Journal of Ultrasound (2011) 14, 110e112
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LETTER TO THE EDITOR
Dyspnea in hemodialysis and early echocardiographic
examination at the bedside: Two case reports
to the department of cardiac surgery and underwent valve
replacement surgery which led to immediate clinical
improvement. Table 1 describes the clinical classification
of mitral stenosis.
Introduction
Clinical case Nr. 2
Dyspnea is an extremely common symptom among patients
on dialysis [1e3]. At first instance nephrologists generally
considers it as a symptom of volume overload in patients
with uremia and manages it by gradually reducing the
patients dry weight. Here we describe two clinical cases in
which echocardiography proved to be a very useful tool in
the differential diagnosis of dyspnea in patients on
hemodialysis.
A 78-year-old female patient treated in our outpatient
nephrology service for severe chronic renal failure. The
first cardiological evaluation carried out at nephrological
referral showed good cardiovascular compensation with no
episodes of angina and/or dyspnea. Electrocardiogram
showed no significant alterations and echocardiographic
examination, performed by a nephrologist, showed the
presence of left ventricular hypertrophy with mild diastolic dysfunction grade I (early/atrial ratio <1). Two
years later the patient started renal replacement therapy,
and in the same period another echocardiographic examination was performed which confirmed good left
ventricular compliance (ejection fraction 55%) despite the
presence of mitral insufficiency with mild to moderate left
atrial enlargement.
About a year later, the patient began to experience
severe episodes of dyspnea resulting in the loss of 4 kg dry
weight in one month, but without showing significant
improvements in respiratory symptoms. The patient was
not affected by anemia (hemoglobin mean levels were
12 g/dl and mean levels of hematocrit were 35%); spirometry examination showed a condition of mild chronic
obstructive pulmonary disease. A new echocardiographic
examination showed a further increase in the left atrium
volume (left atrium area was 26 cm2) and an increase in
mitral regurgitation (moderate to severe with a vena contracta diameter of 15 mm). Estimated pulmonary artery
pressure was 30 mmHg and there was no evidence of pericardial effusion (Fig. 2).
The patient was then referred to the department of
cardiology for a clinical evaluation. The echocardiographic
pattern was completely confirmed, but there was no indication for surgery. However, the patients medication was
modified with the addition of losartan (100 mg/day) and
carvedilol (6.25 mg/day). With this modification, the
patient reported a marked improvement in respiratory
symptoms. Table 2 shows the classification of mitral
regurgitation.
Clinical case Nr. 1
This case describes the clinical picture of a 52-year-old
patient with a long clinical history of post-streptococcal
glomerulonephritis and rheumatic disease, who after two
years of renal replacement therapy started developing
a severe form of secondary hyperthyroidism (intact parathyroid hormone (iPTH): 1417 pg/ml). The patient was
being treated with Sevelamer hydrochloride orally administered (at a dose of 4.8 g/day) and intravenous vitamin D
(at a dose of 3 g/week). Electrocardiogram showed signs of
left ventricular overload, while echocardiography performed by a nephrologists showed left atrial enlargement,
left ventricular hypertrophy and mitral stenosis due to mild
to moderate scleral calcific changes (mitral valve area
estimated to be 2 cm2).
A year later the patient began to experience dyspnea in
connection with also minor efforts and not directly
related to the hemodialysis treatment sessions. Physical
examination revealed a systolic murmur 3/6 in the mitral
valve area. Attempts to reduce the patients dry weight
resulted only in the onset of frequent episodes of hypotension. Echocardiogram showed a substantial increase in
the left atrium size as well as diffuse calcification of the
annulus and the anterior edge of the mitral valve suggesting severe mitral valve stenosis (mitral valve area
estimated to be 0.9 cm2) (Fig. 1) confirmed by threedimensional echocardiography performed in the department of cardiology. At this point the patient was referred
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doi:10.1016/[Link].2011.06.003
Letter to the Editor
111
Table 2 Echocardiographic parameters related to mitral
regurgitation (Ref. Otto C, Textbook of Clinical Echocardiography, Ed Saunders & Co, 2004).
Mitral insufficiency
Light
Medium
Severe
Regurgitation
volume (ml)
Vena contracta (mm)
<30
3e6.9
>60
<3
3e6.9
>7
with chronic kidney disease, ranging from routine ultrasound study of the urinary tract morphology to echocardiographic examination. Nephrologists with basic
ultrasound know-how can perform the initial echocardiography screening in order to refer the patients to the
department of cardiology without delay [6].
Fig. 1 Left atrium dilation and mitral ring calcification (left);
3D rendering of mitral valve area (right).
Table 1 Echocardiographic parameters related to mitral
stenosis (Ref. Otto C, Textbook of Clinical Echocardiography, Ed Saunders & Co, 2004).
Mitral stenosis
Valve area
Light
Medium
2
1.5e2 cm
Severe
2
1e1.5 cm
<1 cm
Supplementary data related to this article can be found
online at doi:10.1016/[Link].2011.06.003.
References
Discussion
Heart valve disease is frequently associated with secondary
hyperparathyroidism in patients with terminal uremia [4,5].
The description of our clinical cases shows that ultrasound
examination is of great help in the treatment of patients
Fig. 2
Appendix. Supplementary material
[1] Tarrass F, Benjelloun M, Zamd M, Medkouri G, Hachim K,
Benghanem MG, et al. Heart valve calcifications in patients
with end-stage renal disease: analysis for risk factors.
Nephrology (Carlton) 2006 Dec;1(6):494e6.
[2] Sharma R, Pellerin D, Gaze DC, Mehta RL, Gregson H,
Streather CP, et al. Mitral annular calcification predicts
mortality and coronary artery disease in end stage renal
disease. Atherosclerosis 2007 Apr;191(2):348e54.
[3] Derici U, El Nahas AM. Vascular calcifications in uremia: old
concepts and new insights. Semin Dial 2006 JaneFeb;19(1):60e8.
Mitral valve regurgitation in left atrium.
112
Letter to the Editor
[4] Varma R, Aronow WS, McClung JA, Garrick R, Vistainer PF,
Weiss MB, et al. Prevalence of valve calcium and association of
valve calcium with coronary artery disease, atherosclerotic
vascular disease, and all-cause mortality in 137 patients
undergoing hemodialysis for chronic renal failure. Am J Cardiol
2005;95:742e3.
[5] Salusky IB, Goodman WG. Cardiovascular calcification in
end-stage renal disease. Nephrol Dial Transplant 2002;17:
336e9.
[6] Floccari F, Di Lullo L, Malaguti M, Polito P, Timio M.
LEcocardiografia e il nefrologo: una Pocket Guide per
nefrologi curiosi. G Tecnol Nefrol Dial Anno 2011;XXIII(1):
38e43.
L. Di Lullo*
Department of Nephrology and Dialysis, S. Giovanni
Evangelista Hospital, Tivoli (Rome), Italy
F. Floccari
Department of Nephrology and Dialysis, S. Paolo Hospital,
Civitavecchia (Rome), Italy
A. Granata
Department of Nephrology and Dialysis, Vittorio Emanuele
Hospital, Catania, Italy
F. Fiorini
Department of Nephrology and Dialysis, Santa Maria della
Misericordia Hospital, Rovigo, Italy
P. Polito
Department of Nephrology and Dialysis, S. Giovanni
Evangelista Hospital, Tivoli (Rome), Italy
*Corresponding author.
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