Evaluating the myocardial functions of the forgotten right ventricle in children with nephrotic syndrome utilizing traditional echocardiography, two-dimensional speckle tracking and three-dimensional echocardiography.
Hussein A, Rakha S, et al. • Italian journal of pediatrics • 2026
Integrative use of variable echocardiographic modalities allows detection of subclinical alterations in RV function in children with primary NS, with more affected parameters in SRNS.
Key Findings
Results
Children with nephrotic syndrome had significantly lower tissue Doppler imaging parameters (s' and e') compared to healthy controls, with values more reduced in steroid-resistant nephrotic syndrome (SRNS) than steroid-sensitive nephrotic syndrome (SSNS).
Study was a case-control observational study conducted from January 2022 to August 2024
40 primary NS patients (including both SRNS and SSNS subgroups) were compared to 40 healthy controls
s' and e' velocities at the tricuspid annulus were significantly lower in NS patients compared to controls
The reduction was more pronounced in SRNS compared to SSNS
Tissue Doppler imaging (TDI) was used to measure these parameters
Results
Children with nephrotic syndrome had significantly higher E/e' ratio and Tei index compared to healthy controls, indicating right ventricular diastolic dysfunction and myocardial performance impairment.
Both E/e' ratio and Tei index were significantly elevated in the NS group compared to controls (p < 0.001)
These findings were more pronounced in SRNS compared to SSNS
The Tei index is a combined measure of systolic and diastolic myocardial performance
E/e' ratio elevation is an indicator of elevated filling pressures and diastolic dysfunction
Results
Two-dimensional speckle-tracking echocardiography revealed significantly reduced right ventricular free wall longitudinal strain (RVFWLS) and RV four-chamber longitudinal strain (RV4CSL) in children with nephrotic syndrome compared to controls.
Both RVFWLS and RV4CSL were significantly reduced in the NS group compared to healthy controls
These 2D STE parameters reflect subclinical myocardial deformation abnormalities not detectable by conventional echocardiography
Differences between SSNS and SRNS subgroups in strain parameters were noted, with SRNS showing more pronounced impairment
2D speckle-tracking echocardiography (2D STE) was used as the imaging modality for strain analysis
Results
Three-dimensional echocardiography-derived right ventricular ejection fraction (EF), TAPSE, stroke volume, and septal strain were all lower in nephrotic syndrome patients compared to controls.
3D auto RV-derived EF, TAPSE, stroke volume, and septal strain were significantly lower in NS compared to controls (p < 0.001)
Notably, there were no significant differences between SSNS and SRNS subgroups for these 3DE-derived parameters
Three-dimensional echocardiography (3DE) provided volumetric and functional RV assessment
These findings indicate global RV systolic impairment detectable by 3DE in NS patients
Results
Significant correlations were detected between certain echocardiographic parameters and biochemical markers including serum cholesterol, albumin, and creatinine in children with nephrotic syndrome.
Correlations were found between RV echocardiographic parameters and serum cholesterol levels
Correlations were also identified with serum albumin levels, which are characteristically low in nephrotic syndrome
Serum creatinine, a marker of renal function, also correlated with echocardiographic parameters
These correlations suggest that the severity of metabolic and renal derangements in NS may be associated with the degree of RV functional impairment
Results
SRNS patients showed more severely affected RV functional parameters compared to SSNS patients across multiple echocardiographic modalities.
Tissue Doppler parameters (s', e'), E/e', and Tei index were more abnormal in SRNS than SSNS
Longitudinal strain parameters (RVFWLS and RV4CSL) were more impaired in SRNS
3DE-derived parameters (EF, TAPSE, stroke volume, septal strain) did not show significant differences between SSNS and SRNS subgroups
This pattern suggests that steroid resistance is associated with greater subclinical RV dysfunction
Conclusions
The study identified subclinical right ventricular dysfunction in children with primary nephrotic syndrome using a multimodality echocardiographic approach, supporting the recommendation for regular RV surveillance in this population.
Conventional echocardiography, TDI, 2D STE, and 3DE were all employed to comprehensively assess RV function
Subclinical alterations were detectable despite patients not necessarily having overt cardiac symptoms
The authors concluded that 'regular surveillance of RV functions in primary NS should be considered'
Few prior studies had specifically investigated RV function in pediatric nephrotic syndrome, highlighting the novelty of this comprehensive RV evaluation
What This Means
This research suggests that children with nephrotic syndrome — a kidney disorder causing protein loss in the urine, swelling, and metabolic disturbances — have measurable but often hidden (subclinical) problems with the right side of their heart. The study compared 40 children with nephrotic syndrome to 40 healthy children using multiple advanced heart imaging techniques, including standard echocardiography, tissue Doppler imaging, speckle-tracking, and three-dimensional echocardiography. All of these methods detected signs of reduced right ventricular function in the nephrotic syndrome group, even when children may not have had obvious cardiac symptoms.
The study also found that children with steroid-resistant nephrotic syndrome (whose disease is harder to treat) tended to have worse right heart function compared to those with steroid-sensitive disease across most measures. Additionally, the degree of heart function impairment appeared to be linked to abnormal blood levels of cholesterol, albumin, and creatinine — chemicals that are typically disturbed in nephrotic syndrome — suggesting that the metabolic effects of the disease may contribute to heart problems.
This research suggests that the right ventricle, which is often overlooked compared to the left ventricle in studies of kidney disease, deserves more attention in children with nephrotic syndrome. Using a combination of imaging tools allows doctors to detect these subtle heart changes earlier. The authors recommend that regular monitoring of right ventricular function be considered as part of the care for children with this condition, particularly those with steroid-resistant disease.
Hussein A, Rakha S, Bakr A, Ali A, Hammad A, Hafez M, et al.. (2026). Evaluating the myocardial functions of the forgotten right ventricle in children with nephrotic syndrome utilizing traditional echocardiography, two-dimensional speckle tracking and three-dimensional echocardiography.. Italian journal of pediatrics. https://doi.org/10.1186/s13052-026-02335-1