الفهرس 
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Abstract
Chronic kidney disease is one of the most potent risk factors for cardiovascular disease. Patients with late stages of chronic kidney disease have a high rate of morbidity and mortality due to cardiac problems.
Cardiac diseases which have a high incidence rate in CKD patients are disturbances in structure as cardiomyopathy and cardiac function as decrease in systolic and diastolic dysfunction.
In CKD patients left ventricular diastolic dysfunction occurs frequently and is associated with heart failure and higher mortality. Diastolic function is assessed by tissue doppler determining the velocities of early (E) and late (A) diastolic transmitral flow and Em/Am ratio.
ADMA is consider as uremic toxin and it’s level elevated in advanced CKD as the kidney has a dual function in it’s metabolism as it excretes ADMA in the urine and is also rich in DDAH, which metabolizes ADMA.
The aim of our study is to identify the relationship between plasma asymmetric dimethyl arginine (ADMA) levels and the myocardial function assessed by tissue Doppler imaging in the CKD population.
Our study was conducted on 90 patients with chronic kidney disease classified to three groups according to estimated GFR
group І: 30 CKD patient stage 3, group 2: 30 CKD patient stage 4, group 3: 30 CKD patient stage 5,from National institute of nephrology and urology outpatient clinic and inpatient department.
Our study included 49 (54.4%) females and 41(45.6%) males, age 17-78 years old with mean age; in group 1(42.33±11.83), in group 2(39.77±13.95), in group 3(38.67 ±10.71).
Patients with active infection, active autoimmune disease, malignancy decompensated liver disease and heart failure class III and IV were excluded from our study. All patients were subjected to thorough history taking including personal and family histories, smoking habits, and previous history of CV disease, such as coronary artery disease and cerebrovascular disease.
Laboratory investigation done for all groups included serum ADMA, serum creatinine, serum urea, serum calcium, serum phosphorus, serum alkaline phosphatase, parathyroid hormone level, CRP titer, lipid profile and albumin.
All patients were subjected to Echocardiography with tissue Doppler study for (systolic function- diastolic function- -right ventricular systolic pressure- left ventricular diameter at end diastole- left ventricular diameter at end systole, septal peak E, Lateral peak E, Ejection fraction, Left ventricular mass index, Left ventricular mass, Left atrial diameter.
Our result showed significant difference between CKD stages as regard ADMA level with the mean range in CKD stage 3,4 and 5 were respectively (12701) ng/L, (14853) ng/L, (18481) ng/L with (p=0.037).
There was a correlation between ADMA level and serum creatinine (r=0.215, p=0.024) and negative correlation with eGFR (r=-0.251, p=0.027) this indicate that ADMA accumulate in blood with progression of the CKD disease.
Result showed significant difference between the CKD stages as regard the lateral and septal peak E (p=0.000) which indicate diastolic dysfunction with the progression of the CKD stages.
Our result showed significant difference between the CKD stages as regard LAD (p=0.024) and IVSD (p=0.000) which indicate a change in the cardiac structure with progression of the CKD stages and accumulation of toxins and fluid retention.
We found a statistically significant correlation between ADMA level and lateral peak E (r=-0.262, p=0.016) and septal peak E (r=-0.219, p=0.038) by the tissue Doppler, this result suggests that elevated ADMA levels may worsen the left ventricular diastolic functions in CKD patients.