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Aplicabilidade do strain auricular esquerdo como parâmetro de avaliação da função diastólica e o seu valor preditivo na doença renal crónica – revisão da literatura e meta-análise
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Abstract(s)
Introdução: Apesar das aplicações clínicas promissoras dos parâmetros de strain da aurícula esquerda (sAE), poucos estudos têm validado o seu papel na doença renal crónica (DRC). Com esta meta-análise pretendemos sintetizar a evidência científica disponível, relativa à relação entre os valores obtidos para o sAE e o estadio de DRC, analisando o seu impacto diagnóstico e preditivo, procurando simultaneamente responder à seguinte questão: Será que o sAE se correlaciona com o estadio da DRC?
Metodologia: Realizámos uma meta-análise de estudos realizados em doentes renais, com idade superior a 18 anos, que realizaram ecocardiograma transtorácico bidimensional, com avaliação de sAE por speckle tracking. A identificação de estudos foi realizada com recurso às bases de dados PubMed, Web of Science e Google Scholar, até 15 de agosto de 2024. A qualidade dos estudos foi avaliada pelas ferramentas da Escala Newcastle-Otawa e da National Institute of Health. A análise estatística foi realizada pelo software IBM SPSS Statistics versão 30. Os estadios de DRC foram agrupados da seguinte forma: 1 e 2 (grupo 1), 3a e 3b (grupo 2) e 4 e 5 (grupo 3). As diferenças médias entre casos e controlos foram expressas como effect size (ES) (diferenças médias não padronizadas - DMNP), com intervalos de confiança (ICF) de 95%. Tendo em conta a estratificação de estadios, foi realizada uma meta-análise por subgrupos. Adicionalmente, foi conduzida uma meta-regressão, de forma a investigar o impacto dos parâmetros avaliados nas diferenças observadas entre os estudos.
Resultados: Foram incluídos 14 estudos, com 4341 doentes renais. Os nossos resultados estatísticos demonstram, de forma consistente, que independentemente do estadio da DRC, os doentes renais apresentam valores reduzidos de sAE reservatório (sAEr) (ES: -12,139, ICF 95%: -14,494 a -9,785, p < 0,001), e de sAE conduto (sAEcd) (ES: -10,682, ICF 95%: -15,503 a -5,861, p < 0,001). A estratificação por subgrupos revelou que nos estadios 1 e 2 da DRC, os únicos parâmetros ecocardiográficos associados à DRC foram o sAEr, com valores significativamente menores nos doentes renais vs. controlos (ES: -7,972, IC 95%: - 13,412 a -2,533, p = 0,004), e a velocidade máxima da onda A do fluxo transmitral, com valores significativamente mais elevados nos doentes renais vs. controlos (ES: 61,169, IC 95%: 50,554 a -71,785, p < 0,001). Nos estadios 3a e 3b da DRC, todas as variáveis analisadas, à exceção da fração de ejeção (Fej.) do ventrículo esquerdo (VE), apresentaram diferenças estatisticamente significativas relativamente aos grupos de controlo. Nos estadios 4 e 5 da DRC, todas as variáveis analisadas, à exceção da velocidade máxima da onda E do fluxo transmitral, apresentaram diferenças estatisticamente significativas, relativamente aos grupos de controlo. A meta-regressão identificou fatores associados à variabilidade do sAEr entre estudos. A heterogeneidade residual demonstrou que as variáveis moderadoras selecionadas explicaram 77,4% da respetiva variabilidade entre os estudos.
Discussão: O sAEr foi a única variável ecocardiográfica, independente do ritmo cardíaco, alterada desde o estadio inicial da doença, emergindo como um potencial preditor de disfunção diastólica, de eventos adversos cardiovasculares major, mortalidade e de declínio da taxa de filtração glomerular. A sua integração em algoritmos de estratificação pode ser determinante no prognóstico de doentes renais. Doentes renais crónicos apresentam menores valores de sAEr e de sAEcd, quando comparados com os controlos. No entanto, não podemos deixar de referir que, apesar de aplicarmos estratégias analíticas para reduzir a heterogeneidade nos estudos, a mesma não foi totalmente eliminada. Também alguns estudos revelaram escassez de resultados estatísticos, essenciais para alguns modelos meta-analíticos, bem como tamanhos de amostras relativamente diferentes.
Background: Despite the promising clinical applications of left atrial strain (LAS) parameters, few studies have validated their role in chronic kidney disease (CKD). This meta-analysis aims to synthesize the available scientific evidence regarding the relationship between LAS values and CKD stage, assessing their diagnostic and predictive impact. Additionally, we seek to answer the following question: Does LAS correlate with CKD stage? Methods: We conducted a meta-analysis of studies involving adult kidney disease patients (>18 years old) who underwent two-dimensional transthoracic echocardiography with LAS assessment via speckle tracking. Study identification was performed using the PubMed, Web of Science, and Google Scholar databases until August 15, 2024. Study quality was assessed using the Newcastle-Ottawa Scale and the National Institute of Health tools. Statistical analysis was performed using IBM SPSS Statistics version 30. CKD stages were grouped as follows: stages 1 and 2 (group 1), stages 3a and 3b (group 2), and stages 4 and 5 (group 3). Mean differences between cases and controls were expressed as effect size (ES) -unstandardized mean differences - with 95% confidence intervals (CI). A subgroup meta-analysis was conducted based on CKD stratification. Additionally, meta-regression was performed to investigate the impact of evaluated parameters on the differences observed between studies. Results: Fourteen studies were included, comprising 4,341 renal patients. Our statistical results consistently demonstrate that, regardless of CKD stage, renal patients exhibit reduced reservoir LAS (LASr) (ES: -12.139, 95% CI: -14.494 to -9.785, p < 0.001) and conduit LAS (LAScd) (ES: -10.682, 95% CI: -15.503 to -5.861, p < 0.001). Subgroup stratification revealed that in CKD stages 1 and 2, the only echocardiographic parameters associated with CKD were LASr, which was significantly lower in renal patients compared to controls (ES: -7.972, 95% CI: -13.412 to -2.533, p = 0.004), and the peak velocity of the mitral inflow A wave, which was significantly higher in renal patients compared to controls (ES: 61.169, 95% CI: 50.554 to 71.785, p < 0.001). In CKD stages 3a and 3b, all analyzed variables, except for left ventricular ejection fraction (LVEF), showed statistically significant differences compared to control groups. In CKD stages 4 and 5, all analyzed variables, except for the peak velocity of the mitral inflow E wave, exhibited statistically significant differences compared to control groups. Meta-regression identified factors associated with LASr variability across studies. Residual heterogeneity analysis demonstrated that the selected moderator variables explained 77.4% of the variability between studies. Conclusion: LASr was the only echocardiographic variable altered from the early stage of the disease, regardless of heart rhythm, emerging as a potential predictor of diastolic dysfunction, major adverse cardiovascular events, mortality, and glomerular filtration rate decline. Its integration into stratification algorithms may be crucial for the prognosis of renal patients. CKD patients exhibit lower LASr and LAScd values compared to controls. However, despite applying analytical strategies to reduce study heterogeneity, it was not completely eliminated. Additionally, some studies lacked essential statistical results for certain meta-analytical models and had relatively different sample sizes.
Background: Despite the promising clinical applications of left atrial strain (LAS) parameters, few studies have validated their role in chronic kidney disease (CKD). This meta-analysis aims to synthesize the available scientific evidence regarding the relationship between LAS values and CKD stage, assessing their diagnostic and predictive impact. Additionally, we seek to answer the following question: Does LAS correlate with CKD stage? Methods: We conducted a meta-analysis of studies involving adult kidney disease patients (>18 years old) who underwent two-dimensional transthoracic echocardiography with LAS assessment via speckle tracking. Study identification was performed using the PubMed, Web of Science, and Google Scholar databases until August 15, 2024. Study quality was assessed using the Newcastle-Ottawa Scale and the National Institute of Health tools. Statistical analysis was performed using IBM SPSS Statistics version 30. CKD stages were grouped as follows: stages 1 and 2 (group 1), stages 3a and 3b (group 2), and stages 4 and 5 (group 3). Mean differences between cases and controls were expressed as effect size (ES) -unstandardized mean differences - with 95% confidence intervals (CI). A subgroup meta-analysis was conducted based on CKD stratification. Additionally, meta-regression was performed to investigate the impact of evaluated parameters on the differences observed between studies. Results: Fourteen studies were included, comprising 4,341 renal patients. Our statistical results consistently demonstrate that, regardless of CKD stage, renal patients exhibit reduced reservoir LAS (LASr) (ES: -12.139, 95% CI: -14.494 to -9.785, p < 0.001) and conduit LAS (LAScd) (ES: -10.682, 95% CI: -15.503 to -5.861, p < 0.001). Subgroup stratification revealed that in CKD stages 1 and 2, the only echocardiographic parameters associated with CKD were LASr, which was significantly lower in renal patients compared to controls (ES: -7.972, 95% CI: -13.412 to -2.533, p = 0.004), and the peak velocity of the mitral inflow A wave, which was significantly higher in renal patients compared to controls (ES: 61.169, 95% CI: 50.554 to 71.785, p < 0.001). In CKD stages 3a and 3b, all analyzed variables, except for left ventricular ejection fraction (LVEF), showed statistically significant differences compared to control groups. In CKD stages 4 and 5, all analyzed variables, except for the peak velocity of the mitral inflow E wave, exhibited statistically significant differences compared to control groups. Meta-regression identified factors associated with LASr variability across studies. Residual heterogeneity analysis demonstrated that the selected moderator variables explained 77.4% of the variability between studies. Conclusion: LASr was the only echocardiographic variable altered from the early stage of the disease, regardless of heart rhythm, emerging as a potential predictor of diastolic dysfunction, major adverse cardiovascular events, mortality, and glomerular filtration rate decline. Its integration into stratification algorithms may be crucial for the prognosis of renal patients. CKD patients exhibit lower LASr and LAScd values compared to controls. However, despite applying analytical strategies to reduce study heterogeneity, it was not completely eliminated. Additionally, some studies lacked essential statistical results for certain meta-analytical models and had relatively different sample sizes.
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Keywords
Strain da auricula esquerda Doença renal crónica Disfunção diastólica Declínio da função renal Left atrial strain Chronic kidney disease Diastolic dysfunction Renal function decline Meta-analysis