Abstract 18286: Relative Prognostic Impact of Various Measures of Right Atrial Pressures on Survival in Patients With End Stage Renal Disease on Hemodialysis: Results From a Prospective Cohort of 442 Patients

Abstract

Background: End stage renal disease (ESRD) patients on hemodialysis (HD) are prone to heart failure (HF) because of volume excess leading to poor functioning, atrial remodeling, pulmonary hypertension (PHTN) and high mortality. Right atrial pressure (RAP) estimate helps in achieving euvolemic status or optimal dry weight. There is limited data on the best measure of RAP in this population. We compared relative prognostic values of clinically assessed jugular venous pressure (RAP-JVP), RAP estimate recommended by ASE (RAP-ASE) and a visual estimate by an expert reader from combination of inferior vena caval (IVC) and hepatic vein size, hepatic congestion and hepatic vein flow (RAP-EXP). Methods: 442 patients who underwent pre-renal transplant evaluation at our cardiology clinic were prospectively followed. Assessment of RAP by CE as elevated JVP, echo evaluation of RAP-ASE and RAP-EXP were performed on same pre or post dialysis day within a hour of each other. Quantitative evaluation of minimum (IVC min), maximum (IVC max) IVC diameters along with collapse (IV max-IVC min/IVC max) was computed following ASE guidelines independently. Logistic regression and Cox proportional hazard ratio were performed for outcomes assessment. Results: Baseline patient characteristics: age 57± 11 years, men 64%, DM in 68 %, CAD 30%, EF 61± 11%. Elevated RAP-JVP was noticed in 15% and RAP-EXP was high in 30% of the patients. Quantitatively, IVC max was 1.39± 0.55 cm, IVC min 0.87± 0.62 cm and mean IVC collapse 44± 29%. 14% patients had IV max of ≥ 2cm. IVC size, collapse or RAP-ASE group were not predictive of survival. However RAP-JVP (HR 2.15, 95 % CI 1.09-4.12, P = 0.03) and RAP-EXP (HR 2.25, 95 % CI of 1.21- 4.20, P = 0.01) were significant predictors of higher mortality on univariable analysis and after adjusting for age, gender, smoking, HTN, DM, LVEF and duration of dialysis. RAP-JVP and RAP-EXP better correlated with each other and HF by, left atrial pressure and PHTN than RAP-ASE. Conclusions: 1) Clinically estimated JVP and an expert assessment of RAP are equally predictive of survival in patients on HD. 2) Echo assessment of RAP by ASE guidelines is twice as sensitive as CE and its use may help achieve euvolemic status in ESRD patients.