Razi Journal of Medical Sciences

fa بررسی اکوکاردیوگرافیک فونکسیون و ژئومتری بطن چپ بعد از پیوند کلیه در کودکان و نوجوانان Echocardiographic evaluation of left ventricular function and geometry in pediatric patients with kidney transplantation قلب کودکان Pediatric Cardiology پژوهشي Research زمینه و هدف: با توجه به بهبود طول عمر کودکان بعد از پیوند کلیه، پیشگیری از عوارض قلبی به عنوان مهم‌ترین عامل مورتالیتی حایز اهمیت است. هدف از این مطالعه، بررسی فونکسیون بطن چپ در کودکان بدون علائم نارسایی قلبی، قبل و بعداز پیوند کلیه با استفاده از معیارهای جدید اکوکاردیوگرافیک است. روش کار: در این مطالعه کوهورت‌، معیار‌های اکوکاردیوگرافیک در ۱۸ بیمار (۲±۲ /۱۲سال) قبل و بعد از پیوند کلیه بررسی و با گروه کنترل مقایسه گردید. جهت بررسی فونکسیون بطن، سرعت امواج سیستولیک و دیاستولیک در سطح دریچه میترال توسط پالس داپلر و داپلر بافتی وهمینطور Myocardial Performance index (MPI)  توسط داپلر بافتی محاسبه شد. یافته‌ها: هیپرترفی بطن چپ در  ۴۴% بیماران دیده شد. میزان MPI بعد از پیوند کاهش ولی نسبت به گروه شاهد همچنان بالاتر بود (۱/۰  ±۳۱/۰   vs. ۱۳/۰  ± ۳۶/۰و 05/0p<). میزان سرعت موج  s’ به عنوان معیار فونکسیون طولی میوکارد بعد از پیوند ارتباط عکس با میزان توده بطن چپ نشان می داد (05/0>p، 46/0-=r) تفاوت آماری مهم در سرعت موج e’ قبل و بعد از پیوند دیده نشد. در هیچ یک از بیماران افزایش E/e’ به عنوان معیار افزایش filling pressure  LV دیده نشد. نتیجه‌گیری: اختلالات ساب کلینیکال فونکسیون بطن چپ در کودکان فاقد علائم نارسایی قلبی که تحت پیوند کلیه قرار گرفته بودند، دیده می‌شود. تغییرات ژئومتریک بطن چپ حتی در بیماران با سیر کوتاهتر نارسایی کلیه، نقش مهمی در فونکسیون میوکارد ایفا می‌کند. لذا ، اقدامات پیشگیری کننده قبل از پیوند جهت کاهش عوارض قلبی پایدار حایز اهمیت می‌باشد. Background: Cardiovascular disease (CVD) is an important, leading cause of mortality and morbidity in patients with chronic kidney disease (CKD) as well as in renal transplant recipients. Cardiovascular complications become more important in children because of the improved life span of children after kidney transplantation (KT).  Recent research programs are looking into the initial stages of renal failure to diagnose early and subclinical cardiac impairment. It has been shown that abnormalities in LV geometry which start early during renal impairment are one of the key mechanisms for developing progressive cardiac complications. Despite improving LV function following KT, cardiac complications are still defined as the main risk factor for mortality in renal recipients. New echocardiographic techniques using Tissue Doppler Imaging (TDI) have been proven to be sensitive and accurate methods for recognizing the initial phase of ventricular dysfunction in a variety of diseases. To our knowledge, there is a little information on severity of cardiac involvement including structural and functional changes in children with KT who have a short duration of renal impairment. This study aimed to evaluate ventricular systolic and diastolic functions by using TDI parameters in a group of post-transplant children who had no symptoms of heart failure before KT. Methods: Clinical and echocardiographic data were prospectively obtained from 18 patients with CKD before kidney transplantation. The inclusion criteria consisted of the following: (1) age under 18 years old, (2) no limitation in ordinary physical activities (NYHA functional class I), (3) LV ejection fraction ≥ 55%, and (4) absence of co-existing disease. The transthoracic echocardiographic study was performed within 3 months before the transplantation by an experienced physician, who was unaware of the status of the subjects. All patients of the study were followed up, and the post-transplant data were obtained during one to three years. The obtained echocardiographic data were analyzed and compared with the control group consisting of 37 age-matched, healthy children. LV hypertrophy (LVH) was deﬁned as LV mass index >51 g/m2.7. LV systolic function was assessed by measuring ejection fraction (LVEF) using modiﬁed Simpson’s method. Tissue Doppler Imaging was used for the assessment of both systolic and diastolic LV functions, and the TDI derived MPI (TDI-MPI) was considered to be a marker of global LV function. In addition, tissue Doppler derived parameters were used for assessing regional longitudinal performances of the left ventricle. Peak early diastolic velocity (e’), peak late diastolic velocity (a’), and peak systolic velocity (s’) were obtained from the septal and lateral sides of the mitral annulus. According to the current guidelines, we evaluated the diastolic function by calculating E/e´ ratio. Results: The mean age at KT was 12.2+2 years. Five patients received maintenance dialysis before KT. Median follow-up after KT was 2.3 (1.3-3) years.  LVEF was within the normal range for all of the patients. LV mass decreased significantly after KT (51 ± 1.5g/m2.7 vs. 43.1±1.6 g/m2.7، p<0.05), but it was still greater than the controls (p<0.05). LVH was found in 8(44%) patients. We observed a positive correlation between pre-transplant hypertension and post-transplant LVMI (r=0.41, p<0.05). The TDI-MPI, as a marker of global LV function, was signiﬁcantly greater in the post-transplantation patients than that in control group (0.36 ± 0.13 vs. 0.31 ± 0.01, p <0.05). Using ROC curve analysis, the TDI-MPI yielded an area under the curve of 0.86 to discriminate the patients against those without subclinical LV dysfunction. Using a TDI-MPI > 0.32 as the cut point, LV dysfunction was identiﬁed with a sensitivity of 75% and speciﬁcity of 48%. We observed a signiﬁcant correlation between the values of TDI-MPI and the presence of LVH before transplantation (r=0.4, p<0.05). Regarding the LV longitudinal systolic function, the myocardial systolic velocity (s´) was significantly different between the post-transplantation patients and the ones in the control group (6.5 ± 0.9cm/s vs. 7.3±0.7cm/s, p<0.05), while the myocardial diastolic velocities did not differ between them. Moreover, an inverse relationship was observed between the values of s´ wave velocity and LVMI (r= -0.46, p<0.05). This association is in favor of the potential role of LV remodeling on the reduced longitudinal function of the myocardium. None of the patients had a ratio of E/e’> 14 as an index of high LV filling pressure. The values of E/e ratio were correlated to LV end- diastolic and systolic diameters (r= 0.36, r= 0.34, p<0.05, respectively). There was no relationship between E/e’ ratio and LV mass. Conclusion: Assessment of the LV function with accurate echocardiographic methods showed subtle LV dysfunction in patients who were asymptomatic for heart failure and with a short pre-transplant duration of renal impairment. Moreover, LVH was the most commonly observed cardiac abnormality in post-transplant pediatric patients. In concordance with previous studies, we found that the restoration of renal function by renal transplantation improved global ventricular function and also reduced the LV mass. (7,8) However, a higher LV mass was often present in KT patients and may lead to a poor outcome. (2) Furthermore, the LV longitudinal systolic function, assessed by measurement of s’ wave velocity, improved significantly after KT. Our findings regarding a correlation of elevated LV mass with both of the TDI-MPI and impaired systolic indices of myocardial function highlight the basic role of LV remodeling on myocardial dysfunction even in the subgroup of the patients with a short period of renal failure. Moreover, its association with pre-transplant hypertension suggests that more complete control of the blood pressure in CKD patients is important for reducing cardiac risk factors. Subtle abnormalities of the LV systolic- diastolic function and LVH are present in children after renal transplantation who have no symptoms for heart failure within the pre-transplant period. Although our study is limited by the small group of the patients, the data might imply that high LV mass may substantially inﬂuence the post-transplant cardiac function. These findings confirm the importance of early initiation of therapeutic interventions to modify permanent cardiac dysfunction.   اکوکاردیوگرافی, پیوند کلیه, عملکرد بطن چپ,کودکان, نارسایی مزمن کلیه chronic kidney disease, echocardiography, kidney transplant, left ventricular function, pediatric 140 149 http://rjms.iums.ac.ir/browse.php?a_code=A-10-5257-1&slc_lang=fa&sid=1 Roya Isa Tafreshi رویا عیسی تفرشی isatafreshi.r@iums.ac.ir 3900319475328460054754 3900319475328460054754 Yes Assistant Professor, Aliasghar Children’s Hospital, Department of Pediatrics, Iran University of Medical Sciences, Tehran , Iran بیمارستان کودکان حضرت علی اصغر (ع)، گروه کودکان، دانشگاه علوم پزشکی ایران، تهران، ایران Nahid Rahimzadeh ناهید رحیم زاده 3900319475328460054755 3900319475328460054755 No Associate Professor, Rasoul Akram Hospital, Department of Pediatrics, Iran University of Medical Sciences, Tehran , Iran بیمارستان حضرت رسول اکرم (ص)، گروه کودکان، دانشگاه علوم پزشکی ایران، تهران، ایران Rozita Hoseini رزیتا حسینی 3900319475328460054756 3900319475328460054756 No Aliasghar Children’s Hospital, Department of Pediatrics, Iran University of Medical Sciences, Tehran , Iran بیمارستان کودکان حضرت علی اصغر (ع)، گروه کودکان، دانشگاه علوم پزشکی ایران، تهران، ایران