Lung ultrasound-guided dry-weight reduction and echocardiographic changes in clinically euvolemic hypertensive hemodialysis patients: 12-month results of a randomized controlled trial.

OBJECTIVE: Left ventricular hypertrophy (LVH) and dysfunction are highly prevalent in hemodialysis patients and are independently associated with adverse outcomes. This study examines the long-term effects of dry-weight reduction with a standardized lung ultrasound (LUS)-guided strategy on echocardiographic indexes of left ventricular (LV) mass and function in hemodialysis patients. METHODS: Seventy-one clinically euvolemic hemodialysis patients with hypertension were randomized to dry-weight reduction guided by pre-hemodialysis LUS (n = 35) or standard-of-care treatment (n = 36) and were followed-up for 12 months. Two-dimensional and tissue-Doppler echocardiographies (TDI) were performed at the baseline and 12-month evaluations. RESULTS: During follow-up, dry-weight reduction took place in more patients in the active arm than in the control arm of the trial (71.4% vs 22.2%; p < 0.001). Left atrial (LA) surface (-1.37 ± 4.50 vs 1.28 ± 5.00 cm2; P = 0.006) and LA volume index (-3.22 ± 11.82 vs 4.76 ± 12.83 ml/m2; P = 0.009) decreased in the active and increased in the control group. LV end-diastolic volume (-0.94 ± 11.45 vs 6.58 ± 13.92 ml/m2; P = 0.015) decreased only in the active group. The LV mass index was unchanged in the active (134.21 ± 44.75 vs 133.57 ± 45.51; P = 0.844) and marginally increased in the control group (134.21 ± 40.96 vs 143.77 ± 50.04 g/m2; P = 0.089). The LV E/e' wave ratio was unchanged in the active (12.45 ± 4.69 vs 12.56 ± 4.89; P = 0.521) and increased in the usual-care group (10.91 ± 4.97 vs12.36 ± 6.43; P = 0.003). LV systolic function did not differ between the two study arms across the trial. CONCLUSION: Over 12 months, LUS-guided dry-weight reduction is associated with reverse LV and LA remodeling, myocardial hypertrophy regression, and improved LV diastolic filling properties.

Lung Ultrasound-Guided Dry Weight Assessment and Echocardiographic Measures in Hypertensive Hemodialysis Patients: A Randomized Controlled Study.

RATIONALE & OBJECTIVE: Left ventricular (LV) hypertrophy and dysfunction are associated with adverse outcomes in hemodialysis patients. Hypertension and hypervolemia play important roles in these cardiac abnormalities. We report on the prespecified secondary outcome, echocardiographic indexes of LV function, from a previously reported study of the effect of lung ultrasound (US)-guided dry weight reduction on systolic blood pressure. STUDY DESIGN: Single-blind randomized trial. SETTINGS & PARTICIPANTS: 71 clinically euvolemic hypertensive hemodialysis patients in Greece and Slovenia. INTERVENTION: The active intervention group's (n=35) volume removal was guided by the total number of lung US B-lines observed every week before a midweek dialysis session. The usual-care group (n=36) was treated using standard-of-care processes that did not include acquisition of US data. OUTCOMES: 2-dimensional and tissue Doppler echocardiographic indexes at baseline and study end (8 weeks) that evaluated left and right heart chamber sizes, as well as systolic and diastolic function. RESULTS: Overall, 19 (54%) patients in the active intervention and 5 (14%) in the usual-care group had ultrafiltration intensification (P<0.001) during follow-up; changes in US B-lines (-5.3±12.5 vs+2.2±7.6; P<0.001) and dry weight (-0.71±1.39 vs+0.51±0.98kg; P<0.001) significantly differed between the active and usual-care groups. Inferior vena cava diameter decreased in the active compared with the usual-care group (-0.43±4.00 vs 0.71±4.82cm; P=0.03) at study end. Left (LA) and right (RA) atrial dimensions decreased more in the active group (LA surface, -1.09±4.61 vs 0.93±3.06cm2; P=0.03; RA surface -1.56±6.17 vs 0.47±2.31; P=0.02). LA volume index nominally decreased more in the active group (-2.43±13.14 vs 2.95±9.42mL/m2), though this was of borderline statistical significance (P=0.05). Reductions in LV end-diastolic diameter and volume were marginally greater in the active group. The change in LV filling pressures was significantly different in the active compared with the usual-care group (early transmitral diastolic velocities ratio [E/e'], -0.38±3.14 vs 1.36±3.54; P=0.03; E wave deceleration time, 35.43±85.25 vs-18.44±50.69; P=0.002]. Systolic function indexes were unchanged in both groups. In multivariable analysis, US B-line reduction was associated with a reduction in the E/e' LV ratio (OR, 4.542; 95% CI, 1.266-16.292; P=0.02). LIMITATIONS: Exploratory study; small sample size. CONCLUSIONS: A US-guided strategy for dry weight reduction is associated with decreased cardiac chamber dimensions and LV filling pressure, but no difference in systolic performance compared with usual care in hypertensive hemodialysis patients. FUNDING: European Renal Association-European Dialysis and Transplant Association. TRIAL REGISTRATION: Registered at ClinicalTrials.gov with study number NCT03058874.