Hemodialysis versus Renal Transplantation: A Comparative Analysis of Cardiovascular Outcomes among End-Stage Renal Disease Patients unveiling the Safer Pathway

Hemodialysis versus Renal Transplantation: A Comparative Analysis of Cardiovascular Outcomes among End-Stage Renal Disease Patients unveiling the Safer Pathway | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Hemodialysis versus Renal Transplantation: A Comparative Analysis of Cardiovascular Outcomes among End-Stage Renal Disease Patients unveiling the Safer Pathway Tooba Noor, Muhammad Tassaduq Khan, Omer Farooq Shaikh, Tahoor Tahir, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9024768/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective Individuals with End-Stage Renal Disease (ESRD) experience a heightened risk of cardiovascular morbidity and mortality, often linked to the hemodynamic instability and chronic physiological stressors inherent due to renal replacement therapies (RRT). The objective of this study was to evaluate the impact of hemodialysis (HD) and renal transplantation (RT) on cardiac health by comparing their transthoracic echocardiographic (TTE) parameters to those of a control group. Methodology The study analyzed records from the Renal Transplant and Dialysis unit of Nephrology department of Dow University Hospital (DUH). The cohort consisted of 104 subjects: 37.5% (n = 39) were HD, 38.5% (n = 40) had received RT and 24% (n = 25) were controls. TTE data were recruited for each participant and statistically analyzed using R Studio. Results The mean age of the study population was 38 ± 13 years, with a male predominance (79.86%). The mean ejection fraction (EF) for HD subjects (55.64 ± 13%) was found to be notably lower than in RT (61.25 ± 7%) and controls (64.4 ± 2%). Both systolic (32.2 mm) and diastolic (46.4 mm) left ventricular diameters were enlarged among HD subjects in comparison to controls (29.8 mm and 43.9 mm, respectively), while the right ventricular diameter was diminished. Furthermore, 62.02% (n = 49) of the entire subjects showed both tricuspid and mitral regurgitation, with HD subjects accounting for 63.26% (n = 31) of these cases. Conclusion The data demonstrates a higher incidence of cardiac abnormalities including reduced EF and adverse ventricular and valvular changes among HD subjects. These findings underscore the importance of exploring long-term renal replacement strategies that mitigate cardiovascular risk, suggesting that RT could be a more favorable option to improve both cardiac and renal outcomes among subjects with ESRD. Health sciences/Cardiology Health sciences/Diseases Health sciences/Medical research Health sciences/Nephrology End Stage Renal Disease Hemodialysis Renal Transplant Transthoracic Echocardiography Ejection Fraction Figures Figure 1 Figure 2 1. Introduction End-Stage Renal Disease (ESRD) is characterized by severe irreversible kidney damage and the reduction in Glomerular Filtration Rate to less than 15 mL/min/1.73 m 2 1 . ESRD is a consequence of chronic kidney disease (CKD) progression or acute kidney injury causing rapid deterioration of kidney function thus necessitating for Renal Replacement Therapy (RRT) 2 , 3 . RRT is the treatment of choice for ESRD patients either in the form of Hemodialysis (HD) or Renal Transplant (RT) depending on patients’ health, comorbidities and cost effectiveness 4 . High costs and limited non-profit RRT centers discourage patients from seeking RRT resulting in early mortality and higher disability adjusted life years, particularly among rural populations, with less than 10% of patients receiving proper care 5 , 6 . Both RRT modalities either HD or RT are associated with their respective complications. Hemodynamic instability, vascular access complications, infections, amyloidosis are some of the problems that arise with patients on HD 7, 8 , while RT recipients face post-transplant Diabetes Mellitus (PTDM), adverse drug effects, persistent immunocompromised state leading to frequent infections and graft rejection. 6, 9 and 10 . Unfortunately, both of the RRT modalities are associated with higher risks of cardiovascular diseases (CVD) in patients with long-term RRT and accounts for about 50% of deaths in those patients 9 . HD clears toxins from the blood, can cause sudden fluid shifts and strain on the heart, often leading to left ventricular enlargement causing arrhythmias and reduced pumping ability resulting end-organ damage and chronic heart failure over the time 10 , 11 . Transplantation typically improves heart health but comes with risks like higher blood pressure and hyperlipidemia that leads atherosclerosis, transient ischemic attacks and thromboembolic events secondarily to required medications 12 , 13 . While ESRD presents a significant public health challenge, its associated cardiovascular complications often remain under‑evaluated, especially in low resource settings 14 , 15 . In South Asian countries, clinical attention has been primarily directed towards initiating and maintaining RRT, with less emphasis placed on managing post RRT associated cardiovascular complications 16 . This highlights the importance of frequent monitoring of cardiac functions at regular intervals. The high cost and complexity of advanced cardiac assessments such as CT angiogram, combined with limited access to diagnostic facilities and trained personnel, further impede early detection of valvular disease, cardiac strain, and other cardiovascular findings 17 , 18 . Moreover, sparse data on long term cardiac outcomes and the competing priorities of managing ESRD itself have contributed to these complications being overlooked in clinical practice and research. Non-invasive monitoring systems can be help in understanding how different treatments affect circulation. Transthoracic echocardiography (TTE), which is the gold-standard investigation to assess cardiac functions, if done regularly among such patients, may be helpful in timely diagnosing the increased cardiovascular morbidity and mortality and suggest a better RRT option with minimum cardiovascular associated challenges 5 , 19 , 20 . This study aims to fill the gap by analyzing heart imaging via TTE among patients undergoing varying RRTs that include HD and RT in relation to healthy controls, considering factors like age, gender, treatment duration, and other health conditions. 2. Materials and Methods 2.1. Study design, duration and sample size: It is a retrospective cohort study conducted at the Department of Nephrology, Dow University of Health Sciences during November, 2024 to May 2025. The sample size was calculated as 30 for each group by using PASS version 24 (NCSS, Kaysville, Utah, USA) software, The calculation was based on a test for two independent means (comparing HD subjects vs. controls) with a 95% confidence interval, 80% power of test, and a 5% margin of error. This approach accounted for the reported 9.4% prevalence of cardiovascular complications in patients receiving RRT 2 . Consequently, the minimum total sample size required was 90 participants (30 per group). Our study exceeded this requirement with a total of 104 subjects: 39 in the hemodialysis (HD), 40 in the renal transplant (RT) while 25 were controls. 2.2. Sample description, Inclusion and Exclusion criteria: Sample data was retrieved via medical record numbers (M.R. #) of selected study groups i.e. HD and RT subjects from data base office of the Department of Nephrology, Dialysis and Renal Transplant Unit, Dow University Hospital (DUH), Dow University of Health Sciences. TTE reports from ESRD participants receiving RRT either in the form of hemodialysis (HD) or renal transplant (RT) for more than six months were included in the study. Whereas, the controls were age and gender matched healthy adults with preserved renal functions diagnosed on the basis of serum creatinine levels ≤ 0.9 mg/dl and GFR more than 70ml/min/1.73m 2 with no history of cardiovascular comorbidities. While, subjects who had ESRD but not receiving any of RRTs, subjects on RRT with pre-existing CVD (like myocardial ischemia, atherosclerotic events, and peripheral vascular disease), subjects admitted in hospital due to severe infections, sepsis, multi-organ failure, cerebrovascular events or any surgical procedure within last six months were thoroughly recruited via medical records and excluded from the study. Age and gender matched healthy controls with history of renal or cardiovascular diseases were also excluded from the study. 2.3. Data collection: Subjects of specific study groups were traced via medical record number (M.R. #) from the Department of Nephrology, Dialysis and Renal Transplant Unit, Dow University Hospital, Dow University of Health Sciences. Relevant data was retrieved from records and used solely for research purpose only. The controls were manually approached after informed consent who visited nephrology or urology outpatient clinics for routine check-ups, renal stone surgeries or infections with normal renal functions (i.e. GFR ≥ 70ml/min/1.73m 2 ). It was made sure that TTE reports were not more than six months old. The data included was their age, gender, cause of ESRD, followed by TTE findings which was done from the associated radiology/ cardiology department of the affiliated institute. 2.4. Transthoracic Echocardiographic Evaluation Protocol: Transthoracic echocardiography (TTE) data of HD and RT subjects was retrieved from the system using their M.R. # while the procedure was performed on all controls at Dow University Hospital. Both HD and RT subjects along with controls follow the same TTE protocol. Scans on controls were performed by a trained echocardiography technician utilizing a standard two-dimensional (2D) and M-mode echocardiography system. Patients underwent examination in a fasting state, positioned in the left lateral decubitus position, using a 3.5 MHz phased-array transducer. The echocardiographic evaluation encompassed structural abnormalities, systolic and diastolic functions, pericardial effusions and valvular abnormalities. Ejection fraction (EF) was estimated using the biplane Simpson's method. The study followed the American Society of Echocardiography (ASE) guidelines but made practical adjustments for the clinical setting. Because advanced strain imaging software was unavailable, we relied on standard 2D and M-mode techniques for all measurements. To avoid the misleading effects of sudden fluid changes, hemodialysis patients were scanned on their off-days when their volume status was most stable. Finally, all heart chamber measurements were indexed to Body Surface Area (BSA) to ensure they were accurate for the specific body types of South Asian population. 2.5. Ethical Approval: The study followed the Helsinki’s principle and ethical approval was sought from the Institutional Review Board (IRB) of Dow University of Health Sciences (DUHS), and Ref. no.: IRB-3012/DUHS/Approval/2023/353. 2.6. Statistical Analysis: Statistical analysis was carried out using R Studio (Posit IDE) version 2025.05.1 (Build 513) [3]. The quantitative data was presented in the form of mean with standard deviation or median with range while the qualitative data in the form of frequency (n) with percentages (%). Normality of continuous variables was tested using the Shapiro-Wilk test. For comparisons between two groups, the independent samples t-test was used. For more than two groups, one-way ANOVA was applied, with Tukey’s HSD for post-hoc analysis. TTE based categorical findings between HD and RT subjects were compared using chi-square test. All statistical tests were carried out keeping the level of significance 5% ( p ≤ 0.05) at 95% confidence interval. 3. Results 3.1. Demographic Characteristics of the study population In total, 104 subjects were recruited for this study that were comprised of three groups, i.e. subjects on HD, subjects received RT and controls that were 37.5% (n = 39), 38.5% (n = 40) and 24% (n = 25), respectively. The mean age of the study population was 37±13 years while 79.8% (n = 83) of them were male. Out of 75.2% (n = 79) ESRD subjects who were either on RT or HD the most common cause of ESRD was hypertensive nephropathy (46.8%, n = 37) followed by diabetic nephropathy (32.9%, n = 26). Remaining ESRD causes (20.3%, n = 11) were secondarily to obstetric complications, systemic lupus erythematous and congenital renal problems while, 6.3% (n = 5) of them were unknown causes. The details of the demographic parameters of the study population are mentioned in table 1. 3.2. Echocardiographic parameters and their comparison 3.2.1. Ejection Fraction TTE revealed notable decline in left ventricular ejection fraction (EF) among patients undergoing Renal Replacement Therapy. ANOVA analysis yields significant differences across the groups (F = 7.9, p < 0.001) as seen in Table 1. Controls showed an overall higher median EF percentages compared to both HD and RT subjects, with HD having more outliers as compared to RT subjects, as seen in Figure 1. This finding emphasizes the long-term impact of HD and its relevant consequences on systolic function. 3.2.2. Ventricular and Atrial Dimensions TTE findings of atrial and ventricular dimensions among different study groups are detailed in table 1. However, the study showed significant alteration in left ventricular diastolic diameter particularly by ANOVA testing (F = 10.7, p < 0.001) which was later confirmed by post-hoc analysis. Statistically significant increases in diastolic diameter were found in both the HD (p < 0.001) as well as RT group (p < 0.01) compared to the control group. 3.2.3. Structural Cardiac Changes Left Ventricular (LV) dilatation and hypertrophy were reported in 43.0% of all patients. Although insignificant (p = 0.14), but notable increased rate of dilated LV was reported among HD group as compared to RT subjects whereas hypertrophic LV was more prevalent among the contrary study group. The details of LV chamber findings among both HD and RT study groups are mentioned in table 2. 3.2.4. Valvular Abnormalities Tricuspid regurgitation was found to be the most common valvular defect 82.3% (n = 65) followed by mitral regurgitation which i.e., 68.3% (n = 54) among the study participants who were on RRT. While 62.0% (n = 49) had both tricuspids along with mitral regurgitation out of them, 63.2% (n = 31) were hemodialysis subjects. Only 13.9% (n = 11) of RRT subjects did not have any type of valvular abnormalities. Our study did not find any type of stenosis or semilunar valves abnormalities. The details of severity of tricuspid and mitral regurgitation among study participants are mentioned in figure 2a and 2b, respectively. Pericardial effusion was reported among 18.4% (n = 14) of study subjects. Discussion This study aimed to evaluate and compare echocardiographic outcomes among subjects receiving maintenance HD, renal allograft with age and gender controls. We observed that subjects on maintenance HD had significantly lower ejection fractions, greater atrial and ventricular enlargement, and markedly higher rates of mitral and tricuspid regurgitation compared to both transplant and control groups. Our finding of reduced ejection fraction observed in the HD group is consistent with the findings of Wang et al. 21 , where echocardiographic data from ESRD patients confirmed that systolic dysfunction is more pronounced among those undergoing dialysis compared to post-renal transplant patients. Similar findings have been reported by Pickup et al. 22 , who demonstrated that RT is associated with reverse remodeling of heart with improved left ventricular function compared to patients remaining on dialysis. However, other studies have highlighted that heart failure with preserved ejection fraction predominates among HD population, and that ejection fraction may not always appear significantly reduced, with strain imaging revealing subclinical systolic dysfunction 23, 24 . Furthermore, some reports suggest that kidney transplantation also does not uniformly normalize systolic function, with persistent abnormalities among subset of recipients 25 . Our observation of increased ventricular and atrial dimensions, along with evidence of left ventricular hypertrophy in both study groups receiving RRT, particularly, LV findings among HD subjects is in line with the local literature 26 , which documented cardiac structural abnormalities and chamber dilatation in Pakistani HD patients. These findings are further supported by Obremska et al. 27 , who reported comparatively larger left atrial and ventricular chamber volumes in dialysis patients compared to transplant recipients, with significant post-transplant regression. Moreover, some existing analysis 28 observed that left atrial function and strain were significantly better in transplant patients compared to those on hemodialysis. The observed disparities in cardiac remodeling between hemodialysis (HD) and renal transplant (RT) stem from the distinct hemodynamic profiles of each therapy. In HD, the heart is subjected to rapid volume expansion between sessions followed by aggressive ultrafiltration, which triggers repetitive "myocardial stunning" and progressive fibrosis 29 . This chronic stress manifests as the significantly higher rates of left ventricular dilatation and lower ejection fractions as seen in our HD cohort. In contrast, transplantation restores continuous renal function, allowing for "reverse remodeling" where the cardiac architecture begins to mirror that of healthy controls 22, 30 and 31 . This transition from a state of constant physiological strain to stability explains why RT subjects in our study demonstrated cardiac parameters closer to the healthy baseline than their HD counterparts. Finally, our finding of significantly more prevalent mitral and tricuspid regurgitation in the hemodialysis group aligns with a Pakistani study by Awan et al. 32 , which emphasized a high burden of valvular heart disease among ESRD patients on HD from Pakistani population. This is also consistent with data by Wang et al. 21 , who similarly reported increased rates of valvular insufficiency in the hemodialysis population. De la Espriellaf et al. 33 also noted that mitral regurgitation was the most frequent valvular lesion in HD patients, while another study 34 identified functional tricuspid regurgitation as a frequent and predictive valvular lesion applicable to cardiovascular morbidity maintenance HD cohorts. Importantly, Kim et al. 13 demonstrated that mitral and aortic regurgitation can be improved following kidney transplantation. However, other analyses indicate that valvular calcification and regurgitation often persist despite transplantation, reflecting long-term structural damage 12 . Long term cohorts in subjects with pre and post -transplant comparisons would yield true picture of cardiac changes. Furthermore, the high prevalence of valvular regurgitation in the HD group highlights a critical but often overlooked complication of South Asian ESRD population 30 . These are actually functional lesions driven by chronic volume overload and increased pulmonary pressures 34 . In a low-resource setting like Pakistan, where access to advanced interventions like valvular repair or CT angiograms is limited, these results advocate for the use of RT as not just a renal therapy, but a primary cardiovascular intervention 30, 35 . By documenting these changes alongside healthy controls, this study provides a regional benchmark that underscores the necessity of proactive, non-invasive echocardiographic monitoring to bridge the diagnostic gap in populations where cardiovascular mortality remains the leading cause of death post-ESRD 35 . One of the key limitations of our study is limited sample size, which may limit statistical power. Additionally, a longitudinal cohort design would have provided better insight into cardiac alternative progression over time. The absence of supporting investigations such as electrocardiograms (ECGs), Holter and stress echocardiography limited our ability to assess conduction abnormalities and left ventricular strain, which could have provided deeper insight into the clinical impact of the structural and functional changes observed. Prospective studies with long term follow-up could provide an insight and would be helpful in developing long term strategies and guidelines to manage the renal replacement therapy associated dilemma. This study reveals a definitive cardiovascular advantage for RT over maintenance HD. A primary distinction of our work is the three-group comparative model i.e. by evaluating both treatment modalities alongside healthy controls, the study established a benchmark for cardiovascular recovery that few regional studies have documented. Given that Pakistan is a global epicenter for ESRD, the findings address critical diagnostic gap in South Asian populations where clinical outcomes often diverge from Western trends. Ultimately, these results advocate for a paradigm shift toward proactive cardiac monitoring. Conclusion Our findings demonstrate that while HD is associated with progressive structural decline characterized by diminished EF, adverse ventricular remodeling, and a higher prevalence of valvular regurgitation RT maintain a cardiac profile that closely mirrors healthy individuals, making it a better choice of RRT for ESRD among the susceptible population. The routine integration of echocardiographic screening and cardiac biomarkers is essential for early diagnosis, offering a vital strategy to mitigate cardiovascular morbidity among the vulnerable population will be step forward towards personalized medicine at a low-resource healthcare setting. Declarations Ethics approval: Ethical approval was obtained from the Institutional Review Board (IRB) of Dow University of Health Sciences (DUHS), Ref.no. IRB-3012/DUHS/Approval/2023/353 and Helsinki’s principle was followed throughout the course of study. Availability of data and materials: Data is presented in manuscript. Raw data will be provided on formal request. Competing interests: There is no conflict of interest by any author in any part of the manuscript. Declaration of Generative AI in Scientific Writing: During the preparation of this manuscript, authors used only Google Gemini to improve the language and readability. After using this tool, the authors reviewed and edited the manuscript where needed and take full responsibility for the content of the publication. Funding: This is a self-funded project, authors did not receive any specific grant from funding agencies in public, commercial, or not-for-profit sectors. Authors' contributions: TN develop the hypothesis of study, developed the initial study design, supervised the project, reviewed and edited the manuscript. MTK helped in data acquisition, clinical guidelines and review of article. OFS and SMRHZ did the data acquisition, arranged the results and wrote discussion TT and SF prepared the first draft of manuscript. All authors have read and approved the final version of this article. Acknowledgements: We are thankful to our supporting staff for co-operating us diligently and our valuable controls for their time and co-operation. References National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(2 Suppl 1): S1-266. Available from: https://www.kidney.org/professionals/kdoqi/guidelines Sarfraz A, Moon F, Wahid A, Tofique M. Echocardiography findings in hemodialysis patients. Pak Heart J. 2022;55(4):331-5. doi:10.47144/phj.v55i4.2333 Zhao Y. Comparison of the effect of hemodialysis and peritoneal dialysis in the treatment of end-stage renal disease. Pak J Med Sci. 2023;39(6):1562-7. doi:10.12669/pjms.39.6.8056 Gupta R, Woo K, Yi JA. Epidemiology of end-stage kidney disease. Semin Vasc Surg. 2021;34(1):71-8. doi: 10.1053/j.semvascsurg.2021.02.008 Khan FA, Fatima SS, Khan GM, Shahid S. Evaluation of kidney injury molecule-1 as a disease progression biomarker in diabetic nephropathy. Pak J Med Sci. 2019;35(4):992-6. doi:10.12669/pjms.35.4.1546 Casagrande V, Federici M, Menghini R. TIMP3 involvement and potentiality in the diagnosis, prognosis and treatment of diabetic nephropathy. Acta Diabetol. 2021;58(12):1587-94. doi:10.1007/s00592-021-01766-y Habas E, Rayani A, Alkanonie W, Habas A, Alzoukie E, Razeik S, et al. Common complications during hemodialysis session: a single-center experience. Austin J Nephrol Hypertens. 2019;6(1):1078. Habas EM, Habas A, Elgamal ME, Shraim BA, Moursi MO, Ibrahim AR, et al. Common complications of hemodialysis: a clinical review. Ibnosina J Med Biomed Sci. 2021;13(4):161-72. Muntner P, Judd SE, Gao L, et al. Cardiovascular risk factors in CKD associate with both ESRD and mortality. J Am Soc Nephrol. 2013;24(7):1159-65. doi:10.1681/ASN.2012070642 El Arbagy AR, Koura MA, El Barbary HS, Abou El Nasr AE. Comparative study of the effect of high-flux versus low-flux dialysis membranes on metabolic abnormalities in chronic hemodialysis patients. Menoufia Med J. 2014;27(3):677-82. Matsuo H, Dohi K, Machida H, Takeuchi H, Aoki T, Nishimura H, et al. Echocardiographic assessment of cardiac structural and functional abnormalities in patients with end-stage renal disease receiving chronic hemodialysis. Circ J. 2018;82(2):586-95. doi:10.1253/circj.CJ-17-0480 Aoki J, Ikari Y, Nakajima H, Morino Y, Shirai S, Hara K. Persistence of valvular calcification after kidney transplantation. Am J Cardiol. 2018;121(4):564-70. doi:10.1016/j.amjcard.2017.11.026 Kim M, Park J, Lee JH, Jeon HJ, Yang J. Changes in valvular regurgitation after kidney transplantation. Front Cardiovasc Med. 2022;9:1035063. doi:10.3389/fcvm.2022.1035063 Manjunath G, Tighiouart H, Ibrahim H, MacLeod B, Salem DN, Griffith JL, et al. Level of kidney function as a risk factor for atherosclerotic cardiovascular outcomes in the community. J Am Coll Cardiol. 2003;41(1):47-55. doi:10.1016/S0735-1097(02)02663-3 Warrens H, Banerjee D, Herzog CA. Cardiovascular complications of chronic kidney disease: an introduction. Eur Cardiol. 2022;17(13). doi:10.15420/ecr.2021.54 Charytan DM, Foley R, McCullough PA, Rogers JD, Zimetbaum P, Herzog CA, et al. Arrhythmia and sudden death in hemodialysis patients: protocol and baseline characteristics of the Monitoring in Dialysis study. Clin J Am Soc Nephrol. 2016;11(4):721-34. doi:10.2215/CJN.08280815 Gori M, Senni M, Gupta DK, et al. Association between renal function and cardiovascular structure and function in heart failure with preserved ejection fraction. Eur Heart J. 2014;35(48):3442-51. doi:10.1093/eurheartj/ehu254 Shivendra S, Doley PK, Pragya P, Sivasankar M, Singh VP, Neelam S. Echocardiographic changes in patients with ESRD on maintenance hemodialysis—a single-center study. J Cardiovasc Dis Diagn. 2014;2(4). Chuasuwan A, Pooripussarakul S, Thakkinstian A, Ingsathit A, Pattanaprateep O. Comparisons of quality of life between patients undergoing peritoneal dialysis and hemodialysis: a systematic review and meta-analysis. Health Qual Life Outcomes. 2020;18(1):191. doi:10.1186/s12955-020-01449-2 Tsilonis K, Sarafidis PA, Kamperidis V, et al. Echocardiographic parameters during long and short interdialytic intervals in hemodialysis patients. Am J Kidney Dis. 2016;68(5):772-81. doi:10.1053/j.ajkd.2016.06.017 Wang Z, Wang Y, Liu J, Hu S, Wang X. Valvular heart disease in dialysis patients: prevalence and outcomes. Clin Kidney J. 2023;16(5):835-44. doi:10.1093/ckj/sfad034 Pickup LC, Bedford M, Dring A. Effects of kidney transplantation on cardiac structure and function: a systematic review and meta-analysis. ESC Heart Fail. 2021;8(1):276-89. doi:10.1002/ehf2.13036 Malik J, Tuka V, Melenovský V. Heart failure with preserved ejection fraction dominates in hemodialysis: pathophysiology and management. Front Cardiovasc Med. 2023; 10: 1130618. doi:10.3389/fcvm.2023.1130618 Zoccali C, Torino C, Tripepi R, Tripepi G, D’Arrigo G, Postorino M, et al. Subclinical systolic dysfunction by strain imaging in dialysis patients: the importance of heart-artery interaction. Nephrol Dial Transplant. 2016;31(6):978-85. doi:10.1093/ndt/gfv382 Lentine KL, Costa SP, Weir MR, Robb JF, Fleisher LA, Kasiske BL, et al. Persistent systolic dysfunction after kidney transplantation. Am J Transplant. 2012;12(8):2184-91. doi:10.1111/j.1600-6143.2012.04076.x Haider A, Ahmed A, Aziz S, Khan M. Echocardiographic assessment of left ventricular hypertrophy in patients on hemodialysis. Pak Armed Forces Med J. 2012;62(3):369-73. Obremska M, Nowak J, Pączek L, Małyszko J. Pre-emptive kidney transplantation and cardiac remodeling. J Clin Med. 2021;10(12):2602. doi:10.3390/jcm10122602 Yildirim U, Celik A, Ozturk D. Assessment of left atrial strain in kidney transplant recipients and patients on dialysis. Cardiol J. 2022;29(1):81-89. doi:10.5603/CJ.a2020.0117 Bhatti NK, Karimi Galougahi K, Paz Y, Nazif T, Moses JW, Leon MB, et al. Diagnosis and management of cardiovascular disease in advanced and end-stage renal disease. J Am Heart Assoc. 2016;5(8): e003648. Prasad GV, Bhamidi V. Managing cardiovascular disease risk in South Asian kidney transplant recipients. World J Transplant. 2021;11(6):147-60. Yoo KD, Kim CT, Kim MH, Noh J, Kim G, Kim H, et al. Superior outcomes of kidney transplantation compared with dialysis: An optimal matched analysis of a national population-based cohort study between 2005 and 2008 in Korea. Medicine (Baltimore). 2016;95(33): e4352 Awan S, Imtiaz S, Shahzad H. Valvular heart disease in end-stage renal disease patients on maintenance hemodialysis: a cross-sectional study from Pakistan. Med Sci Rev. 2023;9(1):43-49. De la Espriella R, Maicas C, Rueda J, Roldán C, Martínez A, García M, et al. Significant left-sided valvular disease in dialysis patients. Clin Kidney J. 2023;16(9):1630-39. doi:10.1093/ckj/sfad210 Zhang Y, Zhang H, Ma X. Predictors of tricuspid regurgitation in maintenance hemodialysis patients. Front Cardiovasc Med. 2020; 7:43. doi:10.3389/fcvm.2020.00043. Awan S, Imtiaz S, Shahzad H. Spectrum of echocardiography findings in patients with end-stage renal disease. J Health Wellness Com Res. 2025; 6(2): 715-22. Tables Table 1. Demographic features and gross Transthoracic Echocardiographic findings of the study population. Characteristics Total (n=104) Controls (n=25) Hemodialysis (n=39) Renal Transplant (n=40) F-Value P-Value Age (Years) 38 ±13 37 ±21 37 ±13 36 ±12 - - Gender n (%) Male 83 (79.8) 18 (72.0) 33 (84.6) 32 (80.0) - - Female 21 (20.2) 7 (28.0) 6 (15.4) 8 (20.0) Ejection Fraction (%) 60.43 ±10 64.4 ±2 55.64 ±13*** , *, ǂ 61.25 ±7* 7.96 <0.001 Left Ventricular Diameter (mm) Systolic 30.8 ±6 30.08 ±5 32.28 ±7 29.81 ±6 1.762 0.177 Diastolic 44.04 ±6 40.36 ±3 46.6 ±6*** 43.89 ±7* 10.76 <0.001 Septal Thickness (mm) 11.18 ±2 10.28 ±1 11.1 ±2*** 11.86 ±3* 3.945 0.0225 Right Ventricular Diameter (mm) 21.778 ±3 23.12 ±1 20.87 ±3** 21.81 ±3 5.813 0.00413 Left Atrial Diameter (mm) 30.37 ±5 28.44 ±3 31.16 ±6 30.85 ±6 2.126 0.125 Pericardial Effusion n (%) 14 (18.42) - 8 (21.05) 6 (15.78) - - ***, **, *, shows significant difference with the control groups, i.e. p<0.001, 0.01, 0.05 respectively. All differences were evaluated at a 95% confidence interval. ǂ shows a significant difference of ejection fraction (%) of Hemodialysis with Renal Transplant group. Table 2. Transthoracic echocardiographic findings of left ventricular wall among study population receiving varying Renal Replacement Therapy Parameters Group Observed n (%) Chi 2 p-Value Total n (%) Normal Left Ventricle Hemodialysis n (%) 20(50%) - - 45(57%) Renal Transplant n (%) 25(63%) Dilated Left Ventricle Hemodialysis n (%) 10(26%) 2.12 0.1449 14(18%) Renal Transplant n (%) 4(10%) Symmetrical Left Ventricular Hypertrophy Hemodialysis n (%) 7(19%) 0.08 0.7772 13(16%) Renal Transplant n (%) 6(16%) Concentric Left Ventricular Hypertrophy Hemodialysis n (%) 2(5%) 0.14 0.7043 7(9%) Renal Transplant n (%) 5(11%) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9024768","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":607521258,"identity":"46fc79d4-1263-42c9-adf2-00c13a23ce3f","order_by":0,"name":"Tooba Noor","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYHACNijNfECCsQHESADiA7jV8yC0sCWQrIXHgDgt9uzNxx78YLgjxy995uNt3h11DPzsOQbMBWfw2MJzLN2wh+GZsWRf7mZr3jOHGSR73hgwz7iBR4tEjpkED8PhxA1neLdJ87YdYDC4AbSF5wN+LZJ/wFp4ngG11DHYE6NFGmILDxtQCzODgQRICz6HnTmWbixjcNhYsofN2HJu22EeiTPPCg7PwON99vbmYw/fVByW4+dhfnjjbVudHH978sbHBcdwa4EAAyRrQcRhQhowATPpWkbBKBgFo2AYAwBwo0tPxPwzRQAAAABJRU5ErkJggg==","orcid":"","institution":"Dow University of Health Sciences","correspondingAuthor":true,"prefix":"","firstName":"Tooba","middleName":"","lastName":"Noor","suffix":""},{"id":607521259,"identity":"f7f2ee81-83b7-4190-8565-98cf939103a8","order_by":1,"name":"Muhammad Tassaduq Khan","email":"","orcid":"","institution":"Dow University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"Tassaduq","lastName":"Khan","suffix":""},{"id":607521260,"identity":"40458515-0e84-46f2-82a2-12ef6da495ce","order_by":2,"name":"Omer Farooq Shaikh","email":"","orcid":"","institution":"Dow International Medical College, Dow University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Omer","middleName":"Farooq","lastName":"Shaikh","suffix":""},{"id":607521261,"identity":"c31e799b-c9f2-4ba7-ae86-12512449133f","order_by":3,"name":"Tahoor Tahir","email":"","orcid":"","institution":"Dow International Medical College, Dow University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Tahoor","middleName":"","lastName":"Tahir","suffix":""},{"id":607521262,"identity":"dcf68c93-addb-4035-a284-5b54e8532797","order_by":4,"name":"Sulaiman Faisal","email":"","orcid":"","institution":"Dow International Medical College, Dow University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Sulaiman","middleName":"","lastName":"Faisal","suffix":""},{"id":607521263,"identity":"26c74407-8bed-447d-97e9-775a18bce51f","order_by":5,"name":"Syed Muhammad Rameez Hasan Zaidi","email":"","orcid":"","institution":"Dow International Medical College, Dow University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Syed","middleName":"Muhammad Rameez Hasan","lastName":"Zaidi","suffix":""}],"badges":[],"createdAt":"2026-03-04 02:09:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9024768/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9024768/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104887531,"identity":"92347174-83a6-4051-af40-b332bd72bc7d","added_by":"auto","created_at":"2026-03-18 10:12:05","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":83287,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eScatter plot showing the distribution of Left Ventricular Ejection Fraction of the study population among different study groups i.e., Controls, Hemodialysis and Renal transplant\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Fig.1.jpeg.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9024768/v1/eee17232a678985b2105694c.jpg"},{"id":104887672,"identity":"8e23c579-3cb5-4fb9-9e20-423a29f64409","added_by":"auto","created_at":"2026-03-18 10:12:30","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":119660,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBar graph illustrating the frequency and percentage of subjects with varying severities of valvular regurgitation in (a) Tricuspid and (b) Mitral in both study groups receiving renal replacement therapy i.e., Hemodialysis and Renal transplant\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Fig.2a.jpeg.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9024768/v1/7c1e9e7417e8311359c50edb.jpg"},{"id":105906409,"identity":"c63f8315-b589-4c39-82aa-4bbe09bd093f","added_by":"auto","created_at":"2026-04-01 10:21:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1510976,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9024768/v1/e3a483bc-a79b-4b58-b580-f01a0fab67f9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eHemodialysis versus Renal Transplantation: A Comparative Analysis of Cardiovascular Outcomes among End-Stage Renal Disease Patients unveiling the Safer Pathway \u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eEnd-Stage Renal Disease (ESRD) is characterized by severe irreversible kidney damage and the reduction in Glomerular Filtration Rate to less than 15 mL/min/1.73 m\u003csup\u003e2 1\u003c/sup\u003e. ESRD is a consequence of chronic kidney disease (CKD) progression or acute kidney injury causing rapid deterioration of kidney function thus necessitating for Renal Replacement Therapy (RRT) \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eRRT is the treatment of choice for ESRD patients either in the form of Hemodialysis (HD) or Renal Transplant (RT) depending on patients\u0026rsquo; health, comorbidities and cost effectiveness \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. High costs and limited non-profit RRT centers discourage patients from seeking RRT resulting in early mortality and higher disability adjusted life years, particularly among rural populations, with less than 10% of patients receiving proper care \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eBoth RRT modalities either HD or RT are associated with their respective complications. Hemodynamic instability, vascular access complications, infections, amyloidosis are some of the problems that arise with patients on HD \u003csup\u003e7, 8\u003c/sup\u003e, while RT recipients face post-transplant Diabetes Mellitus (PTDM), adverse drug effects, persistent immunocompromised state leading to frequent infections and graft rejection. \u003csup\u003e6, 9 and 10\u003c/sup\u003e. Unfortunately, both of the RRT modalities are associated with higher risks of cardiovascular diseases (CVD) in patients with long-term RRT and accounts for about 50% of deaths in those patients \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHD clears toxins from the blood, can cause sudden fluid shifts and strain on the heart, often leading to left ventricular enlargement causing arrhythmias and reduced pumping ability resulting end-organ damage and chronic heart failure over the time \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Transplantation typically improves heart health but comes with risks like higher blood pressure and hyperlipidemia that leads atherosclerosis, transient ischemic attacks and thromboembolic events secondarily to required medications \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWhile ESRD presents a significant public health challenge, its associated cardiovascular complications often remain under‑evaluated, especially in low resource settings \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. In South Asian countries, clinical attention has been primarily directed towards initiating and maintaining RRT, with less emphasis placed on managing post RRT associated cardiovascular complications \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. This highlights the importance of frequent monitoring of cardiac functions at regular intervals. The high cost and complexity of advanced cardiac assessments such as CT angiogram, combined with limited access to diagnostic facilities and trained personnel, further impede early detection of valvular disease, cardiac strain, and other cardiovascular findings \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Moreover, sparse data on long term cardiac outcomes and the competing priorities of managing ESRD itself have contributed to these complications being overlooked in clinical practice and research.\u003c/p\u003e \u003cp\u003eNon-invasive monitoring systems can be help in understanding how different treatments affect circulation. Transthoracic echocardiography (TTE), which is the gold-standard investigation to assess cardiac functions, if done regularly among such patients, may be helpful in timely diagnosing the increased cardiovascular morbidity and mortality and suggest a better RRT option with minimum cardiovascular associated challenges \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study aims to fill the gap by analyzing heart imaging via TTE among patients undergoing varying RRTs that include HD and RT in relation to healthy controls, considering factors like age, gender, treatment duration, and other health conditions.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study design, duration and sample size:\u003c/h2\u003e \u003cp\u003eIt is a retrospective cohort study conducted at the Department of Nephrology, Dow University of Health Sciences during November, 2024 to May 2025. The sample size was calculated as 30 for each group by using PASS version 24 (NCSS, Kaysville, Utah, USA) software, The calculation was based on a test for two independent means (comparing HD subjects vs. controls) with a 95% confidence interval, 80% power of test, and a 5% margin of error. This approach accounted for the reported 9.4% prevalence of cardiovascular complications in patients receiving RRT \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Consequently, the minimum total sample size required was 90 participants (30 per group). Our study exceeded this requirement with a total of 104 subjects: 39 in the hemodialysis (HD), 40 in the renal transplant (RT) while 25 were controls.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Sample description, Inclusion and Exclusion criteria:\u003c/h2\u003e \u003cp\u003eSample data was retrieved via medical record numbers (M.R. #) of selected study groups i.e. HD and RT subjects from data base office of the Department of Nephrology, Dialysis and Renal Transplant Unit, Dow University Hospital (DUH), Dow University of Health Sciences. TTE reports from ESRD participants receiving RRT either in the form of hemodialysis (HD) or renal transplant (RT) for more than six months were included in the study. Whereas, the controls were age and gender matched healthy adults with preserved renal functions diagnosed on the basis of serum creatinine levels\u0026thinsp;\u0026le;\u0026thinsp;0.9 mg/dl and GFR more than 70ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e with no history of cardiovascular comorbidities.\u003c/p\u003e \u003cp\u003eWhile, subjects who had ESRD but not receiving any of RRTs, subjects on RRT with pre-existing CVD (like myocardial ischemia, atherosclerotic events, and peripheral vascular disease), subjects admitted in hospital due to severe infections, sepsis, multi-organ failure, cerebrovascular events or any surgical procedure within last six months were thoroughly recruited via medical records and excluded from the study. Age and gender matched healthy controls with history of renal or cardiovascular diseases were also excluded from the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Data collection:\u003c/h2\u003e \u003cp\u003eSubjects of specific study groups were traced via medical record number (M.R. #) from the Department of Nephrology, Dialysis and Renal Transplant Unit, Dow University Hospital, Dow University of Health Sciences. Relevant data was retrieved from records and used solely for research purpose only. The controls were manually approached after informed consent who visited nephrology or urology outpatient clinics for routine check-ups, renal stone surgeries or infections with normal renal functions (i.e. GFR\u0026thinsp;\u0026ge;\u0026thinsp;70ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e). It was made sure that TTE reports were not more than six months old. The data included was their age, gender, cause of ESRD, followed by TTE findings which was done from the associated radiology/ cardiology department of the affiliated institute.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Transthoracic Echocardiographic Evaluation Protocol:\u003c/h2\u003e \u003cp\u003eTransthoracic echocardiography (TTE) data of HD and RT subjects was retrieved from the system using their M.R. # while the procedure was performed on all controls at Dow University Hospital. Both HD and RT subjects along with controls follow the same TTE protocol.\u003c/p\u003e \u003cp\u003eScans on controls were performed by a trained echocardiography technician utilizing a standard two-dimensional (2D) and M-mode echocardiography system. Patients underwent examination in a fasting state, positioned in the left lateral decubitus position, using a 3.5 MHz phased-array transducer. The echocardiographic evaluation encompassed structural abnormalities, systolic and diastolic functions, pericardial effusions and valvular abnormalities. Ejection fraction (EF) was estimated using the biplane Simpson's method.\u003c/p\u003e \u003cp\u003eThe study followed the American Society of Echocardiography (ASE) guidelines but made practical adjustments for the clinical setting. Because advanced strain imaging software was unavailable, we relied on standard 2D and M-mode techniques for all measurements. To avoid the misleading effects of sudden fluid changes, hemodialysis patients were scanned on their off-days when their volume status was most stable. Finally, all heart chamber measurements were indexed to Body Surface Area (BSA) to ensure they were accurate for the specific body types of South Asian population.\u003c/p\u003e \u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e2.5.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; Ethical Approval:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study followed the Helsinki\u0026rsquo;s principle and ethical approval was sought from the Institutional Review Board (IRB) of Dow University of Health Sciences (DUHS), and Ref. no.: IRB-3012/DUHS/Approval/2023/353.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.6.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Statistical Analysis:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analysis was carried out using R Studio (Posit IDE) version 2025.05.1 (Build 513) [3]. The quantitative data was presented in the form of mean with standard deviation or median with range while the qualitative data in the form of frequency (n) with percentages (%). Normality of continuous variables was tested using the Shapiro-Wilk test. For comparisons between two groups, the independent samples t-test was used. For more than two groups, one-way ANOVA was applied, with Tukey\u0026rsquo;s HSD for post-hoc analysis. TTE based categorical findings between HD and RT subjects were compared using chi-square test. All statistical tests were carried out keeping the level of significance 5% (\u003cem\u003ep\u003c/em\u003e \u0026le; 0.05) at 95% confidence interval.\u003c/p\u003e"},{"header":" 3. Results","content":"\u003cp\u003e\u003cstrong\u003e3.1. Demographic Characteristics of the study population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn total, 104 subjects were recruited for this study that were comprised of three groups, i.e. subjects on HD, subjects received RT and controls that were 37.5% (n = 39), 38.5% (n = 40) and 24% (n = 25), respectively. The mean age of the study population was 37\u0026plusmn;13 years while 79.8% (n = 83) of them were male. Out of 75.2% (n = 79) ESRD subjects who were either on RT or HD the most common cause of ESRD was hypertensive nephropathy (46.8%, n = 37) followed by diabetic nephropathy (32.9%, n = 26). Remaining ESRD causes (20.3%, n = 11) were secondarily to obstetric complications, systemic lupus erythematous and congenital renal problems while, 6.3% (n = 5) of them were unknown causes. The details of the demographic parameters of the study population are mentioned in table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2. Echocardiographic parameters and their comparison\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.1. Ejection Fraction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTTE revealed notable decline in left ventricular ejection fraction (EF) among patients undergoing Renal Replacement Therapy. ANOVA analysis yields significant differences across the groups (F = 7.9, p \u0026lt; 0.001) as seen in Table 1. Controls showed an overall higher median EF percentages compared to both HD and RT subjects, with HD having more outliers as compared to RT subjects, as seen in Figure 1. This finding emphasizes the long-term impact of HD and its relevant consequences on systolic function.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.2. Ventricular and Atrial Dimensions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTTE findings of atrial and ventricular dimensions among different study groups are detailed in table 1. However, the study showed significant alteration in left ventricular diastolic diameter particularly by ANOVA testing (F = 10.7, p \u0026lt; 0.001) which was later confirmed by post-hoc analysis. Statistically significant increases in diastolic diameter were found in both the HD (p \u0026lt; 0.001) as well as RT group (p \u0026lt; 0.01) compared to the control group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.3. Structural Cardiac Changes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLeft Ventricular (LV) dilatation and hypertrophy were reported in 43.0% of all patients. Although insignificant (p = 0.14), but notable increased rate of dilated LV was reported among HD group as compared to RT subjects whereas hypertrophic LV was more prevalent among the contrary study group. The details of LV chamber findings among both HD and RT study groups are mentioned in table 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.4. Valvular Abnormalities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTricuspid regurgitation was found to be the most common valvular defect 82.3% (n = 65) followed by mitral regurgitation which i.e., 68.3% (n = 54) among the study participants who were on RRT. While 62.0% (n = 49) had both tricuspids along with mitral regurgitation out of them, 63.2% (n = 31) were hemodialysis subjects. Only 13.9% (n = 11) of RRT subjects did not have any type of valvular abnormalities. Our study did not find any type of stenosis or semilunar valves abnormalities. The details of severity of tricuspid and mitral regurgitation among study participants are mentioned in figure 2a and 2b, respectively. Pericardial effusion was reported among 18.4% (n = 14) of study subjects.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to evaluate and compare echocardiographic outcomes among subjects receiving maintenance HD, renal allograft with age and gender controls. We observed that subjects on maintenance HD had significantly lower ejection fractions, greater atrial and ventricular enlargement, and markedly higher rates of mitral and tricuspid regurgitation compared to both transplant and control groups.\u003c/p\u003e\n\u003cp\u003eOur finding of reduced ejection fraction observed in the HD group is consistent with the findings of Wang et al. \u003csup\u003e21\u003c/sup\u003e, where echocardiographic data from ESRD patients confirmed that systolic dysfunction is more pronounced among those undergoing dialysis compared to post-renal transplant patients. Similar findings have been reported by Pickup et al. \u003csup\u003e22\u003c/sup\u003e, who demonstrated that RT is associated with reverse remodeling of heart with improved left ventricular function compared to patients remaining on dialysis. However, other studies have highlighted that heart failure with preserved ejection fraction predominates among HD population, and that ejection fraction may not always appear significantly reduced, with strain imaging revealing subclinical systolic dysfunction \u003csup\u003e23, 24\u003c/sup\u003e. Furthermore, some reports suggest that kidney transplantation also does not uniformly normalize systolic function, with persistent abnormalities among subset of recipients \u003csup\u003e25\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eOur observation of increased ventricular and atrial dimensions, along with evidence of left ventricular hypertrophy in both study groups receiving RRT, particularly, LV findings among HD subjects is in line with the local literature \u003csup\u003e26\u003c/sup\u003e, which documented cardiac structural abnormalities and chamber dilatation in Pakistani HD patients. These findings are further supported by Obremska et al. \u003csup\u003e27\u003c/sup\u003e, who reported comparatively larger left atrial and ventricular chamber volumes in dialysis patients compared to transplant recipients, with significant post-transplant regression. Moreover, some existing analysis \u003csup\u003e28\u003c/sup\u003e observed that left atrial function and strain were significantly better in transplant patients compared to those on hemodialysis.\u003c/p\u003e\n\u003cp\u003eThe observed disparities in cardiac remodeling between hemodialysis (HD) and renal transplant (RT) stem from the distinct hemodynamic profiles of each therapy. In HD, the heart is subjected to rapid volume expansion between sessions followed by aggressive ultrafiltration, which triggers repetitive \u0026quot;myocardial stunning\u0026quot; and progressive fibrosis \u003csup\u003e29\u003c/sup\u003e. This chronic stress manifests as the significantly higher rates of left ventricular dilatation and lower ejection fractions as seen in our HD cohort. In contrast, transplantation restores continuous renal function, allowing for \u0026quot;reverse remodeling\u0026quot; where the cardiac architecture begins to mirror that of healthy controls \u003csup\u003e22, 30 and 31\u003c/sup\u003e. This transition from a state of constant physiological strain to stability explains why RT subjects in our study demonstrated cardiac parameters closer to the healthy baseline than their HD counterparts.\u003c/p\u003e\n\u003cp\u003eFinally, our finding of significantly more prevalent mitral and tricuspid regurgitation in the hemodialysis group aligns with a Pakistani study by Awan et al. \u003csup\u003e32\u003c/sup\u003e, which emphasized a high burden of valvular heart disease among ESRD patients on HD from Pakistani population. This is also consistent with data by Wang et al. \u003csup\u003e21\u003c/sup\u003e, who similarly reported increased rates of valvular insufficiency in the hemodialysis population. De la Espriellaf et al. \u003csup\u003e33\u003c/sup\u003e also noted that mitral regurgitation was the most frequent valvular lesion in HD patients, while another study \u003csup\u003e34\u003c/sup\u003e identified functional tricuspid regurgitation as a frequent and predictive valvular lesion applicable to cardiovascular morbidity maintenance HD cohorts. Importantly, Kim et al. \u003csup\u003e13\u003c/sup\u003e demonstrated that mitral and aortic regurgitation can be improved following kidney transplantation. However, other analyses indicate that valvular calcification and regurgitation often persist despite transplantation, reflecting long-term structural damage \u003csup\u003e12\u003c/sup\u003e. Long term cohorts in subjects with pre and post -transplant comparisons would yield true picture of cardiac changes.\u003c/p\u003e\n\u003cp\u003eFurthermore, the high prevalence of valvular regurgitation in the HD group highlights a critical but often overlooked complication of South Asian ESRD population \u003csup\u003e30\u003c/sup\u003e. These are actually functional lesions driven by chronic volume overload and increased pulmonary pressures \u003csup\u003e34\u003c/sup\u003e. In a low-resource setting like Pakistan, where access to advanced interventions like valvular repair or CT angiograms is limited, these results advocate for the use of RT as not just a renal therapy, but a primary cardiovascular intervention \u003csup\u003e30, 35\u003c/sup\u003e. By documenting these changes alongside healthy controls, this study provides a regional benchmark that underscores the necessity of proactive, non-invasive echocardiographic monitoring to bridge the diagnostic gap in populations where cardiovascular mortality remains the leading cause of death post-ESRD \u003csup\u003e35\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eOne of the key limitations of our study is limited sample size, which may limit statistical power. Additionally, a longitudinal cohort design would have provided better insight into cardiac alternative progression over time. The absence of supporting investigations such as electrocardiograms (ECGs), Holter and stress echocardiography limited our ability to assess conduction abnormalities and left ventricular strain, which could have provided deeper insight into the clinical impact of the structural and functional changes observed. Prospective studies with long term follow-up could provide an insight and would be helpful in developing long term strategies and guidelines to manage the renal replacement therapy associated dilemma.\u003c/p\u003e\n\u003cp\u003eThis study reveals a definitive cardiovascular advantage for RT over maintenance HD. A primary distinction of our work is the three-group comparative model i.e. by evaluating both treatment modalities alongside healthy controls, the study established a benchmark for cardiovascular recovery that few regional studies have documented. Given that Pakistan is a global epicenter for ESRD, the findings address critical diagnostic gap in South Asian populations where clinical outcomes often diverge from Western trends. Ultimately, these results advocate for a paradigm shift toward proactive cardiac monitoring.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur findings demonstrate that while HD is associated with progressive structural decline characterized by diminished EF, adverse ventricular remodeling, and a higher prevalence of valvular regurgitation RT maintain a cardiac profile that closely mirrors healthy individuals, making it a better choice of RRT for ESRD among the susceptible population. The routine integration of echocardiographic screening and cardiac biomarkers is essential for early diagnosis, offering a vital strategy to mitigate cardiovascular morbidity among the vulnerable population will be step forward towards personalized medicine at a low-resource healthcare setting.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Institutional Review Board (IRB) of Dow University of Health Sciences (DUHS), Ref.no. IRB-3012/DUHS/Approval/2023/353 and Helsinki\u0026rsquo;s principle was followed throughout the course of study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is presented in manuscript. Raw data will be provided on formal request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no conflict of interest by any author in any part of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Generative AI in Scientific Writing:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the preparation of this manuscript, authors used only Google Gemini to improve the language and readability. After using this tool, the authors reviewed and edited the manuscript where needed and take full responsibility for the content of the publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is a self-funded project, authors did not receive any specific grant from funding agencies in public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTN develop the hypothesis of study, developed the initial study design, supervised the project, reviewed and edited the manuscript. MTK helped in data acquisition, clinical guidelines and review of article. OFS and SMRHZ did the data acquisition, arranged the results and wrote discussion TT and SF prepared the first draft of manuscript. All authors have read and approved the final version of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe are thankful to our supporting staff for co-operating us diligently and our valuable controls for their time and co-operation.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNational Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(2 Suppl 1): S1-266. Available from: https://www.kidney.org/professionals/kdoqi/guidelines\u003c/li\u003e\n\u003cli\u003eSarfraz A, Moon F, Wahid A, Tofique M. Echocardiography findings in hemodialysis patients. Pak Heart J. 2022;55(4):331-5. doi:10.47144/phj.v55i4.2333\u003c/li\u003e\n\u003cli\u003eZhao Y. Comparison of the effect of hemodialysis and peritoneal dialysis in the treatment of end-stage renal disease. Pak J Med Sci. 2023;39(6):1562-7. doi:10.12669/pjms.39.6.8056\u003c/li\u003e\n\u003cli\u003eGupta R, Woo K, Yi JA. Epidemiology of end-stage kidney disease. Semin Vasc Surg. 2021;34(1):71-8. doi: 10.1053/j.semvascsurg.2021.02.008\u003c/li\u003e\n\u003cli\u003eKhan FA, Fatima SS, Khan GM, Shahid S. Evaluation of kidney injury molecule-1 as a disease progression biomarker in diabetic nephropathy. Pak J Med Sci. 2019;35(4):992-6. doi:10.12669/pjms.35.4.1546\u003c/li\u003e\n\u003cli\u003eCasagrande V, Federici M, Menghini R. TIMP3 involvement and potentiality in the diagnosis, prognosis and treatment of diabetic nephropathy. Acta Diabetol. 2021;58(12):1587-94. doi:10.1007/s00592-021-01766-y\u003c/li\u003e\n\u003cli\u003eHabas E, Rayani A, Alkanonie W, Habas A, Alzoukie E, Razeik S, et al. Common complications during hemodialysis session: a single-center experience. Austin J Nephrol Hypertens. 2019;6(1):1078.\u003c/li\u003e\n\u003cli\u003eHabas EM, Habas A, Elgamal ME, Shraim BA, Moursi MO, Ibrahim AR, et al. Common complications of hemodialysis: a clinical review. Ibnosina J Med Biomed Sci. 2021;13(4):161-72.\u003c/li\u003e\n\u003cli\u003eMuntner P, Judd SE, Gao L, et al. Cardiovascular risk factors in CKD associate with both ESRD and mortality. J Am Soc Nephrol. 2013;24(7):1159-65. doi:10.1681/ASN.2012070642\u003c/li\u003e\n\u003cli\u003eEl Arbagy AR, Koura MA, El Barbary HS, Abou El Nasr AE. Comparative study of the effect of high-flux versus low-flux dialysis membranes on metabolic abnormalities in chronic hemodialysis patients. Menoufia Med J. 2014;27(3):677-82.\u003c/li\u003e\n\u003cli\u003eMatsuo H, Dohi K, Machida H, Takeuchi H, Aoki T, Nishimura H, et al. Echocardiographic assessment of cardiac structural and functional abnormalities in patients with end-stage renal disease receiving chronic hemodialysis. Circ J. 2018;82(2):586-95. doi:10.1253/circj.CJ-17-0480\u003c/li\u003e\n\u003cli\u003eAoki J, Ikari Y, Nakajima H, Morino Y, Shirai S, Hara K. Persistence of valvular calcification after kidney transplantation. Am J Cardiol. 2018;121(4):564-70. doi:10.1016/j.amjcard.2017.11.026\u003c/li\u003e\n\u003cli\u003eKim M, Park J, Lee JH, Jeon HJ, Yang J. Changes in valvular regurgitation after kidney transplantation. Front Cardiovasc Med. 2022;9:1035063. doi:10.3389/fcvm.2022.1035063\u003c/li\u003e\n\u003cli\u003eManjunath G, Tighiouart H, Ibrahim H, MacLeod B, Salem DN, Griffith JL, et al. Level of kidney function as a risk factor for atherosclerotic cardiovascular outcomes in the community. J Am Coll Cardiol. 2003;41(1):47-55. doi:10.1016/S0735-1097(02)02663-3\u003c/li\u003e\n\u003cli\u003eWarrens H, Banerjee D, Herzog CA. Cardiovascular complications of chronic kidney disease: an introduction. Eur Cardiol. 2022;17(13). doi:10.15420/ecr.2021.54\u003c/li\u003e\n\u003cli\u003eCharytan DM, Foley R, McCullough PA, Rogers JD, Zimetbaum P, Herzog CA, et al. Arrhythmia and sudden death in hemodialysis patients: protocol and baseline characteristics of the Monitoring in Dialysis study. Clin J Am Soc Nephrol. 2016;11(4):721-34. doi:10.2215/CJN.08280815\u003c/li\u003e\n\u003cli\u003eGori M, Senni M, Gupta DK, et al. Association between renal function and cardiovascular structure and function in heart failure with preserved ejection fraction. Eur Heart J. 2014;35(48):3442-51. doi:10.1093/eurheartj/ehu254\u003c/li\u003e\n\u003cli\u003eShivendra S, Doley PK, Pragya P, Sivasankar M, Singh VP, Neelam S. Echocardiographic changes in patients with ESRD on maintenance hemodialysis\u0026mdash;a single-center study. J Cardiovasc Dis Diagn. 2014;2(4).\u003c/li\u003e\n\u003cli\u003eChuasuwan A, Pooripussarakul S, Thakkinstian A, Ingsathit A, Pattanaprateep O. Comparisons of quality of life between patients undergoing peritoneal dialysis and hemodialysis: a systematic review and meta-analysis. Health Qual Life Outcomes. 2020;18(1):191. doi:10.1186/s12955-020-01449-2\u003c/li\u003e\n\u003cli\u003eTsilonis K, Sarafidis PA, Kamperidis V, et al. Echocardiographic parameters during long and short interdialytic intervals in hemodialysis patients. Am J Kidney Dis. 2016;68(5):772-81. doi:10.1053/j.ajkd.2016.06.017\u003c/li\u003e\n\u003cli\u003eWang Z, Wang Y, Liu J, Hu S, Wang X. Valvular heart disease in dialysis patients: prevalence and outcomes. Clin Kidney J. 2023;16(5):835-44. doi:10.1093/ckj/sfad034\u003c/li\u003e\n\u003cli\u003ePickup LC, Bedford M, Dring A. Effects of kidney transplantation on cardiac structure and function: a systematic review and meta-analysis. ESC Heart Fail. 2021;8(1):276-89. doi:10.1002/ehf2.13036\u003c/li\u003e\n\u003cli\u003eMalik J, Tuka V, Melenovsk\u0026yacute; V. Heart failure with preserved ejection fraction dominates in hemodialysis: pathophysiology and management. Front Cardiovasc Med. 2023; 10: 1130618. doi:10.3389/fcvm.2023.1130618\u003c/li\u003e\n\u003cli\u003eZoccali C, Torino C, Tripepi R, Tripepi G, D\u0026rsquo;Arrigo G, Postorino M, et al. Subclinical systolic dysfunction by strain imaging in dialysis patients: the importance of heart-artery interaction. Nephrol Dial Transplant. 2016;31(6):978-85. doi:10.1093/ndt/gfv382\u003c/li\u003e\n\u003cli\u003eLentine KL, Costa SP, Weir MR, Robb JF, Fleisher LA, Kasiske BL, et al. Persistent systolic dysfunction after kidney transplantation. Am J Transplant. 2012;12(8):2184-91. doi:10.1111/j.1600-6143.2012.04076.x\u003c/li\u003e\n\u003cli\u003eHaider A, Ahmed A, Aziz S, Khan M. Echocardiographic assessment of left ventricular hypertrophy in patients on hemodialysis. Pak Armed Forces Med J. 2012;62(3):369-73.\u003c/li\u003e\n\u003cli\u003eObremska M, Nowak J, Pączek L, Małyszko J. Pre-emptive kidney transplantation and cardiac remodeling. J Clin Med. 2021;10(12):2602. doi:10.3390/jcm10122602\u003c/li\u003e\n\u003cli\u003eYildirim U, Celik A, Ozturk D. Assessment of left atrial strain in kidney transplant recipients and patients on dialysis. Cardiol J. 2022;29(1):81-89. doi:10.5603/CJ.a2020.0117\u003c/li\u003e\n\u003cli\u003eBhatti NK, Karimi Galougahi K, Paz Y, Nazif T, Moses JW, Leon MB, et al. Diagnosis and management of cardiovascular disease in advanced and end-stage renal disease. J Am Heart Assoc. 2016;5(8): e003648.\u003c/li\u003e\n\u003cli\u003ePrasad GV, Bhamidi V. Managing cardiovascular disease risk in South Asian kidney transplant recipients. World J Transplant. 2021;11(6):147-60.\u003c/li\u003e\n\u003cli\u003eYoo KD, Kim CT, Kim MH, Noh J, Kim G, Kim H, et al. Superior outcomes of kidney transplantation compared with dialysis: An optimal matched analysis of a national population-based cohort study between 2005 and 2008 in Korea. Medicine (Baltimore). 2016;95(33): e4352\u003c/li\u003e\n\u003cli\u003eAwan S, Imtiaz S, Shahzad H. Valvular heart disease in end-stage renal disease patients on maintenance hemodialysis: a cross-sectional study from Pakistan. Med Sci Rev. 2023;9(1):43-49.\u003c/li\u003e\n\u003cli\u003eDe la Espriella R, Maicas C, Rueda J, Rold\u0026aacute;n C, Mart\u0026iacute;nez A, Garc\u0026iacute;a M, et al. Significant left-sided valvular disease in dialysis patients. Clin Kidney J. 2023;16(9):1630-39. doi:10.1093/ckj/sfad210\u003c/li\u003e\n\u003cli\u003eZhang Y, Zhang H, Ma X. Predictors of tricuspid regurgitation in maintenance hemodialysis patients. Front Cardiovasc Med. 2020; 7:43. doi:10.3389/fcvm.2020.00043.\u003c/li\u003e\n\u003cli\u003eAwan S, Imtiaz S, Shahzad H. Spectrum of echocardiography findings in patients with end-stage renal disease. J Health Wellness Com Res. 2025; 6(2): 715-22.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Demographic features and gross Transthoracic Echocardiographic findings of the study population.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"881\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=104)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eControls\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=25)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHemodialysis\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=39)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eRenal\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTransplant\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=40)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eF-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (Years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e38 \u0026plusmn;13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e37 \u0026plusmn;21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e37 \u0026plusmn;13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e36 \u0026plusmn;12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e83 (79.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e18 (72.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e33 (84.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e32 (80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e21 (20.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e7 (28.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e6 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e8 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEjection Fraction (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e60.43 \u0026plusmn;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e64.4 \u0026plusmn;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e55.64 \u0026plusmn;13***\u003csup\u003e, *,\u0026nbsp;\u003c/sup\u003eǂ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e61.25 \u0026plusmn;7*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e7.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft Ventricular Diameter (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSystolic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e30.8 \u0026plusmn;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e30.08 \u0026plusmn;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e32.28 \u0026plusmn;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e29.81 \u0026plusmn;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1.762\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.177\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiastolic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e44.04 \u0026plusmn;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e40.36 \u0026plusmn;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e46.6 \u0026plusmn;6***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e43.89 \u0026plusmn;7*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e10.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeptal Thickness (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e11.18 \u0026plusmn;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e10.28 \u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e11.1 \u0026plusmn;2***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e11.86 \u0026plusmn;3*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e3.945\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0225\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight Ventricular Diameter (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e21.778 \u0026plusmn;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e23.12 \u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e20.87 \u0026plusmn;3**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e21.81 \u0026plusmn;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e5.813\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.00413\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft Atrial Diameter (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e30.37 \u0026plusmn;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e28.44 \u0026plusmn;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e31.16 \u0026plusmn;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e30.85 \u0026plusmn;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e2.126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.125\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePericardial Effusion n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e14 (18.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e8 (21.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e6 (15.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e***, **, *, shows significant difference with the control groups, i.e. p\u0026lt;0.001, 0.01, 0.05 respectively. All differences were evaluated at a 95% confidence interval. \u0026nbsp;ǂ shows a significant difference of ejection fraction (%) of Hemodialysis with Renal Transplant group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Transthoracic echocardiographic findings of left ventricular wall among study population receiving varying Renal Replacement Therapy\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"857\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eObserved n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChi\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNormal Left Ventricle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHemodialysis n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e20(50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e45(57%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRenal Transplant n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e25(63%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDilated Left Ventricle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHemodialysis n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e10(26%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.1449\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e14(18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRenal Transplant n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e4(10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSymmetrical Left Ventricular Hypertrophy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHemodialysis n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e7(19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.7772\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e13(16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRenal Transplant n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e6(16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConcentric Left Ventricular Hypertrophy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHemodialysis n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2(5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.7043\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e7(9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRenal Transplant n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e5(11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"End Stage Renal Disease, Hemodialysis, Renal Transplant, Transthoracic Echocardiography, Ejection Fraction","lastPublishedDoi":"10.21203/rs.3.rs-9024768/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9024768/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIndividuals with End-Stage Renal Disease (ESRD) experience a heightened risk of cardiovascular morbidity and mortality, often linked to the hemodynamic instability and chronic physiological stressors inherent due to renal replacement therapies (RRT). The objective of this study was to evaluate the impact of hemodialysis (HD) and renal transplantation (RT) on cardiac health by comparing their transthoracic echocardiographic (TTE) parameters to those of a control group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study analyzed records from the Renal Transplant and Dialysis unit of Nephrology department of Dow University Hospital (DUH). The cohort consisted of 104 subjects: 37.5% (n = 39) were HD, 38.5% (n = 40) had received RT and 24% (n = 25) were controls. TTE data were recruited for each participant and statistically analyzed using R Studio.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean age of the study population was 38 ± 13 years, with a male predominance (79.86%). The mean ejection fraction (EF) for HD subjects (55.64 ± 13%) was found to be notably lower than in RT (61.25 ± 7%) and controls (64.4 ± 2%). Both systolic (32.2 mm) and diastolic (46.4 mm) left ventricular diameters were enlarged among HD subjects in comparison to controls (29.8 mm and 43.9 mm, respectively), while the right ventricular diameter was diminished. Furthermore, 62.02% (n = 49) of the entire subjects showed both tricuspid and mitral regurgitation, with HD subjects accounting for 63.26% (n = 31) of these cases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data demonstrates a higher incidence of cardiac abnormalities including reduced EF and adverse ventricular and valvular changes among HD subjects. These findings underscore the importance of exploring long-term renal replacement strategies that mitigate cardiovascular risk, suggesting that RT could be a more favorable option to improve both cardiac and renal outcomes among subjects with ESRD.\u003c/p\u003e","manuscriptTitle":"Hemodialysis versus Renal Transplantation: A Comparative Analysis of Cardiovascular Outcomes among End-Stage Renal Disease Patients unveiling the Safer Pathway","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-18 10:08:48","doi":"10.21203/rs.3.rs-9024768/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ea6bbd59-a50e-418f-989e-06ab31b0d86a","owner":[],"postedDate":"March 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":64708125,"name":"Health sciences/Cardiology"},{"id":64708126,"name":"Health sciences/Diseases"},{"id":64708127,"name":"Health sciences/Medical research"},{"id":64708128,"name":"Health sciences/Nephrology"}],"tags":[],"updatedAt":"2026-03-31T05:41:09+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-18 10:08:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9024768","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9024768","identity":"rs-9024768","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}