The SA Journal Diabetes & Vascular Disease Vol 13 No 2 (December 2016)

SA JOURNAL OF DIABETES & VASCULAR DISEASE

RESEARCH ARTICLE

VOLUME 13 NUMBER 2 • DECEMBER 2016

Alteration in kidney function predominated in patients with a

longer duration of diabetes, enhancing the effect of both chronic

hyperglycaemia and the ageing process.

3,24

The latter is associated

with changes in vascular structure and function due to clustering of

multiple risk factors, including insulin resistance/hyperinsulinaemia,

oxidative stress and inflammation.

Arterial stiffness, an independent

predictor of morbidity and mortality, has been reported to increase

with age and is associated with high systolic and pulse pressure.

3,24,26

Moreover, the decrease in the number of nephrons, which occurs

with ageing, may result in hyperfiltration, hypertrophy and elevation

in glomerular capillary pressure.

The high prevalence of LVH in CKD patients found in our study

agrees with that of other studies.

28-31

LVH in CKD is thought to

result partly from uraemia-associated risk factors such as anaemia,

calcium-phosphate products and hyperhomocysteinaemia.

Moreover, renal dysfunction activates the renin–angiotensin–

aldosterone system, with subsequent formation of angiotensin

II, known to be essential for the development and progression

of LVH.

The risk of CVD and death increases with the decline

in glomerular filtration rate (GFR) and the major increase in risk

occurs at a GFR < 60 ml/min per 1.73 m

LVH has been reported to predispose to ischaemic heart

disease, arrhythmias and congestive heart failure.

Our results

indicate that patients with severe CKD had higher proportions of

abnormal LV geometry, with concentric remodelling and concentric

hypertrophy as the most frequent pattern. Both eccentric and

concentric hypertrophy may occur in individuals with CKD.4

Eccentric hypertrophy is thought to result from volume overload,

leading to cardiomyocyte drop out. Concentric hypertrophy

is typically the result of hypertension and increased afterload

and is exacerbated by anaemia, hyperparathyroidism and high

angiotensin II concentrations. Eccentric and concentric hypertrophy

have different impacts on the prognosis.

Concentric hypertrophy

confers the worst prognosis, followed by eccentric hypertrophy and

concentric remodelling.

Moderate CKD and a high proportion of hypertension could

explain the pre-eminence of concentric hypertrophy observed

in the present study. In Nigerian hypertensive patients, Aje

et al

reported greater systolic, diastolic, pulse and mean blood pressure

among patients with concentric hypertrophy in comparison with

those with normal geometric patterns.

In our study, hyperuricaemia emerged as the only predictor

of LVH in CKD patients. The mechanisms that could account

for increased uric acid levels in CKD include overproduction to

counteract oxidative stress and endothelial dysfunction, the severity

of diabetes and/or hypertension, impaired renal uric acid clearance,

and insulin resistance/hyperinsulinaemia-induced proximal renal

tubular reabsorption of sodium and urate.

35,36

The association

between hyperuricaemia and LVH could rely upon an association of

uric acid with other risk factors, either isolated or combined in the

metabolic syndrome.

The coexistence of hyperuricaemia and LVH

has been recognised as an independent and powerful predictor of

CVD.

36-38

The interpretation of the results of our study is confounded by

some limitations. The cross-sectional design of the work precludes

any causal relationship between CKD and associated risk factors.

Moreover, the sample size did not allow sufficient power to

detect additional associations. One wonders to what extent the

conclusions of this clinic-based study could be extrapolated to the

general population, given the bias in the referral of patients. The

findings of our study bear, however, some clinical implications for

CKD identification, treatment protocol and estimated prognosis in

hypertensive patients.

Conclusion

This study has shown that LVH is common among type 2 diabetes

patients with CKD. Concentric LVH was the geometric LV pattern

most frequently encountered and its frequency increased with the

decline in renal function. Hyperuricaemia emerged as the unique

independent predictor of the risk of LVH.

Acknowledgements

The authors thank Prof JJ Muyembe, head of the National Institute

of Biomedical Research/Ministry of Health, for the facilities

obtained for the measurements of cholesterol and its sub-fractions.

Particular thanks go to Prof E Kintoki, Division of Cardiology and Dr

M Lelo, Division of Radiology and Imaging, Department of Internal

Medicine, University of Kinshasa Hospital for their contribution to

the evaluation of left ventricular mass and geometry.

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