Kidney failure & dialysis
Volume, LV hypertrophy, pericardium, calcific valves, pulmonary pressure and the fistula — best studied at dry weight.
Echo approach, step by step
Cardiovascular disease is the leading cause of death in CKD. Echo in kidney failure assesses LV hypertrophy, systolic and diastolic dysfunction, volume status, pericardial disease, valve calcification and pulmonary hypertension [206]. Loading changes rapidly with dialysis, so the timing of the study must be recorded [206].
- TimingIdeally on a non-dialysis day, close to dry weight. Record weight and time since dialysis [206].
- LVMass, RWT, LVEF, GLS [1,23].
- DiastolicE/e′, LAVI, TR velocity [2].
- VolumeIVC, B-lines [3,202].
- PericardiumEffusion, tamponade [31].
- ValvesMAC, AS (progresses faster in dialysis), vegetations [5,136].
- RV and PASPPH (volume, fistula flow, left heart) [8].
- High outputLarge AV fistula → high CO, dilated chambers.
- Timing relative to dialysis
- LV mass and geometry
- LVEF, GLS
- Diastolic function
- IVC, B-lines
- Pericardium
- Valves and calcification
- PASP, RV
Causes & echo clues
| Problem | Echo clue | Action |
|---|---|---|
| Volume overload | Plethoric IVC, B-lines, high E/e′ | Adjust dry weight [206] |
| LVH / uraemic cardiomyopathy | Concentric LVH, reduced GLS | BP control, dialysis adequacy [206] |
| HFrEF | Low EF | GDMT as tolerated [12,206] |
| Pericarditis / effusion | Effusion | Intensify dialysis; drain if tamponade [31] |
| Calcific AS / MAC | Calcified valve and annulus | Valve pathway [5] |
| Endocarditis | Vegetation | Cultures, TOE [136] |
| Pulmonary hypertension | High TR velocity | Look for volume, fistula and left-heart causes [8] |
Clinical pathway to the diagnosis
- Symptoms and fluid statusInterdialytic weight gain, BP, oedema.
- Natriuretic peptides are raised in CKD. Use trends rather than single values [206].
- EchoAt baseline (transplant listing, dialysis start) and with symptoms [206].
- Coronary assessmentFor transplant candidates according to risk [139].
Clinical pearls & pitfalls
Practical tipRepeat the echo at dry weight before labelling HFpEF or PH in a dialysis patient. Volume alone can create both [206].
- MAC makes E/e′ unreliable and can cause functional MS [2].
- Large AV fistulas can cause high-output failure and PH [8].
Red flags
- Pericardial rub or effusion → uraemic or dialysis-related pericarditis [31]
- Fever in a haemodialysis patient → endocarditis (catheter-related S. aureus) [136]
- Hypotension during dialysis with a large effusion → tamponade [149]