Cardiorenal Medicine最新文献

This is an overview of some of the impactful studies in the field of cardiorenal medicine that were published in 2024.

Introduction: Cardiorenal syndrome (CRS) is a common and critical complication of sepsis, with high morbidity and mortality rates. Studies on biomarkers for the early prediction of septic CRS are sporadic. Classic and novel potential biomarkers were identified to explore their diagnostic performance of in patients with septic CRS.

Methods: A total of 138 patients with sepsis from Peking University People's Hospital were enrolled in this prospective observational study, which was conducted between May 2019 and June 2022. The patients were divided into non-CRS(n=106) and CRS (n=32) groups. Serum levels of cystatin C, KIM-1, NGAL and α-Klotho were detected at admission using enzyme-linked immunosorbent assay (ELISA). The relationship between the biomarker levels and risk factors of CRS were analyzed, as well as discrimination accuracy comparisons were performed.

Results: The incidence of CRS in patients with sepsis was 23.2% (32/138) during hospitalization, with an obvious mortality. Compared with the non-CRS group, serum cystatin C, BNP, TNI, KIM-1, and NGAL levels were both significantly elevated at admission in patients with sepsis complicated with CRS. Logistic regression analysis revealed that BNP, TNI cystatin C albumin, Lac, D-dimer were risk factors for CRS in sepsis patients. Compared with other biomarkers, serum cystatin C had moderate discriminative power for predicting septic CRS (AUROC 0.746, sensitivity 0.719, specificity 0.783). BNP combined with cystatin C and D-dimer demonstrated an excellent discrimination performance, for its AUROC was up to 0.878 (sensitivity, 0.844; specificity, 0.759).

Conclusion: Serum cystatin C, BNP, TNI, KIM-1, and NGAL levels are elevated in patients with septic CRS. Our study provides reliable evidence that cystatin C in combination with BNP and D-dimer might better predict septic CRS upon admission. Further research on sensitive biomarkers is needed.

Background: Kidney transplantation is the best treatment for patients with chronic renal failure, capable of improving life expectancy and the risk of death from all causes, which, however, remains higher than in the general population. The leading cause of death in transplant patients is cardiovascular events, burdened by a significant impact brought about by anti-rejection therapy. Experimental and clinical studies to date show that in kidney transplant recipients, traditional cardiovascular risk factors (hypertension, diabetes, dyslipidemia, obesity, tobacco, etc.) may be exacerbated or worsened by the dysmetabolic effects of immunosuppressive drugs, which may also result in additional risk factors such as proteinuria, anemia, and arterial stiffness. The aim of this review is an in-depth evaluation of the effect of immunosuppressive treatments on cardiovascular risk factors.

Summary: We have investigated and described the main cardiovascular risk factors related to immunosuppressive drugs. We searched for relevant scientific articles in medicine, transplant, cardiologic and nephrological journals in major medical science libraries.

Key messages: Immunosuppressive drugs allow graft survival and successful bunking of the transplant; however, they are not without significant side effects, and should always be prescribed weighing the risk/benefit ratio and the individual patient's therapeutic needs.

Background: Accumulating evidence has challenged the traditional model of the liver-kidney connection in hepatorenal syndrome. Cirrhosis can significantly impact cardiac function, leading to cirrhotic cardiomyopathy. Recent understanding reveals how cardiac dysfunction plays a pivotal role in the development of renal dysfunction in this setting, suggesting that disturbances traditionally categorized under hepatorenal syndrome may actually represent a hepatic form of cardiorenal syndrome-hepatocardiorenal syndrome-where the liver affects the kidney through cardiorenal pathways.

Summary: Effective management of hepatocardiorenal syndrome and acute kidney injury in cirrhosis relies on accurately assessing a patient's hemodynamic and volume status. Point-of-care ultrasound, including lung and focused cardiac ultrasound, is a valuable diagnostic tool that provides crucial data on fluid tolerance, subclinical pulmonary congestion, and left ventricular filling pressures. This objective, bedside approach offers a comprehensive assessment that directly influences patient management and therapeutic decisions.

Key messages: Point-of-care ultrasound plays an essential role in evaluating and managing hepatocardiorenal syndrome, providing insights into the underlying pathophysiology. By assessing hemodynamic parameters, it helps guide therapy and monitor patient responses, ensuring more accurate and effective treatment of patients with cirrhosis and acute kidney injury.

Introduction: The processes of atherosclerosis, inflammation, and carbamylation are closely linked in cardiovascular (CV) disease, but the potential of carbamylation burden as a CV mortality predictor is unclear, especially in patients with no or mild chronic kidney disease (CKD). This study aimed to investigate whether elevated carbamylated albumin (C-Alb), as a surrogate marker for carbamylation burden, is associated with mortality and arterial stiffness/atherosclerotic burden in patients with no or mild CKD, using pulse pressure (PP) as a marker for arterial stiffness.

Methods: We measured C-Alb in 3,193 participants of the Ludwigshafen Risk and Cardiovascular Health study who had been referred for coronary angiography and followed up for 10 years.

Results: The mean age was 62.7 years, and 30.4% were female. Mean blood pressure was 141/81 mm Hg, and mean C-Alb was 5.54 mmol/mol. Increase in C-Alb levels was associated with older age; female sex; increased PP, high-sensitivity C-reactive protein, and interleukin-6 levels; and increased incidence of coronary artery disease (CAD), peripheral artery disease (PAD), and carotid stenosis. In contrast, BMI, diastolic blood pressure (DBP), albumin, and the proportion of active smokers decreased with increasing C-Alb levels. In particular, C-Alb showed a highly significant correlation with CAD severity: Friesinger (Pearson correlation coefficient [r] = 0.082, p < 0.001) and Gensini score (r = 0.066, p < 0.001). The area under the curve (AUC) for all-cause mortality prediction by the European Society of Cardiology Heart Score (ESC-HS) significantly improved from 0.719 to 0.735, and the AUC for CV mortality prediction based on C-Alb increased from 0.726 to 0.750 in patients without previously known CV disease. C-Alb correlated directly and significantly with PP (r = 0.062, p < 0.001), which was consistently the strongest predictor of mortality across all C-Alb tertiles. The hazard ratios (HRs) for all-cause mortality per 10 mm Hg increase (or 1,000 mm Hg/min increase for double product [DP]) in the 1st tertile of C-Alb were 1.18, 1.13, 1.11, and 1.11 for PP, mean arterial pressure (MAP), systolic blood pressure (SBP), and DP, respectively, but the HR for DBP did not reach significance. In the 3rd tertile of C-Alb, the HRs were 1.13, 1.05, and 1.09, for PP, SBP, and DP, respectively, but the HR for MAP did not reach significance.

Conclusion: C-Alb may be a valuable biomarker for assessing CV risk and improving mortality prediction even in patients with no or mild CKD. The findings support the notion of a crosslink between carbamylation, inflammation, atherosclerosis, and mortality. While these results are promising, further research is needed to fully elucidate the role of C-Alb in CV disease progression and risk stratification.

Background: Heart failure with preserved ejection fraction (HFpEF) and chronic kidney disease (CKD) have a strong pathophysiological interrelationship, and their combination worsens prognosis.

Summary: This article briefly reviews the bidirectional epidemiological burden and the pathophysiological interplay between HFpEF and CKD. It also discusses some of the controversial aspects regarding the diagnosis and screening of HFpEF in CKD patients and focuses on the most effective therapeutic approaches to improve symptoms and prognosis in this high-risk population.

Key messages: Due to its prevalence and prognostic significance, HFpEF screening should be considered in patients with CKD, with careful use of traditional diagnostic tools in this population. Optimal medical therapy has seen major recent advances in patients with both HFpEF and CKD. SGLT2 inhibitors, finerenone, and semaglutide have consistently demonstrated cardio- and renoprotective effects in both conditions.

Introduction: Haemodialysis (HD) is a life-sustaining treatment for individuals with end-stage kidney disease. However, the risk of mortality remains significantly higher compared to the general population, even when matched for age and sex. Global longitudinal strain (GLS), derived from speckle tracking echocardiography, has shown promise as a predictor of mortality in HD patients. However, its prognostic utility in patients with multiple cardiovascular risk factors such as diabetes mellitus (DM) and receiving HD remains unclear. This study aimed to evaluate the prognostic value of GLS in HD patients, with and without DM.

Methods: This prospective study was a long-term follow-up extension study of an earlier published study that investigated a cohort of HD patients from a single centre with a comprehensive cardiovascular imaging protocol. All patients had an echocardiography with the use of speckle tracking software to determine GLS. Patients were divided into group A (with DM) and group B (without DM). Patients were followed up until death, major adverse cardiovascular events, transplantation, or the censoring date (29 February 2024). Statistical analyses were performed using univariate and multivariate Cox proportional hazards models.

Results: A total of 184 patients receiving HD were included in the analysis. Patients with DM (group A) had significantly higher all-cause mortality (ACM) (47.1% vs. 20.7%, p < 0.001) and a lower chance of receiving a kidney transplant (13.2% vs. 43.1%, p < 0.001). In group A, GLS did not predict ACM, whereas in group B, a GLS cut-off of -15.76% correlated with higher 5-year ACM (p = 0.036). Left ventricular ejection fraction (LVEF) was a significant predictor of ACM in group A (HR 0.98; p = 0.036).

Conclusion: GLS is a poor predictor of adverse outcomes in HD patients with DM, likely due to their high cardiovascular risk. In contrast, GLS was a significant predictor of mortality in non-diabetic HD patients. LVEF may be a more reliable prognostic indicator in high-risk diabetic patients.

Background: The complex relationship between heart and kidney dysfunction has been a subject of medical inquiry since the 19th century. The term "cardio-renal syndrome" (CRS) was introduced in the early 2000s and has since become a focal point of research. CRS is typically categorized into five subtypes based on the sequence of cardiovascular and kidney disease events.

Summary: The cardiovascular-kidney-metabolic (CKM) syndrome, as defined by the American Heart Association, describes a set of interrelated metabolic risk factors and their effects on the kidneys and cardiovascular system. This syndrome emphasizes the complexity of managing patients with combined conditions and identifies several knowledge gaps, including disease mechanisms, clinical phenotype variability, and the impact of social determinants of health. The chronic cardiovascular-kidney disorder (CCKD) framework proposes a shift from the term "syndrome" to "disorder," focusing on concurrent cardiovascular and kidney problems regardless of their sequence.

Key messages: (i) The CCKD concept calls for simplification and conceptual clarity, arguing that understanding the bidirectional acceleration of disease progression between heart and kidney dysfunction can lead to more effective treatment strategies. (ii) Both CKM and CCKD share common pathophysiological mechanisms and risk factors, including hypertension, diabetes, obesity, and dyslipidemia. Managing these conditions requires a comprehensive approach that addresses the underlying risk factors and pathophysiological mechanisms. (iii) Future directions include embracing precision medicine, public health strategies, interdisciplinary care models, and ongoing research and innovation. Both frameworks underscore the need for comprehensive, interdisciplinary care models and innovative treatment strategies to address the complex interplay between cardiovascular and kidney diseases.

Background: Patients with chronic kidney disease (CKD) have an increased cardiovascular (CV) risk. The lower the glomerular filtration rate, the higher the CV risk.

Summary: Current data suggest that several uremic toxins lead to vascular inflammation and oxidative stress that, in turn, lead to endothelial dysfunction, changes in smooth muscle cells' phenotype, and increased degradation of elastin and collagen fibers. These processes lead to both functional and structural arterial stiffening and explain part of the increased risk of acute myocardial infarction and stroke reported in patients with CKD. Considering that, at least in patients with end-stage kidney disease, the reduction of arterial stiffness is associated with a parallel decrease of the CV risk; vascular function is a potential target for therapy to reduce the CV risk.

Key messages: In this review, we explore mechanisms of vascular dysfunction in CKD, paying particular attention to inflammation, reporting current data in other models of mild and severe inflammation, and discussing the vascular effect of several drugs currently used in nephrology.

Background: Diabetes mellitus is a prevalent chronic disease that is becoming increasingly common worldwide and can lead to a number of dangerous complications. The Wnt signaling pathway is important for the onset and progression of diabetes. Wnt3a is a typical Wnt ligand that can increase the stability of β-catenin, control TCF7L2 expression, promote β-cell proliferation, and reduce apoptosis.

Summary: The involvement of the Wnt3a/β-catenin/TCF7L2 signaling pathway in the development of diabetes and associated problems related to the kidneys is reviewed in this article.

Key message: We believe that a thorough comprehension of the molecular connections between diabetes and signaling pathways will eventually lead to improved diabetes management.