Left atrial strain by speckle-tracking: incremental role in diastolic assessment of pediatric patients with chronic kidney disease
Authors: Penachio Flora Maciel , Laurino Rosana Sbruzzi Prado , Watanabe Andreia , Diniz Maria de Fátima , Sawamura Karen Saori Shiraishi , Lianza Alessandro Cavalcanti , Menezes Carolina da Rocha Brito , Silva Isabela de Souza Lobo , Leal Gabriela Nunes 
Published: September 2022

Background: cardiovascular complications are the leading
mortality cause among children with chronic kidney diseases (CKD), being
responsible for up to 30% of deaths. Left ventricle (LV) diastolic
dysfunction is common and has been linked to poor cardiovascular
outcomes. Echocardiographic assessment of diastolic function in CKD
children is usually limited to spectral and tissue Doppler imaging,
known to be less reliable techniques in pediatrics. Two-dimensional
Speckle tracking echocardiography (2DST) evaluation of LA strain has
recently been confirmed as a robust measure of diastolic function, in
different clinical scenarios. Objectives: to investigate LA
strain role in diastolic function assessment of children at different
stages of CKD, comparing it with standard echocardiographic parameters.
Methods: From February 2019 to July 2022, 55 consecutive
pediatric CKD patients without cardiovascular symptoms and 55 healthy
volunteers were evaluated by standard and 2DST echocardiograms. Clinical
data were collected from medical records by the attendant physician.
Results: patients and controls had similar age [9.78 (0.89 –
17.54) years vs. 10.72 (1.03 – 18,44) years; p = 0.41] and
gender (36M:19F vs. 34M:21F; p = 0.84). The median duration of
the disease was 8.1 (0.83 - 17.5) years. There were 7 (12.8%) CKD stage
I, 4 (7.3%) CKD stage II, 12 (21.8%) CKD stage III, 2 (3.6%) CKD
stage IV and 30 (54.5%) CKD stage V patients. Standard echo reveled
preserved (≥ 55%) LV EF in all of them. Although average E/e’ was
higher in CKD [6.99 (4.75 – 14.20) vs. 6.38 (3.88 – 11.11); p
= 0.009], it was above normal limits in only one individual. Comparing
CKD and controls, LA reservoir strain was lower (48.22 ± 10.62% vs.
58.52 ± 10.70%; p < 0.0001) and LA stiffness index was higher
[0.14 (0.08 – 0.48) % vs. 0.11 (0.06 – 0.23)
% ; p < 0.0001]. LV hypertrophy was
associated with lower LA reservoir strain (42.05 ± 8.74% vs. 52.99 ±
9.52%; p < 0.0001), higher LA stiffness index [0.23
(0.11 – 0.48) % vs. 0.13 (0.08 – 0.23) %
; p < 0.0001) and filling index
(2.39 ± 0.63 cm/s x % vs. 1.74 ± 0.47 cm/s x %
; p = 0.0001). Uncontrolled hypertension was
associated with lower LA reservoir strain (41.9 ± 10.6% vs. 50.6 ± 9.7;
p = 0.005). CKD stage showed negative correlation with LA
reservoir strain ( r = - 0.37; p = 0.006) and conduit
strain ( r = - 0.28; p = 0.0035), besides positive
correlation with LA stiffness index (r = 0.48; p = 0.0002). E/e’ showed
inferior accuracy in differentiating CKD patients from controls (AUC =
0.64), when compared with LA reservoir strain (AUC = 0.75) and LA
stiffness index (AUC = 0.73). LA reservoir strain showed the best
accuracy in differentiating dialysis form non dialysis patients (AUC =
0.77). Conclusions: LA strain parameters, especially reservoir
strain and stiffness index, showed better accuracy than conventional
E/e’ ratio concerning diastolic evaluation in pediatric CKD population.
Since diastolic dysfunction bears strong prognostic value in CKD,
incorporation of LA strain in routine echocardiographic evaluation of
this particular pediatric population seems to be an appropriate strategy