Original article

33 Journal of The Association of Physicians of India Vol. 69 October 2021

original article

Study of Pulmonary Arterial Hypertension in Patients of Chronic Kidney Disease Stage IV and V

Atul Mann1*, Geeta Kampani2, Sandeep Bansal3, Sunil Ranga4

Abstract

Introduction: Pulmonar y ar terial hyper tension (PAH) is an overlooked complication in CKD. PAH may be induced or aggravated by various risk factors found in CKD but the pathogenesis is not fully elucidated.

Aim: To study the occurrence of PAH in CKD stage 4 and 5 and to study the risk factors for development of PAH in these patients.

leading to pulmonary vasoconstriction,7 decreased compliance of pulmonary vasculature, exposure to dialysis membranes,4,7 pulmonary artery calcification and stiffening4 secondary to hyperparathyroidism, increased thromboxane B2, and increased pro-brain natriuretic peptide.

Method: An observational cross-sectional study was conducted on 100 patients

In a recent review by H. Suresh et

of CKD stage 4 and 5 at VMMC and Safdarjung Hospital and all necessary

al,8 the prevalence of PH in patients

investigations were done.

with CKD especially ESRD, is found

Results: Out of 100 CKD patients, PAH was found in 61 patients, of which 23 had mild, 34 had moderate and 4 had severe PAH. Significant association was seen of systolic and diastolic blood pressure with high systolic blood pressure also associated with increased PAH severity. Significant association was seen of haemodialysis, arteriovenous fistula (AVF), CKD severity & haemodialysis duration. Increased hemodialysis duration & AVF were significantly associated with PAH severity also. Anaemia, low calcium, high phosphate, increased calciumphosphate product and increased intact-parathormone were significantly associated with PAH while except calcium, these were also significantly associated with increased PAH severity. Lower LVEF% was also significantly associated with PAH and its severity. None of them was an independent significant risk factor for PAH.

to be around 43.5%. The mortality rate in the study population was also two times higher among the patients with PH compared to those without PH and the mean dialysis duration was found to be higher among the patients with PH than those without PH. Majority of the cases in stage 3 and 4 CKD had mild PH but in stage 5, it was predominantly moderate PH which indicates that PH increases in severity with progression of CKD.

Qian Zhang et al,9 in their study

Conclusion: PAH is an important complication in CKD and its severity increases

noted the overall prevalence of PH to

with deterioration of renal function in CKD. Various risk factors are present

be 47.38%, of which mild, moderate and

and treatment of these can decrease the progress and severity of PAH, thereby

severe PH accounted for 22.13, 15.04

decreasing the morbidity and mortality in CKD.

and 10.21%, respectively. They found

that prevalence of PH was much higher

in patients who were on dialysis when

Introduction

Cardiovascular disease is the most common cause of morbidity and mortality in patients with chronic kidney disease (CKD).1 The focus is usually on left ventricular failure causing increased morbidity and mortality in the patients of CKD whereas pulmonary arterial hypertension (PAH) is an overlooked cardiovascular complication of CKD, especially in end-stage renal disease (ESRD).

Elevated pulmonary arterial pressure (PAP) can be observed secondary to

fully elucidated in patients of CKD[3]. It is considered to be because of the interaction of multiple aspects of altered cardiovascular physiology, elevated left ventricular filling pressure and pulmonary venous hypertension due to myocardial dysfunction are some of the important causes of PAH in CKD.4 The other important factors implicated are increased cardiac output (CO),3 volume overload, anemia, increased pulmonary blood flow due to shunting across arteriovenous fistula (AVF),5,6 endothelial dysfunction

compared to non-dialysis patients. Independent risk factors of PH in CKD patients were found to be body mass index (BMI), proteinuria, triglyceride (TG), hemoglobin, parathyroid hormone (PTH) and estimated glomerular filtration rate (eGFR).

Mehta KS et al10 in their cross sectional and prospective study also found that out of total 200 patients included in their study, 121 patients (60.5%) had PH. Majority, 56 (46.28%) of CKD patients showed moderate PH. Significant association was seen between PH and presence of diabetes,

heart, lung, or systemic disorders.

PAH is defined as "a mean pulmonary

1Resident Doctor, Department of General Medicine, 2Consultant and Professor, Department of General Medicine, 3Consultant

artery pressure more than or equal to 25

& Professor, Department of Cardiology, 4Consultant & Professor, Department of Pathology, VMMC & Safdarjung Hospital, New

mmHg at rest or 30 mmHg at exercise."2 The pathogenesis of PAH is not

Delhi; *Corresponding Author Received: 08.12.2020; Accepted: 12.01.2021

34 Journal of The Association of Physicians of India Vol. 69 October 2021

Table 1: Characteristics of patients with and without PH

Parameters Age BMI SBP DBP CKD stage 4 CKD stage 5 Presence of hemodialysis Hemodialysis duration (weeks) Presence of AVF Presence of diabetes Hemoglobin S. Uric Acid S. Calcium S. Phosphate Calcium Phosphate product iPTH LVEF%

With PH (n=61) 31.21 ? 8.69 22.64 ? 1.66 148.3 ? 11.91 87.54 ? 7.47 19 42 49 11.12 ? 4.99 11 11 7.35 ? 0.56 7.14 ? 0.95 7.59 ? 0.48 6.79 ? 0.7 51.3 ? 3.86 396.21 ? 62.69 35.77 ? 6.14

hypertension, presence of AVF, CKD stage, CKD duration, presence of hemodialysis, HD duration, calcium phosphate product and S. creatinine levels. They also found that severity of PH increased with increased duration of CKD and increased duration of hemodialysis.

However the relationship between PH and CKD has been inconsistent so far. Another study conducted by Ezgi Coskun Yenigun et al,11 showed that the prevalence of PH in patients with early stage CKD was similar to those with stage 5 CKD and no significant difference was noted in PH in cases undergoing hemodialysis and those without hemodialysis. Another prospective study done by Unal et al.12 showed that AVF flow rate does not affect remarkably the systolic PAP.

PAH is an independent predictor of increased mortality in patients with CKD and its presence has been recently suggested to be associated with a poor outcome13 in these patients. Hence further studies are needed to assess the association of PAH in CKD patients. This study was conducted to study the occurrence of PAH in CKD focusing on stage IV and V patients and to study the risk factors for development of PAH in CKD stage IV and V.

Materials and Methods

This was an observational cross section study conducted on 100 patients of CKD stage 4 and 5 (based on KDIGO 2012 criteria) attending medicine OPD or admitted to the medicine wards in VMMC and Safdarjung Hospital, New Delhi from 2018-2020. Each patient

Without PH (n=39) 33.28 ? 8.85 22.3 ? 1.62 136.44 ? 12.12 82.97 ? 6.42 31 8 18 5.78 ? 3.56 0 10 8.29 ? 0.41 7.08 ? 1.05 8.16 ? 0.39 4.37 ? 0.43 35.58 ? 3.43 138.79 ? 36.28 52.69 ? 5.6

P value 0.263 0.316 ................
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