The Heart in Acute Glomerulonephritis:

Echocardiographic
Study
Pnina

Vardi,

M.D.,

Egon Riss, M.D.,

Walter

Front the !)epartment.sKbiousbiy

School

Markiewicz,

and Abraham

of

of Pediatrics,
.%hdicine,

Haifa,

ABSTRACT.
Patients
with acute
glomerulonephritis
often
are seen with signs suggesting
heart
failure.
Whether
these
signs
are due to fluid overload
secondary
to kidney
damage
only, or whether
there
is associated
inyocardial
damage
has
not been elucidated.
Fourteen
children
with acute glomerulonephritis
were
studied
by echocardiography
during
the
edematous
phase
of the disease
and five months
later
to
evaluate
cardiac
function
in this disease.
Left ventricular
size
and function
remained
normal
in all children
throughout
the
study.
The
most
consistent
finding
was enlargement
of the
left atrium
during
the edematous
phase with a return
toward
normal

values

five

nionths

later.

There

was

no

correlation

between
blood
pressure
and the echocardiographic
findings.
This
study
suggests
that
signs
of heart
failure
in acute
glomentlonephritis
are not due to myocardial
damage
but
probably
reflect
fluid overload.
Pediatrics
63:782-787,
1979,
echocardiography,
acute
glornerulonephritis,
heart
failure,
left

atrial

enlargement.

M.D.,

Benderley,

Cardiology,

Joseph

and

disease,

Diagnostic

for

anemia

one

due

admission
a

full

tis

signs

(AGN),

and

symptoms

suggesting

tive
heart
failure
develop.
investigations,
it is not clear
function
is depressed
in this
the

signs

suggesting

overload,
In

sion.i
children
further

heart

or to other
this study,
with
insight

AGN
into

failure

are

clinical

factors
such
we evaluated

of

patients.

Fourteen

epidemic
classic

and
tration

(G3).
782

children

were

of

AGN

edema,

studied

of the third
None
had

0 titer
component

previous

during

AGN.

On

12-lead

of the
performed

all

subjects,

on

right
the

aortic

ejection

dimensions

(Fig

were

leaflets.

at end

systole

evaluated

1).

Left

at

atrial

from

and

from

obtained

Left

aortic
posterior

was

fractiont

shortening

of

pericardiuni.

state

of fractional

dimensions

evaluation

interventricu-

and

contractile

calculating

ventricular

for

ventricle,

ventricle,

ventricular

percentage

used

left

the

left

atrial

the

and

level

dimension

wall
to the
atrial
wall

the

the

of
was

anterior

border

strong
echo

anterior
(Fig
2).

Aortic
dimension
The upper
limit
aorta,
and left

was measured
at end diastole.
for normal
values
of left atrium,
ventricle
used
in the study
are

those

by

reported
on

the

Feigenbaunr
l)ody

surface

and
area.

varied
The

deupper

an

All had

including

elevated

antistreptolysin

including

in

4).

underwent

METHODS

of poststreptococcal
signs

proteinuria,

AND

no.

roentgenogram
studies
were

were

left atrium,

septum,

pending
PATIENTS

of

techniques

measured

to gain
of these

Aba

7.5

of the posterior
edge
of the

by echocardiography
the
cardiac
status

Center,

all children

admission

days

due

as hypertena group

(subject

hospital,
examination

two

the

fluid

.Iedieal

discharge
from the hospital
in eight subjects,
and
five months
thereafter
in all 14 subjects.
The ultrasonic
studies
were
performed
on an
ultrasonoscope,
using
a 2.25
MHz
transducer
focused
at
cm, and a recorder.
All the children
were
examined
in the semi-left
lateral
decubitus
position
with
the head
elevated
by a wedge.

aortic

to

thalassemia

within

conges-

to

to the

numerous
myocardial
or whether

Despite
whether
disease,

Ra7nbanl

and

by

glomenilonephri-

Radiology,

electrocardiogram
chest.
Echocardiographic

Left
acute

M.D.,

all had
previously
been
healthy,
child who had chronic
hemolytic

and

except

lar

with

Olga Adler,

Israel

Routine

patients

Levy, M.D.,

M.D.

the aorta,

In many

An

hematuria,

sedimentation

and

the
rate,

depressed

concen-

of the

complement

history

of

kidney

Received
1978.
ADDRESS
rics A,

April
FOR
Rambam

7; revision

REPRINTS:
Medical

accepted
(P.V.)
Center,

for publication
Department
Haifa,
Israel.

PEDIATRICS
Vol. 63 No. 5 May 1979
Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on January 16, 2015

August
of Pediat-

8,

#{149}cg

T*

1. Representative
admission
(left) and

(ACW

unchanged.

limit

for

normal

left

noinial

is

1.26,

ejection

shortening

6) echocardiographic
examination
of the ventricles
taken
on
later (right).
Left ventricular
end diastolic
dimension
remains
chest
wall;
RV
right
ventricle;
IVS
interventrictilar
left ventricle;
En = endocardium;
P
pericardium.)

anterior

LV

se1)ttllll;

laboratory

atrial-aorta

whereas

fraction

ratio

the
and

in children

II

(subject
five months

Fig

lower

percent

is 55%

and

in

our

years).

for

sq

limit

findings

of fractional

25%,

Mean

m with

on

in Table

respective-

ly.
For

the

was

when
blood
Hg.
Left

flilli

diagnosed

Liebm

of this

pllIpose

an

by

Chest

was

hypertension

EGG

using

was

criteria

roentgenograms

by an exl)erienced
cardiotnegalv
and
sis

studs,

pressure
ventricular

performed

using

t-tests

for

analysis

sions,

and

using

correlation
l)etWeen
and
increased
size

of

none

by

two-tailed

paired

in

Fisher

exact

the presence
or thickness

cardiac
test

dimenthe

of hypertension
of heart
cham-

bers.
RESULTS
There
of 6.7

were

0.9

eight
years

boys
(mean

and

six girls

SEM)

with
(range

an
3 to

was

of

receiving

echocardiogram
dren
had
normal
bicarbonate,
and
study.

Student

for

were

intramuscular
evidence

third

reviewed

for
evidence
of
Statistical
analy-

changes

the

suggested

age
12

area

0.5

admission

hypertension

and
had

were

radiologist
heart
failure.

was

higher
than
hvpertrophy

surface
of

to

and

1.2

at

was
sq

m.

Mean

body

treated

with

injections
residual
any

0.8 1
The

are

water

an enlarged

rest,
with

restriction

at the

None
and
time

the

was performed.
All chilsodium,
potassium,
chloride,
calcium
values
throughout
the
weight

was

22.4

2.3

admission
and
21.0 2.3
kg
on
(P < .01).
Mean
heart
rate
increased
80.6 5.1 to 92.3 3.9 beats per minute
the same
period
(P < .05).
The echocardiographic
findings
are
Table
II, and the correlation
of selected
diographic
data with roentgenographic
cal findings
is given
in Table
III. Eleven

had

given

by bed
Patients

of reserpine.
kidney
damage,

treatment

0.06

clinical

discharge

I. All children
were
treated
diet, and penicillin.

low-potassium

diagnosed
1:30/90

body
a range

left

atrium

on admission.

ARTICLES
Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on January 16, 2015

kg

on

discharge

from
during
given
in
echocarand clinichildren
Left

783

2. Representative
echocardiographic
study of the aorta and left atrium
of the same patient,
showing
reduction
of left atrial
size from 3.4 cm on admission
(left) to 2.8 cm five months
later
(right).
(RVOT
= right ventricular
outflow
tract;
AAo = anterior
aortic
wall; PAO = posterior
aortic
wall;
Ao = aorta;
LA
left atrium.)
Fig

TABLE
FINDINGs

CLINICAL

atrial

14 CHILDREN

IN

WITH

ACUTE

CLOMERULONEPHHITIS

Clinical

bindings

Number

of

Patients

The
On

On
Adm

Proteinuria,

cylindruria

<20
rng/dl
on ECGt

Cardiolnegaly

on

roentgeno-

...

...

the

grainl

Congestive
heart
roentgenogram
#{176}Nlean of

tLVH
:1:(;htst

two

Left

failure

weeks

on

later.

ventricular

roentgenograln

hypertrophy.
was

not

available

for

review

patient.

784

HEART IN GLOMERULONEPHRITIS

to normal

values

in all but

one

mean

left

atriumaorta
reduced

in

one

first

study

(P

ratio
from

was
1.61

similarly
0.07

to

.01) during
the same
period.
Seven
of eight
children
already
demonstrated
a
reduction
in the left atrial
size when
studied
at
the end of hospitalization,
a mean of 14 days after

0
0
0
0
0

14
14
10
0

edema

returned

significantly
1.33 0.05

is5

Hypertension

Clinical

BUN
LVH

ission

size

subject
when
measured
five nionths
later.
Mean
left atrial
size was 3. 1 1 0. 14 cm on admission
vs 2.52
0.10
cm five months
later
(P < .01).

<

had

been

done.

Five

of these

seven

children
demonstrated
a further
reduction
in left
atrial
size when
studied
five months
later.
Left
ventricular
internal
dimension,
percentage
of
fractional
shortening,
and ejection
fraction
were
normal
in all children
throughout
the
study.
There
was a small but significant
decrease
in the
thickness
of the interventricular
septum
(P < .05)
and of the left ventricular
posterior
wall (P < .05)

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on January 16, 2015

TABLE

II

ECHOCARDIOGRAPHIC

FINDINGS

hnthng

Mean

On Admission
Left

atrium

(ES)t

(cm)

Left

atrium/aorta
Aorta
(cm)
(ED)
Left

ventricular

internal
septum

Left

ventricular

posterior

Right

ventricle

Ejection

5N
tES
IED

change

the

study

was

observed

right

ventricle.

noted
atrial

between

left

shortening

of patients

with

adequate

5 Months

Later

0.14
0.07
0.10
0.15

2.52
1.33
1.91
3.68

0.10
0.05
0.07
0.13

0.05
0.06
1.16 0.15
79 1.7
41 1.7

0.50

0.48

3.11
1.61
1.96
3.65

0.61

0.58

0.04
0.04
0.85 0.08
78 2.5
41 2.3

echocardiographic

N#{176}

<.01
<.01
NS
NS

14
14
14
12

<.05
< .05

12
12
12
12
12

NS

NS
NS

measurements.

diastole.

whereas

in the

no

size

of the

significant

aorta

In many

and

relationship

wall

posterior

DISCUSSION

significant
tis,

was

presence
of hypertension,
and increased
thickness

enlargement,
ventricular

End

No

(cm) (ED)

systole.

period,

the

wall

of fractional

End

(ED)

(cm)

(%)

Number

(cm)

(ED)

(cm)

fraction

Percentage

during

dimension

(ED)
Interventricular

SEM

or interventricular

TABLE

Subject
No.

BETWEEN

Echocardio

graphic

(cm)

LVED

8
9
10
11
12
13
14
#{176}LA
=
left

acute

glomerulonephri-

suggesting

congestive

III

ECHOCARDIOGRAPHIC

Findings0

AND

X -Ray

CLINICAL

an d Clinical

FINDINGs

Findingst
-

-5----,

with

symptoms

LA

1
2
3
4
5
6

SELECTED

and

heart
failure
. Various
etiologic
factors
have been put forth
to explain
the appearance
of
heart
failure.
In recent
years,
the attention
has
focused
on
three
possible
causative
factors:

left
of the

septuni.

ConsETIoN

patients

signs

2.9(E)
3.1(E)
2.9(E)
4.0(E)
2.9(E)
3.4(E)
3.3(E)
2.6
3.1(E)
2.3
2.8(E)
2.8
4.2(E)
3.3(E)

(cm)

-.-.----

III
2.4
1.8
1.9
3.2(E)
2.5
2.8
2.8
2.8
2.8
2.2
2.3
2.7
2.6
2.5

%FS

Heart
Siz4

.-

I
3.2
3.4
2.9
3.8
4.2
4.1
4.3
3.8
4.0
2.9
NA
NA
3.2
4.0

111
2.9
3.3
2.8
4.2
3.8
4.1
4.0
3.5
3.8
3.7
3.0
3.2
4.0
4.0

lii

41
35
34
39
45
34
35
47
42
48
NA
NA
50
45

45
45
35
33
47
44
35
25
53
41
46
37
40
50

CDM
CDM
N
CDM
N
N
CDM
N
CDM
CDM
N
NA
CDM
N

BP

CHFI
(mm

+
+

0
+

0
+
+

0
+

0
0
NA
+
0

Hg)

180/120
120/
130/100
150/100
120/
150/110
180/120
120/
140/100
120/
120/
130/
130/
170/120

70

80

80
80
80
80
90

BSA
(sq m)

0.6
0.6
0.6
0.7
0.8
0.9
1.1
0.9
1.1
0.6
0.5
0.7
1.0
1.2

Age
(Years)

3
4
3
5
7

8
10
7
11
3
4
5
12
12

LVED
left ventricular
dimension
at end diastole;
%FS
percentage
of
I and III refer to echocardiographic
measurements
on admission
and five
months
later,
respectively;
E = enlarged;
NA
not available
or inadequate.
tCHF
=
Congestive
heart
failure;
BP
blood
pressure;
BSA = body
surface
area;
CDM
=
cardiomegaly;
NA = not available
or inadequate.
:1:
Found
on chest roentgenogram.
fractional

atrium;

shortening;

ARTICLES

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on January 16, 2015

785

myocardial
volemia

damage,
secondary

Gore

and

mortem
died
of

The

Saphir

found

examination
acute
and

histologic
few

and

of

at

consisted

of
cells
The

in

heart

causing

who

the

interstitial

and
role

cardiac

elevation

of

pulmonary

al

and

De

Fazio

the

pulnionarv
pressure,

et

at

might

The

interpreted

be

has

an

wedge

findings

as

function
changes

overload

a critical

role

of the
the

in

and
ob-

circulatory

in

have
factor

investigators

a causative

red

of

suggested
in the

failure.
However,
other
was a poor
correlation
severity
of hypertension

mass.

Some

that hypertension
development
of

is

authors
noted
that
between
the presence
and the development

study,

function

and

and

during

age
of
fraction
These
dial

after

faulted
ables.

and
throughout

measurements

are

but

response

ultrasonic

the myocardial
during
the
that

the

to changes

increased

subjects

indices

indices

in afterload,4

or

sympathetic
in

were

hypertensive

exam

ination

tone.
our

at the
; increased

was
the

rose

in

time

many

of the

HEART

thickness

AGN

vagal

that

been
phase.

be

the

for

this

ventricular

the
left

Since

noted

between

ventricular
septum

we

and

with

left

walls

during
of the

phenomenon.
was

of the

children

with

of these

are

posteniand the

of the

opinion

was not a causative

factor.
on admission
demonstrated

thickness

dren

wall
the

ventricular
hypentrophy
or
of the myocardmm
by fluid

of hypertension,

three

and
The

interventnic-

increased
overload

thickness
of the left
or of the interventnicular

creased

subjects

posterior
during

thickness

relationship

that hypertension
echocardiogram

all

the

ventricular
significantly

slightly
Diastolic

responsible

significant

in

the disease
the study.

of both

and the left

slightly
but

presence

most

AGN

first

would

cases

The

interventricular
of

the

The
in-

septum

left

ventricular

but

none
of the
evidence
of
contrast
to

In

glomerulonephritis,

rarely

have

hypertrophy

chil-

voltage
and

criteria
tend

to

for
have

of AGN.

most

in our

consistent

study

of the
increased

was

left

one

left

dent

the

echocardiographic
abnormality

atrium.
in all but

edematous

The

afterload

normal

phase
of
throughout

causing
left
infiltration

increased
or wall

hypothesis

tend
to depress
and not to increase
ejection
phase
indices.
Second,
five months
later,
mean
heart
rate nieasured
during
the acute
phase
of AGN
was
significantly
lower
than
during
the recovery
pen-

786

no

but

First,

for

suggesting

could

in response

This

patients.

be

vanto the
of

of

increased

decreased
amplitude
of the R waves
in tracings
taken
early
in the course
of the illness.
This
difference
may be related
to the transient
nature
of the hemodynamic
and pathologic
alterations
in

ejection
study.

may

contractility
acute
phase

measured

unlikely

size

of myocar-

they

by variations
in other
hemodynamic
Thus,
consideration
must
be given

disease,

seems

useful
although

possibility
that
truly
reduced

to

shortening
normal

contractilityli

value

study,

was

edematous
unchanged

chronic

of children
examined
of AGN.
The percentthe

the

patients

heart

the

dimension

during
remained

in two children,
electrocardiographic
hypertrophy.

group
episode

fractional
remained

internal

posterior
wall
children
had
left
ventricular

a
an

on the

not

to the
during

phase

to

there
and
of

present

in

data

hypertensive

attributed

in

we

was

of admission
uncommon

heart

congestion.

In this

tone

time
is not

We think that our findings

indicate
that
left
ventricular
function
was normal
in all the patients
and, therefore,
that
signs suggesting
congestive
heart
failure
cannot
be explained
on the basis of
myocardial
dysfunction.
Likewise,
left ventricular

ventricle
interstitial

vascular

causation

cell

been

might
have
edematous

circulatory
congestion
has
been
advanced
by
others.
Thus
Eisenberg,2
in studying
the
blood
volunie
of ten patients
with
AGN,
found
that
the
plasma
volume
was
significantly
increased
during
the
edematous
phase,
without
alteration

and

has

ulan septum
decreased

resistance.

these

edematous

mean

and

peripher-

to hypervolemia.

that

play

volume,

nivocardial
hemodynamic

due

suggestion
may

stroke

sympathetic
the

tone.

little
or
of such

failure

capillary
and normal
vascular

arteriolar

normal
that
the

served

and

artery

pulmonary

indicating
suggested

tree

output

that

increased
at
Bradycardia

and

been
questioned.
Thus
Davies
found
a normal
cardiac
output
in five patients
with
AGN.
De
Fazio
and associates
studied
seven patients
with
AGN
by cardiac
catheterization
and
found
an
increased

suggesting

unduly
hospital.

post-

160 patients
glomerulonephritis.

inflaiiiiiiatory
cell destruction.

myocarditis

od,

hyper-

disease.

myocarditis

in 16
subacute

findings

edema
with
no myocardial
serious

hypertension,
the renal

to

phase
child

and

when

atrium-aorta

on body

Thus
three

surface

proposed

as a better

similarly

decreased

returned

area
indicator
significantly

in the

size

left
atnial
size
children
during

measured

ratio,

finding

noted

to

normal

in

five

months

later.

which

and

was
the

is less

which
of left
during

all

depen-

has been
atrial
the

size,7
study

period.
The reason
for left atrial
enlargement
has
not
been
directly
investigated
in this
study.
However,
it has been
well documented
that left
atnial
size can markedly
and rapidly
change
in

IN GLOMERULONEPHRITIS

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on January 16, 2015

to

response

variations

in

pulmonary

flow7

or

response
to fluid infusion,
and we think
that
it is
reasonable
to suggest
that
the enlargement
of the
left atriuni
noted
on admission
was secondary
to
the
increase
edematous

The

in
phase

ratio

period

of the

to

the

tioli

of

vascular

time

and

8.

serially

might

have
9.

on the pulmonary
circulapatients.
Since
pulmonic
valve
echonot routinely
obtained,
right
ventnic-

our

ular systolic
in this study.

time

intervals

could

not

be

10.

measured
11.

CONCLUSION
This

study

12.

demonstrates

that

heart
failure
in patients
coccal
glomerulonephnitis
dial
damage
but
probably
Treatment
circulating

should
blood

prove

myocardial

1111

signs

suggesting

with
acute
poststreptoare not due to myocarreflect
fluid
overload.

aini at
volume

reducing
rather

the
than

increased
trying

13.
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function.

TR,

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FD: The heart
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1956.
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18.

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human
subjects.
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ic stimulation.
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787

The Heart in Acute Glomerulonephritis: An Echocardiographic Study

Pnina Vardi, Walter Markiewicz, Joseph Levy, Olga Adler, Egon Riss and Abraham
Benderley
Pediatrics 1979;63;782
Updated Information &
Services

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright 1979 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on January 16, 2015

The Heart in Acute Glomerulonephritis: An Echocardiographic Study

Pnina Vardi, Walter Markiewicz, Joseph Levy, Olga Adler, Egon Riss and Abraham
Benderley
Pediatrics 1979;63;782

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/63/5/782

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright 1979 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on January 16, 2015