73 m2sek, to second group patients with GFR less than 60 ml / min / 1,73m2sek. Echogeometric and functional parameters of the heart was examined by echocardiography. The results were processed statistically using the Student's t test for unrelated variables. All patients were studied in the dynamics of electrocardiography, also the results of the general analysis of blood, general urinalysis, urinanalysis by the method of Nechiporenko, blood biochemistry analysis, creatinine, coagulation too were examined, all the patients after the initial inspection and verification of the diagnosis diuretics were given antiagreganty- to improve blood flow cardiomagnil, angiotensin of converting enzyme (ACE) inhibitors, according to indicated cardiac glycosides. Results and discussion showed that the content of urea and blood creatinine was high. Non-specific performance-level inflammation fibronogena and ESR (15–25mm) in patients with chronic heart failure were increased. A significant decrease in the level of hemoglobin (80–110g / L), probably, is subject to be a manifestation of erythropoietic disorders of kidney function.

The study of echocardiographic parameters was conducted during treatment by the instrument ALOKA SSD 500 (Japan). It had been determined the following indicators: final-diastolic dimension (CRA), final-systolic dimension (DAC) of the left ventricle, inter-ventricular septum thickness (IVST), posterior wall thickness of left ventricular (PWTHKV) in diastole. Left ventricle myocardial mass (LVM) was calculated in the two-dimensional mode, using the formula «area-length», where A1 — sectional area of the left ventricle with the walls (epicardial contour), A2 — sectional area of the left ventricular free wall (endocardial contour), t — the average thickness of the myocardium and the long axis of the left ventricle. LF myocardial mass index (LVMMI) was defined as the ratio of the mass of the myocardium to body surface area. (PPT). LVH was diagnosed in cases where the corresponding indexed LVM exceeded the thresholds: for indexing to BSA> 102 g / m2 for men and> 88 g / m2 for women (ASE recommendations, 2005). LV remodeling was evaluated by the ratio of LVM and relative wall thickness (UTS) using the formula: UTS (IVST TZSLZH +) / CRA LV. They were identified following types of LV remodeling: Adaptive and maladaptive remodeling of the left ventricle. Remodeling was determined in the following manner. Adaptive remodeling of the left ventricle (corresponds to stage II A). 1. Symptoms (see the corresponding definition in the II stage A). 2. Systolic dysfunction (ejection fraction LZH≤45 % + LV sphericity index in systole (the ratio of left ventricular short axis to the long axis of the left ventricle)> 0.70, and / or the relative thickness of the left ventricular wall (IVST TZSLZH + / KDR LV)> 0.30 and <0.45. 3. Diastolic dysfunction (IVST (inter-ventricular septum thickness) + TZSLZH (LV wall thickness) ÷ 2> 1.3 cm and / or TZSZH> 1.2 cm + pseudonormal type spectrum TMDP≥1,1 and ≤ 2.0. maladaptive remodeling of the left ventricle (corresponds to stage II B). 1. Symptoms (see. the corresponding definition in II B stage). 2. systolic dysfunction (ejection fraction LZH≤45 % + LV sphericity index in systole (the ratio of the short axis of the left ventricle to the the long axis of the left ventricle)> 0.80, and / or the relative thickness of the left ventricular wall (IVST TZSLZH + / KDR LV) ≤0,30.3. Diastolic dysfunction (IVST (interventricular septum thickness) + TZSLZH (LV wall thickness) ÷ 2> 1.3 cm and / or TZSZH> 1.2 cm + restrictive type of migrant domestic workers range> 2.0. for the analysis of LV DF used conventional Doppler indices of transmitral flow (migrant domestic workers) and the flow in the pulmonary veins (PLV). We calculated the conventional indicators for mitral Doppler flow maximum speed in the early (E) and late (A) LV filling, their ratio (E / A), deceleration time of early diastolic flow (the DT), isovolumic relaxation time LV (IVRT). For violation of DF believed ratio E / A <1, IVRT> 90 ms, DT> 220 ms. In the spectrum of PLV was measured top speed of systolic wave (S) and antegrade diastolic wave (D), their ratio (S / D), and the speed and duration of retrograde diastolic wave A. In terms of PLV for violating thought S / D ratio of less than 1, A wave duration> = 35 ms. Evaluation of Doppler flow in the pulmonary veins was carried out at the confluence of the right superior pulmonary vein to the left atrium (LA) at a distance of 2 cm in depth.

Results

The results of studying the state of echocardiographic parameters are shown in Table 2.

As follows from the results of our study, the mean GFR in both groups of patients was 69.1 + — 9,6ml / min / 1,73m2 seconds. Thus patients (1/3 patients) are GFR was lower than 60 ml / min / 1,73m2, 22 patients (64.7 %), respectively, GFR was greater than 60 ml / min / 1.73 m2. In 23 patients (67.6 % more than half of the surveyed) change was detected echogeometry of mitral valve. Mitral regurgitation in most cases was moderate, met mitral regurgitation I and II degree. It seen that patients with the second group of mitral regurgitation are more common than in patients of the second group (respectively, 6 of 22 patients in the first group and 7 of 12 patients of the second group). It is known that left ventricular hypertrophy is one of the main causes of diastolic dysfunction (DD) of the left ventricle in heart failure [7].

This study found that in group I DD signs were detected in 15 (44.1 %) patients: with impaired relaxation in 8 patients (47.5 %), pseudonormal type in 5 (29.4 %), have a restrictive type 2 (5.9 %). Among patients of group II DD was detected in 16 (94.1 %): the type of impaired relaxation of treated in 8 (47.5 %), pseudonormal in 6 (37.5 %) and restrictive in 2 patients (12.5 %). The average value of the PV index in all groups of observation did not differ from normal, reflecting the intact contractile features. Thus, the decline in GFR less than 60 mL / min / 1,73m2sek in patients with chronic heart failure were observed in almost every third patient, and it is important to measuring glomerular filtration rate in patients with CHF. Deviation of echogeometric parameters of the mitral valve from normal value occurs twice as often in patients with chronic heart failure with lower glomerular filtration rate. Therefore, the identification of mitral regurgitation by echocardiography, it is affordable and at the same time informative method of predicting the progression of renal dysfunction in patients with CHF. Multivariate regression analysis of patients of group II showed independent effect on Hb content of all studied indicators DD.

Obviously, the most important in the development of both diastolic and systolic dysfunction of left ventricular myocardium in patients with CHF are «non-traditional» factors, the severity of which increases in this group of patients. Analysis of the impact of the studied parameters of lipid spectrum, the state on the functional state of the ventricular myocardium in patients with chronic heart failure showed no significant correlation in any of the groups. The most common clinical manifestations of heart failure in patients with renal dysfunction were dyspnea (29 %; 66,2 %), decreased physical activity (40 %; 66,9 %) and tachycardia (38 %; 65,7 %), the frequency of which escalated significantly with increasing stage of renal dysfunction. Often these symptoms as signs of heart failure were seen with chronic kidney disease. Similar symptom manifestation of CKD and heart failure are due to the same type of pathological mechanisms of these diseases. Combination of clinical signs and indicators of the functional state of left ventricular myocardium were the basis for diagnosis in 86 % of predialysis patients with CHF. 1^st part covered, the frequency of which was 52 %; 65,4 %. A significant number of patients with mild impairment of LV myocardial function, in part, due to the treatment with drugs that affect the progression of the basic mechanisms of how CKD and CHF; is primarily angiotensin converting enzyme inhibitors.

Echocardiographic parameters in patients with chronic heart failure

Conclusions:

1. Echocardiography is an essential method of examination of patients to evaluate the geometry and function of the heart, the degree and nature of heart failure. Detection of mitral regurgitation by echocardiography, it is affordable and at the same time informative method of predicting the progression of renal dysfunction in patients with CHF.
2. Chronic heart failure is one of the most important factors leading to disruption of the functioning of the glomerular apparatus of kidneys. Every fourth patient with chronic heart failure occurs as a result of mitral calcification of left ventricular systolic dysfunction.
3. Deviation ehogeometric parameters of the mitral valve from normal value occurs twice as often in patients with chronic heart failure with lower glomerular filtration rate.

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