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A5713 - Prevalence and Associated Mortality of an Echocardiographic Diagnosis of Pulmonary Hypertension in End-Stage Renal Disease Patients: A Systematic Review and Meta-Analysis
Author Block: N. Schoenberg1, R. G. Argula2, H. W. Farber3, E. S. Klings4, K. C. Wilson5; 1Pulmonary and Critical Care, Boston University Medical Center, Boston, MA, United States, 2Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC, United States, 3Boston Univ Sch of Med, Boston, MA, United States, 4Pulm Ctr/Houseman R304, Boston Univ Sch of Med, Boston, MA, United States, 5Documents and Medical Affairs, American Thoracic Society, NY, NY, United States.
Rationale:
Development of pulmonary hypertension (PH) in the setting of end-stage renal disease (ESRD) is a complex process with important prognostic and therapeutic consequences. The vast majority of studies investigating this phenomenon are small, single-center observational studies and case series that report a wide range of prevalence and mortality rates. In this systematic review, we sought to define the prevalence and mortality of PH in patients with ESRD, identified either by transthoracic echocardiography (TTE) or right-heart catheterization (RHC).
Methods:
Three databases (Medline, the Cochrane Library, and the Cumulated Index to Nursing and Allied Health Literature (CINAHL) were searched by two investigators using a sensitive search strategy built around the medical subject headings of “hypertension, pulmonary” and “kidney failure, chronic”. Keywords, including variations on “dialysis,” “ESRD,” and “pulmonary vascular disease” were also utilized. Study selection criteria included: 1) Enrollment of patients with ESRD on either hemodialysis or peritoneal dialysis, 2) Assessment for the presence of PH using TTE (based on a derived pulmonary artery pressure) or RHC (using mean pulmonary artery pressure), and 3) Determination of PH prevalence or associated mortality. Data were extracted, analyzed, and, when appropriate, meta-analyses were performed using the ReviewManager 5.3 software.
Results:
The search identified 413 publications in Medline, 599 in the Cochrane Library, and 34 in the CINAHL database. Duplicates were removed, and the majority of articles were excluded through review of title and abstract. A full text review was performed on 67 publications and thirty studies were selected for analysis; all thirty studies reported prevalence, and eight reported mortality. A meta-analysis found that the prevalence of PH identified by echocardiographic criteria in the enrolled ESRD patients was 36% (95% CI 31 to 42%), which was similar to the prevalence identified by RHC and higher than the prevalence reported in the general population. Mortality was significantly increased among ESRD patients with PH compared to ESRD patients without PH (RR 1.94, 95% CI 1.63 to 2.30).
Conclusions:
Despite the potential limitations of using echocardiography to assess the presence of PH, echocardiographic evidence of PH was common in patients undergoing dialysis across a wide variety of geographic and institutional settings. Such evidence was associated with a significant increase in mortality in the ESRD population, suggesting that routine screening of ESRD patients using TTE may be a viable strategy for identifying those at higher risk of poor outcomes.