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Background Diastolic dysfunction is common in chronic kidney disease (CKD) patients and is associated with reduced exercise capacity. The ratio of early diastolic mitral inflow velocity to early diastolic mitral annulus velocity (E/e’) correlates with invasively measured left ventricular pressures, both at rest and during exercise. The aim of our study was to evaluate the relationship of resting and exercise E/e’ to exercise capacity in patients with stage 3 and 4 CKD. Methods CKD patients were prospectively recruited. All patients were required to be in sinus rhythm, without previous cardiac disease and with normal LVEF. The E/e’ ratio was assessed at rest and patients were stratified into 3 groups based on conventional clinical classifications (normal: ≤8, indeterminate: 8-14, raised: &amp;gt;14). Patients then underwent a symptom limited exercise stress echocardiogram whereby patients with resting E/e’ &amp;lt;14 additionally had post exercise E/e’ measured. Exercise capacity was assessed as metabolic equivalents (METs). A raised exercise E/e’ was defined as exercise E/e’ of ≥13. Lastly, we grouped patients based on abnormalities of baseline and exercise E/e’ (resting E/e’&amp;lt;14 &amp; exercise E/e’&amp;lt;13, resting E/e’&amp;lt;14 &amp; exercise E/e ≥13, resting E/e’ ≥14) and the relationship to METs achieved was evaluated. Results The cohort consisted of 156 CKD patients (62.8 ± 10.6 yrs, male 62%). 85% had hypertension and 39% had diabetes mellitus. 52/156 (34%) CKD patients had resting E/e’ of ≥14. Of the 104/156 (66%) CKD patients with normal/indeterminate resting E/e’, 66/104(63%) had normal exercise E/e’ &amp;lt;13 whilst 38/104(37%) had exercise E/e’ ≥13. Patients with resting E/e" &amp; raised exercise E/e’ ≥13 achieved significantly lower METs compared to CKD patients with resting E/e’ &amp;lt;14 &amp; exercise E/e’ &amp;lt;13 (5.0 ± 2.2 vs 8.8 ± 2.5, p&amp;lt; 0.01). Of note, METs achieved in this group were comparable to that achieved by CKD patients with raised resting E/e’ ≥ 14 (5.0 ± 2.2 METs vs 5.3 ± 2.6 METs, p = 0.55). Conclusion In CKD patients with normal/indeterminate resting E/e’, there is utility in performing exercise E/e’, which was increased in 37% of patients. Raised exercise E/e’ is associated with poorer exercise capacity and is a potential tool to refine diastolic abnormalities in patients with CKD. Group Total (n,%) METs Achieved Exercise Duration (minutes) Resting E/e’ ≤ 14 &amp; Exercise E/e’ ≤ 13 66/156 (42%) 8.8 ± 2.5 8.4 ± 3.1 Resting E/e’ ≤ 14 &amp; Exercise E/e’ ≥ 13 38/156 (24%) 5.0 ± 2.2 6.0 ± 3.1 Resting E/e’ ≥ 14 52/156 (34%) 5.3 ± 2.6 5.6 ± 2.2

P246 Exercise E/e refines diagnosis of diastolic impairment in patients with chronic kidney disease