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\begin{document}

\title{Effect of hemodialysis on left atrial function in patients with
end-stage renal failure evaluated by two-dimensional speckle tracking
Imaging}



\author[1]{Yunxiang Miao}%
\author[1]{Li Wang}%
\author[1]{Ying Yin}%
\author[1]{BingYuan Zhou}%
\author[1]{Yuping Liao}%
\affil[1]{First Affiliated Hospital of Soochow University}%


\vspace{-1em}



  
  \date{May 18, 2024}


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\selectlanguage{english}
\begin{abstract}
Abstract Objective: We sought to evaluate the left atrial (LA) strain
parameters of maintenance hemodialysis (MHD) patients before and after
dialysis by two dimensional speckle tracking imaging (2D- STI), and to
explore the effect of volume load change on LA function. Methods: 76
patients with end stage renal disease (ESRD) on hemodialysis (HD) were
enrolled in the study protocol. The median duration of dialysis was 24.0
(7.5, 59.5) months. In addition, 30 healthy subjects were selected as
control group. Comprehensive echocardiography was performed immediately
before and after hemodialysis to compare the changes in left atrial
function. Results: Regarding LA strain parameters in patients of pre-HD,
the median (25th, 75th) LA reservoir, LA conduit, and LA contractile
reserve were 28.0 (23.0, 34.5), -15.5 (-10.0, -21.5),-12.0 (-9.0, -16.0)
respectively; the post-HD were 26.0 (21.0, 29.0), -12.0 (-9, -15.5),
-12.5 (-9, -15.5) respectively; and controls were 43.0 (36.0, 48.0),
-24.0 (-18.0, -32.0), -17.0 (-15.0, -22.0) respectively. The left atrial
strain parameters before HD were lower than controls, the differences
were statistically significant (P \textless{} 0.05). The reservoir
function and conduit function of LA strain decreased after hemodialysis,
the differences were statistically significant (P \textless{} 0.05).
Regarding the contraction of LA, the differences between pre- and
post-HD were not statistically significant (p \textgreater{} 0.05).
Conclusion: New echocardiographic parameters, such as left atrial
strain, can quantitatively evaluate the changes in left atrial function
before and after hemodialysis in ESRD patients, which can provide
valuable information for the overall cardiac evaluation in this specific
population.%
\end{abstract}%



\sloppy


\textbf{Introduction:}

End stage renal disease (ESRD) is the terminal state of various chronic
kidney diseases. Such patients often accompany with different degrees of
myocardial remodeling and dysfunction. Hemodialysis is one of the main
treatment methods for these patients. It removes excessive fluid and
toxins in the body, with the decrease of preload, the final cardiac
systolic and diastolic function will also change slightly.Therefore,
echocardiography is needed to assess early changes in subclinical
cardiac function in ESRD patients \textsuperscript{{[}1-3{]}}.
Evaluation of left atrial strain by speckle tracking imaging has been
shown to play an important prognostic role in several different specific
populations \textsuperscript{{[}4-7{]}}, but there are few studies on
evaluation of left atrial strain before and after single hemodialysis.

\textbf{Methods}

\textbf{Study populations}

A total of 76 ESRD patients who received hemodialysis three times a week
in the First Affiliated Hospital of Soochow University from March 2022
to November 2023 were selected. There were 40 males and 36 females with
an average age of 48.9 \selectlanguage{ngerman}± 13.0 years. Exclusion criteria: (1) patients
with poor echocardiographic image quality; (2) Patients with persistent
atrial fibrillation or severe arrhythmia; (3) Patients with LVEF
\textless{} 45\% or records of ischemic heart disease; (4) Severe
valvular heart disease and patients after valvular heart disease
operation. In addition, 30 healthy people in the same period were
selected as the control group. The research was in accordance with the
Declaration of Helsinki and was approved by the ethics committee of the
First Affiliated Hospital of Soochow University. Written informed
consent was obtained from each patient.

\textbf{Echocardiography}

GE vivid E95 color Doppler ultrasound diagnostic instrument was used for
echocardiography, equipped with M5Sc probe (frequency 2.5
\textasciitilde{} 5.0 MHz). All patients underwent echocardiography
before and after hemodialysis on the same day, and recorded the basic
data. All the images were imported into EchoPac 204 version.

Measurement: According to the guiding principles of American
Echocardiography Society \textsuperscript{{[}8{]}}: (1) Input the height
and weight of patients to obtain BSA;(2) The left ventricular outflow
tract (LVOT) was measured on the parasternal long axis section of the
left ventricle; (3) The peak E and peak A of diastolic mitral valve flow
spectrum were measured by pulsed Doppler in apical four-chamber section;
The mitral annulus e' velocity (septal e'and lateral e ') in early
diastole was obtained by tissue Doppler imaging; And calculate the
average E/E' ratio; (4) Pulsed Doppler measurement of systolic left
ventricular outflow tract spectrum and calculation of cardiac output
(CO) on apical five-chamber plane; (5) Left atrial volume (LAV), left
atrial volume index (LAVI), left ventricular end-diastolic volume
(LVEDV), left ventricular end-systolic volume (LVESV) and left
ventricular ejection fraction (LVEF) were measured by Simpson's biplane
method.

The four parameters for evaluating the left ventricular filling pressure
were: (1) Annular e' velocity: septal e' \textless{} 7 cm/s, lateral e
'\textless{} 10 cm/s; (2) Average E/E'ratio \textgreater{} 14; (3) Left
atrial volume index (LAVI) \textgreater{} 34 mL/m2; (4) Peak TR velocity
\textgreater{} 2.8 m/s (Figure 1). According to the joint recommendation
from the American Society of Echocardiography (ASE) and the European
Association of Cardiovascular Imaging (EACVI) \textsuperscript{{[}9,
10{]}}, it was proposed to use a combination of these echocardiographic
parameters to grades diastolic function.

The strain of left ventricle and left atrium is recommended according to
the guidelines of the European Heart Association in
2018\textsuperscript{{[}11{]}}: select apical four-chamber,
three-chamber and two-chamber cardiac planes, analyze the strain of left
ventricle, avoid enveloping mitral chordae, tendineae and papillary
muscles, and trace closely to the edge of endocardium to ensure
satisfactory tracking. The system automatically tracks the myocardial
spots layer by layer. Figure 2.

The left atrial strain needs to include complete left atrial free wall,
atrial septum and roof. Because the left atrial free wall is not easy to
be fully displayed in apical two-chamber section, if \textgreater{} 1/3
of left atrial tracking points fall off, the result will be discarded.
Therefore, a single four-chamber section is used to measure left atrial
strain in this study, and biplane method is the choice when the image is
clear \textsuperscript{{[}12{]}}: Starting from the atrial septum side
of mitral annulus, the atrial septum and roof (across pulmonary vein
opening) to the side wall of mitral annulus are traced in turn to
eliminate the interference of left atrial appendage. According to the
thickness of atrial wall, the ROI width is adjusted to 3mm. We use ECG R
wave pacing as a reference point to calculate LA strain, and identify LA
reservoir strain (LASr), LA conduit strain (LAScd) and LA contractile
strain (LASct). Figure 3.

\textbf{Statistics}

SPSS 22.0 statistical software was used to analyze the data. All
measurement data were tested for normality. The measurement data
conforming to normal distribution were compared between the two groups
by independent sample \emph{t} test, and the data were expressed
by\emph{± s} ; The measurement data that did not conform to the normal
distribution were expressed by \emph{M (P25, P75)} , and the
nonparametric Wilcoxon rank sum test was used for comparison between
groups. \emph{P} \textless{} 0.05 was statistically significant.

\textbf{Results}

Baseline clinical characteristics

Finally, 64 patients with ESRD were enrolled, including 37 males and 27
females, aged 25-79 (49.6 ± 14.9) years, height 167.8 ± 7.4 cm,
pre-dialysis weight 61.0 ± 10.3 kg, body surface area (BSA) 1.69 ± 0.16
m\textsuperscript{2}, median dialysis age 24.0 (7.5, 59.5) months, fluid
removal 2.0 ± 0.84 L. There were 30 healthy controls in the same period,
including 17 males and 13 females, aged 24-74 (47.7 ± 16.6) years,
height 164.1 ± 7.2 cm, body weight 61.2 ± 9.2 kg, BSA 1.67 ± 0.14
m\textsuperscript{2} , as shown in Table 1.

Difference of Conventional echocardiographic measurements

Compared with the control group, SBP, DBP, LVEDV, LVESV, SV, RA, RV, CO,
LAV, LAVI, E-peak, A-peak, E/E 'and PASP in ESRD group were higher than
those in the control group (\emph{P} \textless{} 0.05), while septal e'
and lateral e' in ESRD group were lower than those in the control group
(\emph{P} \textless{} 0.05). There was no significant difference in
LVEF, heart rate, E/A, EDT between the two groups
(P\emph{\textgreater{}} 0.05).

Compared with before hemodialysis, SBP, LVEDV, LVESV, SV, RA, RV, CO,
LAV, LAVI, E peak, A peak, E/A, septum E ', sidewall E' and PASP after
hemodialysis were significantly lower than those before hemodialysis
(\emph{P} \textless{} 0.05); There was no significant difference in DBP,
LVEF, heart rate, EDT and E/E'between the two groups
(\emph{P}\textgreater{} 0.05), as shown in Table 2.

Difference of strain parameters

Compared with the control group, there was no significant difference in
LVGLS parameters (subendocardium, midmyocardium and subepicardium)
before hemodialysis (\emph{P}\textgreater{} 0.05). Before hemodialysis,
the left atrial strain parameters (LASr, LAScd, LASct) were
significantly lower than those of the control group (\emph{P}
\textless{} 0.05).

Compared with before hemodialysis, LVGLS (subendocardium, midmyocardium
and subepicardium) decreased after hemodialysis, and the difference was
statistically significant (\emph{P} \textless{} 0.05). After
hemodialysis, LASr and LAScd decreased, and the difference was
statistically significant (\emph{P} \textless{} 0.001). There was no
significant difference between LASCT and before hemodialysis
(\emph{p}\textgreater{} 0.05), as shown in Table 3.

\textbf{Discussion}

Cardiovascular complications have a serious impact on the survival and
quality of life of uremic patients, and left ventricular diastolic
dysfunction is its most prominent feature. Echocardiography needs to
find subclinical damage of left ventricular function early. 2D-STI is a
new echocardiography technique, which can provide objective
quantification of cardiac function on the basis of analyzing myocardial
deformation.

Previous studies have confirmed \textsuperscript{{[}1, 13{]}} that left
ventricular global longitudinal strain (LVGLS) can accurately evaluate
left ventricular systolic function, while GLS is affected by volume
load\textsuperscript{{[}14{]}}. Recently, experts
recommended\textsuperscript{{[}15-17{]}} to add left atrial strain to
the evaluation of left ventricular diastolic function. Therefore,
speckle tracking imaging was used to evaluate left atrial strain
function before and after dialysis in ESRD patients, and to explore the
influence of volume load on left atrial function.

During the cardiac cycle, LA has three main functions: the reservoir
function when blood fills LA in systole, constrit function corresponding
to passive LV filling in early diastole, and the active contractile
function in late diastole.

Reservoir function is the ability of left atrium to receive blood flow
from pulmonary vein during ventricular systole and mitral valve closure.
It is determined by atrial stiffness and compliance, and is also
affected by left ventricular contractile force. After hemodialysis, the
strain value of LASr decreased, which proved that the blood entering the
left atrium from pulmonary vein corresponding to the decreased volume.

Conduit function is the difference between reservoir function and
contractile function. In the early stage of ventricular diastole, blood
flows directly into left ventricle through left atrium, which is mainly
determined by left atrial compliance, and is also closely related to
left ventricular diastolic tension and stiffness. After hemodialysis,
the strain value of LAScd also decreased, indicating that the blood
flowing through left atrium and entering left ventricle decreased in
early diastole.

The contractile function is the plateau strain value in the late
diastolic period of the ventricle, which reflects the active pump
function of the left atrium. In the late diastole, the left atrium plays
an autonomous booster pump function, and the atrial muscle actively
contracts, pumping out the remaining blood and increasing the left
ventricular filling \textsuperscript{{[}18{]}}. It plays a vital role in
maintaining the best cardiac circulation. Once the left ventricular
myocardium is damaged and the compliance is decreased, in order to
maintain sufficient cardiac output, the left atrium will do compensatory
work to supplement the left ventricular
filling\textsuperscript{{[}15{]}}. In this study, after hemodialysis,
while blood volume decreased, the cardiac output was still in the normal
range, the passive function of atrium (LASr, LAScd) decreased, but the
pump function of atrium itself (LASct) did not change significantly.
Furthermore, uremic patients are in a state of volume overload for a
long time, and the cardiac output after hemodialysis is more in line
with their physiological needs, so there is no need for extra work of
the left atrium.

Consistent with Frank-Starling law: in a certain range, when the volume
load increases, the myocardial fiber adjusts its initial length, which
improves the myocardial deformation ability, that is, the myocardial
contractility increases. In this study, the volume was overloaded before
hemodialysis, and the LVGLS parameters (subendocardium, midmyocardium
and subepicardium) were close to those of the normal control group.
After the excess fluid was removed, the heart cavity became smaller, the
myocardium returned to physiological length, and the LVGLS decreased.
Consistent with Breetveld N-M et al. \textsuperscript{{[}19{]}}, under
the condition of normal myocardial contractility, left ventricular
myocardial fibers reshape with the change of volume load, and the
absolute value of myocardial strain decreases with the decrease of
volume load after hemodialysis. However, Sun MM et
al.\textsuperscript{{[}20{]}} put forward different viewpoints. The
incidence of myocardial damage in patients with renal insufficiency is
higher, and the compensatory ability of myocardium is weaker than that
of normal people. A large amount of fluid is removed, and myocardial
blood perfusion is reduced, which can cause myocardial cell injury and
stunning, resulting in a decrease in left ventricular strain.

It may be possible to detect subclinical cardiac changes in patients
early by strain of left atrium. The thickness of atrial muscle is
thinner than that of ventricular, and atrial myocardium is more
vulnerable to damage due to long-term deposition of uremic toxins and
metabolites and retention of water and sodium. In this study, the atrial
strain parameters (LASr, LAScd, LASct) before hemodialysis were lower
than those in the control group. It can be found that ESRD patients are
overloaded with volume, and the damaged left ventricular myocardial
fibers are passively stretched. At this time, the left ventricular
strain value has not decreased, and the atrial strain parameters have
already decreased. After hemodialysis, the pump function of atrium
itself has no obvious change, which further indicates that the passive
function of atrium (LASr, LAScd) is greatly affected by volume load,
while the active deformation (LASct) is less affected.

Consistent with previous studies, traditional Doppler parameters of
diastolic function and left ventricular globe strain parameters depend
on volume load \textsuperscript{{[}21{]}}. When these parameters are
still normal, LA strain parameters evaluated by STE can find subclinical
LA dysfunction in ERSD patients early, provide more quantitative
indicators for cardiac function evaluation and prognosis evaluation of
such patients, and find subclinical myocardial damage in time, so as to
obtain more timely treatment and improve clinical results.

\textbf{Limitations} : 1. She is a study of left atrial function with
single center; 2. The patients with end-stage renal disease in this
study had left ventricular wall hypertrophy and left atrial strain had
decreased. It is necessary to to expand the size to study the changes of
left atrial function in the early stage of renal insufficiency.

\textbf{Author contributions}

Z B-Y and L Y-P contributed the study conception and design. Y Y
contacted with the patients for the echocardiography. M Y-X and W L
wrote the manuscript. M Y-X and W L performed the statistical analysis.
M Y-X and W L were responsible for image off-line analysis. Z B-Y and L
Y-P reviewed and edited the manuscript before submission. All authors
read and approved the final manuscript.

\textbf{Funding}

No funding was received for this study.

\textbf{Availability of data and materials}

The datasets generated and/or analysed during the current study are not
publicly available due to departmental management, but are available
from the corresponding author on reasonable request.

\textbf{Declarations}

\textbf{Ethics approval and consent to participate}

The study protocol was in accordance with the Declaration of Helsinki
and was approved by the ethics committee of the First Affiliated
Hospital of Soochow University. Written informed consent was obtained
from each patient.

\textbf{Acknowledgements}

None.

\textbf{Competing interests}

The author declare that they have no competing interests.

\textbf{Author details}

\textsuperscript{1}Department of Echocardiography, The First Affiliated
Hospital of Soochow University, Suzhou 215000, China.

\textsuperscript{2}Department of Hemodialysis Center, First Affiliated
Hospital of Soochow University, Suzhou 215000, China.

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Table 1 Baseline clinical characteristics of the study population\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
Variable & Hemodialysis (n= 76) & Controls (n= 30)\tabularnewline
Age (years) & 48.9 \selectlanguage{ngerman}± 13.0 & 47.7 \selectlanguage{ngerman}± 16.6\tabularnewline
Sex (male,\%) & 40 (52.6\%) & 16 (53.3\%)\tabularnewline
Height (cm) & 167.8 \selectlanguage{ngerman}± 7.4 & 164.1 \selectlanguage{ngerman}± 7.2\tabularnewline
Pre-dialysis weight (kg) & 61.0 \selectlanguage{ngerman}± 10.3 & 61.2 \selectlanguage{ngerman}± 9.2\tabularnewline
Body surface area (m\textsuperscript{2}) & 1.69 \selectlanguage{ngerman}± 0.16 & 1.67 \selectlanguage{ngerman}±
0.14\tabularnewline
Duration of dialysis (months) & 24.0 (7.5, 59.5) &\tabularnewline
Hemoglobin (g/L) & 113.8 \selectlanguage{ngerman}± 15.4 &\tabularnewline
Erythrocyte (10\^{}12/L) & 3.78 \selectlanguage{ngerman}± 0.58 &\tabularnewline
Creatinine (\selectlanguage{greek}μ\selectlanguage{english}mol/L) & 894.1 \selectlanguage{ngerman}± 365.9 &\tabularnewline
Blood urea nitrogen (mmol/L) & 24.8 (17.9, 28.8) &\tabularnewline
Calcium (mmol/L) & 2.34 \selectlanguage{ngerman}± 0.17 &\tabularnewline
Phosphorus (mmol/L) & 1.96 \selectlanguage{ngerman}± 0.49 &\tabularnewline
Potassium (mmol/L) & 4.76 \selectlanguage{ngerman}± 0.63 &\tabularnewline
Low density lipoprotein cholesterol (mmol/L) & 1.96 (1.49, 2.60)
&\tabularnewline
High density lipoprotein cholesterol (mmol/L) & 0.97 (0.76, 1.19)
&\tabularnewline
Triglyceride (mmol/L) & 3.93 (3.34, 4.83) &\tabularnewline
Total cholesterol (mmol/L) & 1.45 (0.86, 2.10) &\tabularnewline
Parathyroid hormone (pg/mL) & 263.7 (157.8, 457.6) &\tabularnewline
Fluid removal (L) & 2.0 \selectlanguage{ngerman}± 0.84 &\tabularnewline
\bottomrule
\end{longtable}

Data are presented as mean \selectlanguage{ngerman}± SD or median (25th to 75th percentile).

Table 2 Conventional echocardiographic parameters of patients\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
Measurement & Pre-hemodialysis (n= 64) & Post-hemodialysis (n= 64) &
Controls (n= 29) & \emph{P\textsubscript{1}} -value &
\emph{P\textsubscript{2}} -value & \emph{P\textsubscript{2}}
-value\tabularnewline
SBP (mmHg) & 143.9 \selectlanguage{ngerman}± 20.3 & 132.1 \selectlanguage{ngerman}± 20.0 & 118.9 \selectlanguage{ngerman}± 15.8 & <0.001 &
<0.001 & <0.001\tabularnewline
DBP (mmHg) & 86.0 \selectlanguage{ngerman}± 13.7 & 84.0 \selectlanguage{ngerman}± 13.5 & 75.9 \selectlanguage{ngerman}± 11.4 & 0.072 & 0.017 &
0.017\tabularnewline
IVSd (mm) & 11.0 (10.0, 12.0) & 11.0 (10.0, 12.0) & 9.0 (8.0, 9.0) &
0.712 & <0.001 & <0.001\tabularnewline
PWd (mm) & 10.0 (9.0, 11.0) & 10.0 (9.0, 11.0) & 8.0 (8.0, 9.0) & 0.591
& <0.001 & <0.001\tabularnewline
LVEDV (ml) & 91.0 (76.0, 103.5) & 73.5 (55.5, 83.0) & 71.0 (63.0, 77.0)
& <0.001 & 0.001 & 0.001\tabularnewline
LVESV (ml) & 34.0 (27.0, 41.5) & 27.0 (21.0,35.0) & 27.0 (22.0, 30.0) &
<0.001 & 0.01 & 0.01\tabularnewline
LVSV (ml) & 54.5 (48.5, 65.0) & 41.5 (35.0, 52.0) & 43.0 (39.0,50.0) &
<0.001 & 0.001 & 0.001\tabularnewline
LVEF (\%) & 61.8 \selectlanguage{ngerman}± 5.87 & 60.7 \selectlanguage{ngerman}± 6.41 & 62.1 \selectlanguage{ngerman}± 4.50 & 0.250 & 0.947 &
0.947\tabularnewline
RA (mm) & 38.7 \selectlanguage{ngerman}± 4.47 & 34.2 \selectlanguage{ngerman}± 4.52 & 33.7 \selectlanguage{ngerman}± 1.76 & <0.001 & <0.001 &
<0.001\tabularnewline
RV (mm) & 34.4 \selectlanguage{ngerman}± 3.76 & 31.0 \selectlanguage{ngerman}± 3.02 & 31.2 \selectlanguage{ngerman}± 2.36 & <0.001 & 0.028 &
0.028\tabularnewline
HR (bpm) & 76.1 \selectlanguage{ngerman}± 10.29 & 78.1 \selectlanguage{ngerman}± 10.81 & 70.2 \selectlanguage{ngerman}± 10.80 & 0.208 & 0.115 &
0.115\tabularnewline
CO (l/min) & 6.96 (6.23, 8.08) & 6.08 (5.41, 7.59) & 5.4 (4.37, 5.89) &
0.023 & <0.001 & <0.001\tabularnewline
LAV (ml) & 60.5 (44.5, 82.5) & 45.0 (34.5, 63.5) & 33.0 (30.0, 38.0) &
<0.001 & <0.001 & <0.001\tabularnewline
LAVI (ml) & 38.0 (28.7, 51.4) & 28.9 (22.0, 37.2) & 20.4 (17.9, 23.7) &
<0.001 & <0.001 & <0.001\tabularnewline
E-wave (cm/s) & 81.5 (69.0, 108.0) & 61.5 (52.5, 73.0) & 75.5 (62.0,
84.5) & <0.001 & 0.002 & 0.002\tabularnewline
A-wave (cm/s) & 88.0 (70.0, 110.0) & 80.0 (68.5, 101.5) & 66.5 (56.0,
85.0) & <0.001 & <0.001 & <0.001\tabularnewline
E/A & 0.90 (0.75, 1.18) & 0.80 (0.60, 0.97) & 1.13 (0.80, 1.70) &
<0.001 & 0.136 & 0.136\tabularnewline
EDT (ms) & 205.27 \selectlanguage{ngerman}± 67.51 & 201.98 \selectlanguage{ngerman}± 52.97 & 186.64 \selectlanguage{ngerman}± 42.88 & 0.718 &
0.211 & 0.211\tabularnewline
Septal e' (cm/s) & 7.14 \selectlanguage{ngerman}± 2.27 & 6.22 \selectlanguage{ngerman}± 1.95 & 9.02 \selectlanguage{ngerman}± 3.04 & <0.001 &
0.006 & 0.006\tabularnewline
Lateral e' (cm/s) & 10.07 \selectlanguage{ngerman}± 3.28 & 8.65 \selectlanguage{ngerman}± 3.13 & 12.25 \selectlanguage{ngerman}± 3.89 & <0.001
& 0.013 & 0.013\tabularnewline
E/e' & 9.50 (7.35, 12.65) & 8.30 (7.0, 10.79) & 7.0 (5.90, 8.70) & 0.108
& 0.001 & 0.001\tabularnewline
PASP (mmHg) & 28.0 (25.0, 33.5) & 26.0 (22.5, 29.0) & 23.5 (21.5, 25.0)
& 0.001 & <0.001 & <0.001\tabularnewline
Grading of LVDD (n, \%) & Grading of LVDD (n, \%) & Grading of LVDD (n,
\%) & Grading of LVDD (n, \%) & Grading of LVDD (n, \%) & Grading of
LVDD (n, \%) & Grading of LVDD (n, \%)\tabularnewline
Normal & 28 & 37 & 29 & & &\tabularnewline
Grade 1 & 1 & 9 & 0 & & &\tabularnewline
Grade 2 & 17 & 10 & 0 & & &\tabularnewline
Indeterminate & 18 & 8 & 0 & & &\tabularnewline
\bottomrule
\end{longtable}

Data are presented as mean \selectlanguage{ngerman}± SD or median (25th to 75th percentile).

\emph{P\textsubscript{1}} -value:comparison between pre- and
post-HD;\emph{P\textsubscript{2}} -value:comparison between pre-HD and
controls; SBP:Systolic blood pressure; DBP: Diastolic blood pressure;
IVSd: Interventricular septum thickness at end-diastole; PWd: left
ventricular posterior wall thickness at end-diastole; LVEDV: left
ventricular end-diastolic volume; LVESV: left ventricular end-systolic
volume ;LVEF: Left ventricular ejection fraction; RA: Right atrium minor
axis dimension; RV: Right ventricular basal diameter; HR: Heart rate;
CO: cardiac output; LAV: left atrial volume; LAVI: left atrial volume
index; E-wave: Peak velocity in early diastole; A-wave: Peak velocity in
late diastole; E/A: mitral inflow peak early velocity (E)/mitral inflow
peak late velocity (A); DT: deceleration time; Septal e': Septal mitral
annulus velocity; Lateral e': Lateral mitral annulus velocity; E/e'=
Mitral valve E-wave / Average e' ratio; PASP: Pulmonary artery systolic
pressure; LVDD: left ventricular diastolic dysfunction.

Table 3 Left ventricle and left atrium deformation parameters\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
Measurement & Pre-hemodialysis (n= 64) & Post-hemodialysis (n= 64) &
Controls (n= 29) & \emph{P\textsubscript{1}} -value &
\emph{P\textsubscript{2}} -value\tabularnewline
GLS (\%) & -20.70 (-18.55, -23.10) & -17.85 (-14.90, -20.4) & -21.7
(-20.6, -22.7) & <0.001 & 0.322\tabularnewline
GLS epi (\%) & -17.65 (-15.95, -19.95) & -14.95 (-12.70, -17.65) & -19.2
(-18.3, -20.2) & <0.001 & 0.112\tabularnewline
GLS endo (\%) & -24.15 (-22.0, -26.75) & -21.05 (-17.40, -23.95) & -24.6
(-23.4, -25.3) & <0.001 & 0.854\tabularnewline
PSD (ms) & 42.16 \selectlanguage{ngerman}± 14.93 & 51.05 \selectlanguage{ngerman}± 18.72 & 32.72 \selectlanguage{ngerman}± 11.16 & 0.002 &
0.011\tabularnewline
LASr (\%) & 28.0 (23.0, 34.5) & 26.0 (21.0, 29.0) & 43.0 (36.0, 48.0) &
0.003 & <0.001\tabularnewline
LAScd (\%) & -15.5 (-10.0, -21.5) & -12.0 (-9, -15.5) & -24.0 (-18.0,
-32.0) & 0.006 & 0.025\tabularnewline
LASct (\%) & -12.0 (-9.0, -16.0) & -12.5 (-9, -15.5) & -17.0 (-15.0,
-22.0) & 0.965 & <0.001\tabularnewline
\bottomrule
\end{longtable}

Data are presented as mean \selectlanguage{ngerman}± SD or median (25th to 75th percentile).

\emph{P\textsubscript{1}} -value:comparison between pre- and
post-HD;\emph{P\textsubscript{2}} -value:comparison between pre-HD and
controls; GLS: left ventricular longitudinal global strian of
midmyocardium; GLS epi: left ventricular longitudinal global strian of
subepicardium; GLS endo: left ventricular longitudinal global strian of
subendocardium; PSD: peak strain dispersion; LASr: left atrial reservoir
strain; LAScd: left atrial conduit strain; LASct: left atrial
contractile strain.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Figure 1: Echocardiographic indices of LV diastolic function. Panel a:
Apical 4-chamber image with peak E and peak A of mitral valve flow
spectrum; Panel b: septal e' ; Panel c: lateral e' ;Panel d: peak TR
velocity; Panel e and f: biplane method to acquire left atrial volume
index.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

Figure 2: Bull's eye map for GLS. Panel a: results of pre-HD; Panel b:
results of post-HD. (endo: subendocardium, mid: midmyocardium, epi:
subepicardium).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

Figure 3: Left atrial strain curves. Panel a: results of pre-HD; Panel
b: results of post-HD. (LASr: left atrial strain during reservoir phase,
LAScd: left atrial strain during conduit phase, LASct: left atrial
strain during contraction phase).

\textbf{Hosted file}

\verb`\begin{CJK}{UTF8}{gbsn}图片.\end{CJK}\selectlanguage{english}docx`  available at \url{https://authorea.com/users/753246/articles/723599-effect-of-hemodialysis-on-left-atrial-function-in-patients-with-end-stage-renal-failure-evaluated-by-two-dimensional-speckle-tracking-imaging}

\textbf{Hosted file}

\verb`\begin{CJK}{UTF8}{gbsn}表格.\end{CJK}\selectlanguage{english}docx`  available at \url{https://authorea.com/users/753246/articles/723599-effect-of-hemodialysis-on-left-atrial-function-in-patients-with-end-stage-renal-failure-evaluated-by-two-dimensional-speckle-tracking-imaging}

\selectlanguage{english}
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\end{document}

