Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
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Aug 2018

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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : December | Volume : 16 | Issue : 12 | Page : OC09 - OC13 Full Version

Cardiac Dysfunction in Early Stages of Diabetic Kidney Disease- Fact or Fiction: A Case-control Study

Published: December 1, 2022 | DOI:
Richard Bruno Michael, V Joseph

1. Assistant Professor, Department of Internal Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India. 2. Associate Professor, Department of Internal Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India.

Correspondence Address :
Dr. V Joseph,
Room No. 210, Department of General Medicine, 1st Floor, OPD Block, Pondicherry Institute of Medical Sciences, Ganapathychettykulam, Kalapet, Puducherry-605014, India.


Introduction: The occurrence of kidney dysfunction in diabetics promotes early cardiac dysfunction. The timing of Diabetic Kidney Disease (DKD) and the impact of the stage of DKD on cardiac dysfunction is far from elucidated in current literature.

Aim: To evaluate the association between the early stages of DKD and cardiac dysfunction by echocardiography.

Materials and Methods: The present descriptive, case-control study was conducted in the Pondicherry Institute of Medical Sciences (PIMS), Kalapet, Puducherry, India, from November 2018 to November 2020. All diabetic patients between 25-60 years, who attended the Medicine Outpatient Department (OPD) or were admitted into the medical wards, were screened, among which 280 subjects were selected for the study. Patients with Estimated Glomerular Filtration Rate (eGFR) of more than 45 mL/min/1.73m2 were characterised as cases and those with eGFR of more than 90 mL/min/1.73m2 were controls. Echocardiographic parameters were recorded. Chi-square test, Mann-Whitney U test, and unpaired t-test were used for statistical analysis. Multivariate logistic regression analysis was done using an odd’s ratio to assess the association between early DKD and cardiac dysfunction.

Results: The number of diabetics with early kidney disease (cases) were 139 and without kidney disease (controls) were 141. The mean age of the cases was 54.63±4.84 years and the controls were 52.61±7.916 years. The number of males among the cases and controls were 68 (48.92%) out of 139 and 96 (68.08%) out of 141, respectively. The prevalence of systolic dysfunction among diabetic patients with early kidney disease was 12.23% (17/139) and diastolic dysfunction was prevalent in 99.28% (138/139). Systolic dysfunction was 9.68 times more common in cases (n=139) than in controls (n=141). Women had a 2.6 times higher likelihood, and hypertension had (an independent association which was) a 2.6 times higher likelihood of developing cardiac dysfunction in the early stages of DKD.

Conclusion: Systolic cardiac dysfunction is significantly higher (9.68 times more common) in those with early DKD when compared to those without kidney disease; with female gender and systemic hypertension as independent and significant risk factors.


Diabetic cardiomyopathy, Diabetic nephropathy, Renocardiac syndrome

Type 2 diabetes mellitus, heart failure and chronic kidney disease are the three important pandemics of the 21st century. Type 2 diabetes mellitus affects more than 400 million people worldwide and India contributes up to 49% of it (1). Diabetes mellitus is related to the development of kidney disease which is termed Diabetic Kidney Disease (DKD) and is associated with all causes of cardiovascular mortality (2). Varying degrees of kidney dysfunction is found in 50.4% of the patients with diabetes mellitus (3). Of around 1,20,000 incident cases of End-stage Renal Disease (ESRD), half are attributed to diabetes (4). Type 2 diabetes mellitus is also a powerful risk factor for the development of heart failure. It renders the person two to four times more susceptible to cardiac dysfunction; and two-thirds of all deaths due to heart failure, have type 2 diabetes mellitus (3).

Flash pulmonary oedema, cardiac failure, and sudden cardiac death are more common, among patients with diabetes mellitus, especially those with DKD. This has been called “The Reno Cardiac Syndrome” in recent times (5). Hyperglycaemia of diabetes mellitus, through advanced glycation products, augment Left Ventricular (LV) stiffness and LV mass, resulting in LV diastolic dysfunction without impeding global LV function (5). Advanced Glycation end Product (AGP) deposition results in cross-linking of collagen in the myocardial architecture and causes myocardial fibrosis (5),(6). Both these processes lead to diastolic dysfunction. The occurrence of kidney dysfunction in diabetics promotes early cardiac dysfunction thus setting up a vicious cycle (7). A study has documented this condition as diastolic dysfunction and another has documented as an isolated systolic dysfunction (8),(9). So far, hardly any studies have looked for cardiac dysfunction in early diabetic nephropathy and quantified it. Also, the impact of the stage of DKD on cardiac dysfunction is far from elucidated in current literature. What is known about this is that the hazard ratio for heart failure in those with diabetic nephropathy is 2.22 (95% Confidence interval, 1.51-3.27) (10). LV diastolic dysfunction and E/E’ are predictors of death in patients with diabetic nephropathy (11).

Perhaps early detection and treatment of cardiac dysfunction in DKD could diminish morbidity and mortality too. So, this study aimed to evaluate the association between the early stages of DKD and cardiac dysfunction (by echocardiography). The primary objective was to determine the proportion of patients with cardiac dysfunction among those with early stage DKD. The secondary objective was to determine the magnitude of cardiac dysfunction and the associated risk factors.

Material and Methods

This descriptive, case-control study was conducted in the Pondicherry Institute of Medical Sciences (PIMS), Kalapet, Puducherry, India, from November 2018 to November 2020. The approval of the Institutional Research and Ethics Committee was obtained (RC/18/72).

Sample size calculation: The prevalence of cardiovascular disease in patients with mild renal impairment (glomerular filtration rate >50 mL/min) was assumed to be 30% (12). A total of 280 patients were required to establish the association between DKD and cardiac dysfunction with 95% confidence interval and 7% precision. A total of 536 patients were screened, 296 were selected and 16 repeat entries were removed from the database during the final analysis. Thus, 280 participants were included in the study.

Inclusion criteria: All diabetic patients {fasting plasma glucose ≥126 mg% or random plasma glucose ≥200 mg% or glycated haemoglobin (HbA1c) ≥6.5} between 25-60 years who attended the medicine OPD or were admitted into the medical wards were screened.

Estimated GFR (eGFR) was calculated using the CKD-EPI formula (13):

In men (eGFR)=141×min (SCr/κ, 1)α×max (SCr/κ, 1)-1.209

In women (eGFR)= 141×min (SCr/κ, 1)α×max (SCr/κ, 1)-1.209×1.018

Participants whose GFR was more than 45 mL/min/1.73 m2 BSA were included in the study. Glucose profile and urine albumin excretion were done in all recruited patients; who then underwent a Master’s 2 Step Stress Test before echocardiography.

Exclusion criteria: Patients who failed the test, and who were on drugs that suppress myocardial function were excluded from the study.

The patients were divided into cases and controls:

Cases: Patients with eGFR of more than 45 mL/min/1.73m2 were characterised as cases and

Controls: Patients with eGFR of more than 90 mL/min/1.73 m2 were controls.

Study Procedure

Echocardiographic parameters were recorded in the case report form. The treatment of participants was decided by the treating physician. Glucose profile and urine albumin excretion were done in all recruited patients; who then underwent a Master’s 2 Step Stress Test before echocardiography.

Echocardiography was done using Philips i33 Echocardiography machine. Diastolic dysfunction was evaluated by pulsed doppler echocardiography according to recommendations of the American Society of Echocardiography. Pulsed-wave Doppler (PWD) derived transmitral inflow velocities were obtained in the apical 4-chamber view, with the sample volume placed at the mitral valve leaflets’ tips. Measurements included the transmitral early diastolic rapid filling (E-wave) and atrial contraction late filling (A-wave) velocities to calculate the E/A ratio, Isovolumetric Relaxation Time (IVRT) and Deceleration Time (DT).

For Tissue Doppler Imaging (TDI), the mitral annulus velocity was obtained with a 2 mm sample volume on the lateral side and septal side of the mitral annulus. Diastolic dysfunction was labeled according to the standard guidelines. LV overall ejection fraction (systolic function) was calculated by modified Simpson’s method, and LV Ejection Fraction (LVEF) ≥50% was considered normal. Echocardiography was done by the principal investigator and 10% of the total sample size was scrutinised by an expert. Left ventricular diastolic dysfunction was assessed as (14):

- Grade 1: Mitral E/A ratio ≤0.8;
- Grade 2: Mitral E/A ratio >0.8 but less than 2;
- Grade 3: Mitral E/A ratio ≥2

In 2D echocardiography, the following parameters were measured with TDI: Inter ventricular septal thickness, posterior wall thickness, LV diastolic diameter, LV systolic diameter, fractional shortening, Left Atrial (LA) diameter, end diastolic volume, end systolic volume, LVEF, time to peak filling rate, E/A ratio, DT, IVRT, LA length in systole and diastole, LA area in systole and diastole, LA volume, Tissue doppler in the lateral and septal wall, E/E’ (E’ denotes the mitral annular early diastolic velocity).

The following parameters were included:

E/E’ >14, Septal E’< 7 cm/s, Lateral E’ <10 cm/s, LA Volume >34 mL/m2, E <50 cm/s, E> 50 cm/s, E/A: >2, E/A: 0.8-2, E/A: <0.8, DT >240 ms, IVRT >90 ms.

E/A Ratio

The rapid early diastolic filling was measured by echocardiography and denoted by E. The late diastolic filling was measured as atrial systole A. Based on the patterns obtained on the transmitral doppler inflow, the different stages of diastolic dysfunction were ascertained. This is represented as the E/A ratio.

E/E’ Ratio

E’ denotes the mitral annular early diastolic velocity. E represents the rapid early diastolic ventricular filling. E/E’ represents the best measure of mean LV end-diastolic pressure in a normal heart.

Statistical Analysis

Data were entered into Microsoft Excel and analysed using the Statistical Package for the Social Sciences (SPSS) software for windows. Descriptive statistics like mean and standard deviation were used for quantitative variables and frequency or percentage for qualitative variables. Chi-square test, Mann-Whitney U test, and unpaired t-test were used for association. The p-value ≤0.05 was considered significant. Multivariate logistic regression analysis was done using an odd’s ratio to assess the association between early DKD and cardiac dysfunction.


In total sample, early-stage DKD (cases) was identified in 139 (25.93%) participants among whom the majority were males. The mean age was 53.6 years. The mean creatinine was within normal limits but the mean Low Density Lipid Cholesterol (LDL-C) and Glycated Haemoglobin (HbA1c) were high (Table/Fig 1),(Table/Fig 2).

The prevalence of systolic dysfunction among the cases was 12.23% (95% CI: 7.8-18.7) and diastolic dysfunction was prevalent in 99.29% (Table/Fig 3).

The mean±SD age among the cases was 54.63±4.84 years and for controls was 52.61±7.916 years. The majority of the cases were females (51.08%) in the age group of >55 years (61.15%). Among controls, the majority were males (68.1%) in the age group of >55 years (56.03%). This age difference was statistically insignificant. There were 48.92% and 68.1% males in the cases and controls, respectively, this gender difference was statistically significant. 20.14% cases and 21.28% controls had nicotine dependence; 19.42% cases and 19.86% controls had alcohol dependence. Neither was statistically significant.

Among the cases, 69.06% had diabetes for >5 years, 37.41% had hypertension and 13.67% had Coronary Artery Disease (CAD). In the control group, 63.12% had diabetes for >5 years, 18.4% had hypertension and 3.55% had CAD. The cases had a longer duration of diabetes which was statistically insignificant. The association between hypertension and CAD, with early DKD, was statistically significant.

The fasting blood sugar, postprandial blood sugar, HbA1c levels, and urine albumin creatinine ratio were comparable between the groups. However total cholesterol, LDL cholesterol, and triglycerides levels were significantly higher among the cases (Table/Fig 2),(Table/Fig 4).

Multivariate logistic regression analysis was applied to determine the independent role played by important predictors which resulted in cardiac dysfunction in diabetics with early stages of DKD. Hypertension, CAD and dyslipidemia did not contribute to the development of cardiac dysfunction. However, cardiac dysfunction in women with diabetes and early stages of DKD showed a 3.4 times higher likelihood of developing cardiac dysfunction (Table/Fig 5).

Diabetes and hypertension are closely related to CAD. To understand the independent risk involved with the risk factors, a subgroup analysis excluding CAD was performed which showed that women had a 2.6 times higher likelihood; and hypertension had a 2.6 times higher likelihood of developing cardiac dysfunction in the early stages of DKD. Similarly, elevated LDL levels’ association was established with statistical significance but the Odd’s ratio was nearly one (Table/Fig 6). Also, systolic dysfunction was 9.68 times more common in cases than in controls (Table/Fig 7).


The association of cardiac dysfunction in ESRD is well established, but at what stages of DKD and how the stage of DKD is related significantto major or minor cardiovascular events is still not sufficiently researched. Hence, the present study aimed to study and assess the prevalence of cardiac dysfunction in the early stages of DKD.

Among cases, 12.23% had systolic dysfunction, and a majority (88.49%) had grade 2 diastolic dysfunction. Diabetic cardiomyopathy is a discrete clinical entity that can develop irrespective of the traditional risk factor of CAD and hypertension (15). Cardiomyopathy can present phenotypically as either diastolic or systolic dysfunction (16). It is therefore likely that this cardiac dysfunction signifies diabetic cardiomyopathy.

A prospective case-control study by Patil VC et al., observed 54.33% (n=69) of the cases to have significant diastolic dysfunction similar to this study, but the cases in this study included diabetic subjects with early kidney disease and controls included diabetic subjects without early kidney disease (8). In contrast, a study by Ernande L et al., was the first to observe systolic dysfunction despite normal diastolic function, emphasises that diastolic dysfunction should not be considered the first marker of preclinical diabetic cardiomyopathy (9). Contrarily, systolic strain abnormality may be proposed as the first indicator of diabetic cardiomyopathy and as a therapeutic target. But in this study, there were greater proportions of diabetics with simultaneous diastolic and systolic dysfunction. Ernande L et al., also found a 47% prevalence of diastolic dysfunction, with 33% being a grade I and 14% being grade II; but this study had a higher prevalence of grade 2 diastolic dysfunction (9). The high variability in the prevalence of diastolic dysfunction (23-75%) is due to variability in study subjects’ and differences in the methods adopted for determination.

A study by Di Bonito P et al., found TDI helpful in detecting cardiomyopathy early in diabetics and lesser duration of diabetes despite normal cardiac functions; which was associated with insulin resistance (17). Similarly, another study by Otsuka T et al., found LV diastolic dysfunction even in patients with early stages of CKD (18). These subtle changes due to kidney disease could be detected by TDI as in this study too. By TDI method, a few authors have shown both diastolic and systolic cardiac dysfunction in diabetics (8),(19),(20). However, most of the subjects in those studies had hypertension and obesity which could have contributed to diastolic dysfunction. Most of those studies used the TDI technique in diabetics to evaluate early cardiomyopathy as did this study.

Secondary Objective

The secondary objective was to determine the risk of cardiac dysfunction among diabetics with early stage kidney disease. To ascertain this, the proportion of cardiac dysfunction among those with and without early kidney disease was compared. Systolic cardiac dysfunction was significantly higher in those with early DKD with female gender and systemic hypertension as independent and significant risk factors.

A study by Fiseha T and Tamir Z found the prevalence of CKD to be 46.9% in participants above 60 years and 22.6% in those below 60 years; also, the prevalence of CKD was lower in men (14.8%) than in women (36.9%) which concurs with this study (21). In contrast to this study, Ravindran R et al., found the prevalence of nephropathy among diabetics to be 13%. A lower prevalence was due to the exclusion of patients with uncontrolled hypertension (22).

Ravindran R et al., and Anjana RM et al., found smoking and alcohol consumption to be risk factors for diabetes (22),(23). Unnikrishnan RI et al., also recorded a significant correlation between smoking and the development of diabetic nephropathy and their findings were in contradiction to this study (24). The contradiction is probably because this study focussed on patients with early DKD. This meant a shorter duration of diabetes mellitus. Had the duration of diabetes been longer an association may have been observed?

In a study by Veeramani Kartheek As and Srinivas Reddy VC, 97.4% of patients with albuminuria had statistically significant LVH, also there was an association between the findings of 2D-Echo and lipid profile; an elevated serum cholesterol level of >200 mg/dL correlated well with systolic dysfunction (15.38%), diastolic dysfunction (41.67%) and a combined systolic and diastolic dysfunction (10%) all of which were statistically significant (25). In this study, a higher prevalence of global hypokinesia in patients with elevated total serum cholesterol value of >200 mg/dL was noted, with statistical significance. Furthermore, on univariate analysis, systolic dysfunction was 9.68 times more common in cases than in controls.

Earlier studies, have shown hypertension and diabetes (despite the influence of the kidneys) to have a profound effect on cardiac function emphasising interorgan dependence (25),(26),(27). A few other studies chiefly Chinese, have reported the development of diabetic complications such as CAD, heart failure, stroke and ESRD with the onset of diabetes rather than the onset of DKD (28),(29),(30). Univariate analysis of demographic and biochemical parameters among cases and controls showed female gender, hypertension and CAD to pose a greater risk of developing diastolic dysfunction. Also, elevated urea levels and dyslipidaemia (elevated LDL and TCL) contributed to diastolic dysfunction. These findings suggest that uraemia and hyperlipidaemia increase the risk of cardiac dysfunction in patients with early renal disease. So, it may be inferred that treatment of dyslipidemia could play a role in retarding the progression of cardiac dysfunction in patients with early diabetic nephropathy. On performing a multivariate logistic regression analysis, it was observed that the female gender is a statistically significant risk factor. Hypertension, CAD and dyslipidemia as risk factors were statistically insignificant.

The occurrence of LV diastolic dysfunction before the onset of systolic dysfunction in the presence of early stages of kidney disease has been documented by Otsuka T et al., in the Japanese population (18). In a Danish Study by Poulsen MK et al., impaired cardiac relaxation has been observed in the diabetic population (31). Both those studies suggested that age, female gender, and uncontrolled hypertension may contribute to the development of cardiac dysfunction. An Indian study by Chandey M et al., observed that diastolic dysfunction was present in 81% of the studied population, of which 43.2% were males and 56.7% were females. Thirty-five out of 45 (77.8%) males and 46 out of 55 (83.6%) females had diastolic dysfunction, although LV diastolic dysfunction was more prevalent in females (32). To address this association between early stage DKD and the development of cardiomyopathy; and to exclude the dependent variable of CAD, a subgroup analysis was done which concurred with the established data; that is, age, female gender, and hypertension contributed to the development of cardiomyopathy.

Diabetes is a robust risk factor not only for cardiovascular disease but also for the progress of CKD (33). The risk of early-stage renal disease increases by 12-fold with diabetes (34). Roughly 40% of diabetics have signs of CKD upon screening for decreased eGFR and albuminuria (35). Even though subjects with CKD, mostly those with DKD, frequently have concomitant traditional risk factors for cardiovascular disease, these do not fully explain the augmented incidence of cardiovascular events and mortality (36). In addition, a few traditional risk factors such as dyslipidemia, systemic hypertension, and obesity have shown an inverse association with cardiovascular disease in subjects with advanced CKD. Hence, through this study, it was found that there exists an increased prevalence of cardiomyopathy in diabetic patients with early kidney disease, especially in those with modifiable risk factors of systemic hypertension, CAD and dyslipidemia; and the non modifiable risk factor i.e., female gender.


Asymptomatic/symptomatic CAD was not ascertained by coronary angiography.


Systolic cardiac dysfunction was present in 12.23% of patients and diastolic cardiac dysfunction in nearly 90% of those with type 2 diabetes mellitus and early-stage kidney disease (ASE Guidelines 2017). Systolic cardiac dysfunction is significantly higher (9.68 times more common) in those with early DKD when compared to those without kidney disease with female gender and systemic hypertension as independent and significant risk factors. Controlling modifiable risk factors of systemic hypertension and dyslipidemia could play an important role in reducing cardiac dysfunction. The very high risk (Odd’s ratio of 3.4) associated with the female gender needs more exploration to determine if additional interventions like physical exercise and weight reduction will be beneficial.


Cho NH, Shaw JE, Karuranga S, Huang Y, da Rocha Fernandes JD, Ohlrogge AW, et al. IDF Diabetes atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res Clin Pract. 2018;138:271-81. [crossref] [PubMed]
Seshasai SRK, Kaptoge S, Thompson A, Di Angelantonio E, Gao P, Sarwar N, et al. Diabetes mellitus, fasting glucose, and risk of cause-specific death. N Engl J Med. 2011;364(9):829-41. [crossref] [PubMed]
Rørth R, Jhund PS, Mogensen UM, Kristensen SL, Petrie MC, Køber L, et al. Risk of incident heart failure in patients with diabetes and asymptomatic left ventricular systolic dysfunction. Diabetes Care. 2018;41(6):1285-91. [crossref] [PubMed]
Saran R, Robinson B, Abbott KC, Agodoa LYC, Albertus P, Ayanian J, et al. US renal data system 2016 annual data report: Epidemiology of kidney disease in the United States. Am J Kidney Dis. 2017;69(3 Suppl 1):A7-A8. Doi: 10.1053/j. ajkd.2016.12.004. [crossref] [PubMed]
Van Heerebeek L, Hamdani N, Handoko ML, Falcao-Pires I, Musters RJ, Kupreishvili K, et al. Diastolic stiffness of the failing diabetic heart: Importance of fibrosis, advanced glycation end products, and myocyte resting tension. Circulation. 2008;117(1):43-51. [crossref] [PubMed]
Heymes C, Vanderheyden M, Bronzwaer JGF, Shah AM, Paulus WJ. Endomyocardial nitric oxide synthase and left ventricular preload reserve in dilated cardiomyopathy. Circulation. 1999;99(23):3009-16. [crossref] [PubMed]
Braunwald E. Diabetes, heart failure, and renal dysfunction: The vicious circles. Prog Cardiovasc Dis [Internet]. 2019;62(4):298-302. Available from: https://doi. org/10.1016/j.pcad.2019.07.003. [crossref] [PubMed]
Patil VC, Patil HV, Shah KB, Vasani JD, Shetty P. Diastolic dysfunction in asymptomatic type 2 diabetes mellitus with normal systolic function. J Cardiovasc Dis Res. 2011;2(4):213-22. Doi: 10.4103/0975-3583.89805. [crossref] [PubMed]
Ernande L, Bergerot C, Rietzschel ER, De Buyzere ML, Thibault H, Pignonblanc PG, et al. Diastolic dysfunction in patients with type 2 diabetes mellitus: Is it the first marker of diabetic cardiomyopathy? J Am Soc Echocardiogr [Internet]. 2011;24(11):1268-75.e1. Available from: file:///C:/Users/Admin/Downloads/ Diastolic dysfunction First marker of Diabetic cardiomyopathy ernande.pdf. [crossref] [PubMed]
Kaze AD, Santhanam P, Erqou S, Ahima RS, Bertoni A, Echouffo-Tcheugui JB. Microvascular disease and incident heart failure among individuals with type 2 diabetes mellitus. J Am Heart Assoc. 2021;10(12):e018998. Doi: 10.1161/ JAHA.120.018998. Epub 2021 Jun 10. [crossref] [PubMed]
Tang C, Huang J, Zhu J, Gu X. Differences between diabetic and non-diabetic nephropathy patients in cardiac structure and function at the beginning of haemodialysis and their impact on the prediction of mortality. J Int Med Res. 2021;49(3):300060521997588. Doi: 10.1177/0300060521997588. [crossref] [PubMed]
Amaresan MS. Cardiovascular diseases in chronic kidney disease. Indian J Nephrol. 2005;15:01-07.
Madero M, Sarnak MJ. Creatinine-based formulae for estimating glomerular filtration rate: Is it time to change to chronic kidney disease epidemiology collaboration equation? Curr Opin Below Nephrol Hypertens. 2011;20(6):622- 30. Doi: 10.1097/Mnh.0b013e32834ba210. PMID: 21941179 Review. [crossref] [PubMed]
Boyer JK, Thanigaraj S, Schechtman KB, Pe´rez JE. Prevalence of ventricular diastolic dysfunction in asymptomatic, normotensive patients with diabetes mellitus. Am J Cardiol. 2004;93(7):870-75. [crossref] [PubMed]
Nichols GA, Gullion CM, Koro CE, Ephross SA, Brown JB. The incidence of congestive heart failure in type 2 diabetes: An update. Diabetes Care. 2004;27(8):1879-84. [crossref] [PubMed]
Seferović PM, Paulus WJ. Clinical diabetic cardiomyopathy: A two-faced disease with restrictive and dilated phenotypes. Eur Heart J. 2015;36(27):1718-27, 1727a-1727c. [crossref] [PubMed]
Di Bonito P, Moio N, Cavuto L, Covino G, Murena E, Scilla C, et al. Early detection of diabetic cardiomyopathy: Usefulness of tissue doppler imaging. Diabet Med. 2005;22(12):1720-25. [crossref] [PubMed]
Otsuka T, Suzuki M, Yoshikawa H, Sugi K. Left ventricular diastolic dysfunction in the early stage of chronic kidney disease. J Cardiol. 2009;54(2):199-204. Doi: [crossref] [PubMed]
Fang ZY, Yuda S, Anderson V, Short L, Case C, Marwick TH. Echocardiographic detection of early diabetic myocardial disease. J Am Coll Cardiol. 2003;41(4):611-17. [crossref] [PubMed]
Andersen NH, Poulsen SH, Eiskjaer H, Poulsen PL, Mogensen CE. Decreased left ventricular longitudinal contraction in normotensive and normoalbuminuric patients with Type II diabetes mellitus: A doppler tissue tracking and strain rate echocardiography study. Clin Sci (Lond). 2003;105(1):59-66. Available from: [crossref] [PubMed]
Fiseha T, Tamir Z. Prevalence and awareness of chronic kidney disease among adult diabetic outpatients in Northeast Ethiopia. BMC Nephrol. 2020;21:129. [crossref] [PubMed]
Ravindran R, Kalaivalli S, Srinivasagalu S, Karthik L. A study on prevalence and risk factors of diabetic nephropathy in newly detected type 2 diabetic patients. J Diabetol. 2020;(2):109-14.
Anjana RM, Deepa M, Pradeepa R, Mahanta J, Narain K, Das HK, et al. Prevalence of diabetes and prediabetes in 15 states of India: Results from the ICMR-INDIAB population-based cross-sectional study. lancet Diabetes Endocrinol. 2017;5(8):585-96. [crossref] [PubMed]
Unnikrishnan RI, Rema M, Pradeepa R, Deepa M, Shanthirani CS, Deepa R, et al. Prevalence and risk factors of diabetic nephropathy in an urban South Indian population: The Chennai Urban Rural Epidemiology Study (CURES 45). Diabetes Care. 2007;30(8):2019-24. [crossref] [PubMed]
Veeramani Kartheek As, Srinivas Reddy VC. Assessment of cardiac dysfunction in patients with end stage renal disease in a tertiary care hospital. J Evid Based Med Healthc. 2019;6(24):1668-72. [crossref]
Lewis BS, Milne FJ, Goldberg B. Left ventricular function in chronic renal failure. Br Heart J [Internet]. 1976;38(12):1229-39. Available from: https://pubmed.ncbi. [crossref] [PubMed]
Greaves SC, Gamble GD, Collins JF, Whalley GA, Sharpe DN. Determinants of left ventricular hypertrophy and systolic dysfunction in chronic renal failure. Am J Kidney Dis Off J Natl Kidney Found. 1994;24(5):768-76. [crossref] [PubMed]
Chan JCN, So W, Ma RCW, Tong PCY, Wong R, Yang X. The complexity of vascular and non-vascular complications of diabetes: The Hong Kong diabetes registry. Curr Cardiovasc Risk Rep. 2011;5(3):230-39. Available from: https:// [crossref] [PubMed]
Luk AOY, Ma RCW, Lau ESH, Yang X, Lau WWY, Yu LWL, et al. Risk association of HbA1c variability with chronic kidney disease and cardiovascular disease in type 2 diabetes: Prospective analysis of the Hong Kong diabetes registry. Diabetes Metab Res Rev. 2013;29(5):384-90. [crossref] [PubMed]
Ng IHY, Cheung KKT, Yau TTL, Chow E, Ozaki R, Chan JCN. Evolution of Diabetes care in Hong Kong: From the Hong Kong diabetes register to JADE-PEARL program to RAMP and PEP program. Endocrinol Metab (Seoul, Korea). 2018;33(1):17-32. Available from: https://pubmed.ncbi.nlm.nih. gov/29589385. [crossref] [PubMed]
Poulsen MK, Henriksen JE, Dahl J, Johansen A, Gerke O, Vach W, et al. Left ventricular diastolic function in type 2 diabetes mellitus prevalence and association with myocardial and vascular disease. Circ Cardiovasc Imaging. 2010;3(1):24-31. [crossref] [PubMed]
Chandey M, Kamboj R, Sikri NKT. Left ventricular dysfunction in hypertensive patients with type 2 diabetes mellitus. Int J Adv Med. 2020;7(1):2349-3925. [crossref]
Fox CS, Larson MG, Leip EP, Culleton B, Wilson PWF, Levy D. Predictors of new- onset kidney disease in a community-based population. JAMA. 2004;291(7):844-50. [crossref] [PubMed]
Brancati FL, Whelton PK, Randall BL, Neaton JD, Stamler J, Klag MJ. Risk of end-stage renal disease in diabetes mellitus: A prospective cohort study of men screened for MRFIT. Multiple Risk Factor Intervention Trial. JAMA. 1997;278(23):2069-74. [crossref] [PubMed]
Garg AX, Kiberd BA, Clark WF, Haynes RB, Clase CM. Albuminuria and renal insufficiency prevalence guides population screening: Results from the NHANES III. Kidney Int. 2002;61(6):2165-75. [crossref] [PubMed]
Longenecker JC, Coresh J, Powe NR, Levey AS, Fink NE, Martin A, et al. Traditional cardiovascular disease risk factors in dialysis patients compared with the general population: The choice study. J Am Soc Nephrol. 2002;13(7):1918-27. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/59963.17351

Date of Submission: Aug 31, 2022
Date of Peer Review: Oct 17, 2022
Date of Acceptance: Nov 06, 2022
Date of Publishing: Dec 01, 2022

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

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