Cardiorenal Medicine最新文献

Background: The growing complexity of patient data and the intricate relationship between heart failure (HF) and acute kidney injury (AKI) underscore the potential benefits of integrating artificial intelligence (AI) and machine learning into healthcare. These advanced analytical tools aim to improve the understanding of the pathophysiological relationship between kidney and heart, provide optimized, individualized, and timely care, and improve outcomes of HF with AKI patients.

Summary: This comprehensive review article examines the transformative potential of AI and machine-learning solutions in addressing the challenges within this domain. The article explores a range of methodologies, including supervised and unsupervised learning, reinforcement learning, and AI-driven tools like chatbots and large language models. We highlight how these technologies can be tailored to tackle the complex issues prevalent among HF patients with AKI. The potential applications identified span predictive modeling, personalized interventions, real-time monitoring, and collaborative treatment planning. Additionally, we emphasize the necessity of thorough validation, the importance of collaborative efforts between cardiologists and nephrologists, and the consideration of ethical aspects. These factors are critical for the effective application of AI in this area.

Key messages: As the healthcare field evolves, the synergy of advanced analytical tools and clinical expertise holds significant promise to enhance the care and outcomes of individuals who deal with the combined challenges of HF and AKI.

Introduction: Cardiovascular diseases constitute a significant cause of morbidity and mortality in individuals with autosomal dominant polycystic kidney disease (ADPKD). This study aimed to assess the long-term effects of tolvaptan on the kidneys and heart in rapidly progressing ADPKD.

Methods: Among 354 patients diagnosed with ADPKD, 58 meeting the eligibility criteria for tolvaptan were included in the study. The study comprised two groups with similar demographic and clinical characteristics: 29 patients receiving tolvaptan treatment and 29 in the control group. Several included genetic analysis, magnetic resonance imaging, and echocardiography. Clinical and cardiac changes were recorded in both groups after a 3-year follow-up.

Results: Tolvaptan treatment demonstrated a significant reduction in the rate of eGFR decline compared to the control group. Furthermore, it was observed that tolvaptan could prevent the development of cardiac arrhythmias by inhibiting an increase in QTc interval and heart rate.

Conclusion: These findings suggest that, in addition to slowing kidney progression in ADPKD management, tolvaptan may potentially benefit in preventing cardiac complications.

Introduction: The efficacy and safety of emerging therapies for heart failure with reduced ejection fraction (HFrEF) have never been compared in specific subgroups of patients.

Methods: PubMed, Cochrane Registry, Web of Science, Scopus, and EMBASE libraries were used to extract data. We used the following keywords: (heart failure with reduced ejection fraction OR HFrEF) AND (treatment OR therapy) OR (cardiovascular death) OR (hospitalization for heart failure). We compared randomized clinical trials for HFrEF emerging therapies focusing on the elderly (patients >65 years old and >75 years old), chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR) < 60 mL/min), patients with diabetes mellitus (DM), coronary heart disease (CAD), New York Heart Association (NYHA) class III/IV, women, patients on sacubitril/valsartan (S/V). The primary outcome was the efficacy composite endpoint of cardiovascular death (CVD) and HF hospitalization (HFH).

Results: S/V significantly reduced the primary outcome in patients >65 years old (RR: 0.80; 95% CI: 0.68-0.94) and with CKD (RR: 0.79; 95% CI: 0.69-0.90); dapagliflozin in patients >65 (RR: 0.72; 95% CI: 0.60-0.86) and >75 years old (RR: 0.68; 95% CI: 0.53-0.87), in those with CKD (RR: 0.72; 95% CI: 0.59-0.88), DM (RR: 0.75; 95% CI: 0.63-0.89), and CAD (RR: 0.77; 95% CI: 0.65-0.92); empagliflozin in patients >65 years old (RR: 0.78; 95% CI: 0.66-0.93), those with DM (RR: 0.72; 95% CI: 0.60-0.86), CAD (RR: 0.82; 95% CI: 0.68-0.99), women (RR: 0.59; 95% CI: 0.44-0.79), and in patients on S/V (RR: 0.64; 95% CI: 0.45-0.91); vericiguat in patients with CKD (RR: 0.84; 95% CI: 0.73-0.97) and NYHA class III/IV (RR: 0.87; 95% CI: 0.77-0.98); omecamtiv mecarbil in patients with CAD (RR: 0.90; 95% CI: 0.82-0.99) and NYHA III/IV (RR: 0.88; 95% CI: 0.80-0.97).

Conclusion: Emerging HFrEF therapies show a clinical benefit with the reduction of the primary composite endpoint of CVD and HFH, with each drug being more effective in specific patient population.

Introduction: Shock index (SI) and its derivatives have been reported to have prognostic value in various cardiovascular diseases. This study aims to ascertain the utility of shock index creatinine (SIC) in predicting mid-term mortality among patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR).

Methods: We conducted a retrospective analysis of 555 patients with severe AS who underwent TAVR from April 2016 to March 2023. SIC was calculated as (SI × 100) - estimated creatinine clearance (CCr). The primary endpoint was all-cause mortality during the follow-up period, and secondary endpoints included in-hospital complications as defined by the Valve Academic Research Consortium-3 (VARC-3) criteria. Patients were stratified into two groups based on the optimal cutoff value determined by the receiver-operating characteristic (ROC) curve. Cox regression analysis was employed to identify independent predictors of all-cause mortality. Additionally, restricted cubic spline (RCS) was deployed to illustrate the relationship between SIC and mortality risk. The predictive performance of risk scores was evaluated using the area under the ROC curve (AUC).

Results: Over a mean follow-up period of 21.5 months, there were 51 cases of all-cause mortality. Patients with a high SIC, identified by a cutoff of 16.5, exhibited a significantly higher cumulative all-cause mortality compared to those with a low SIC (18.3% vs. 5.2%, p < 0.001; adjusted HR = 2.188; 95% CI 1.103-4.341, p = 0.025). Patients with a high SIC were older (p = 0.002) and exhibited a higher prevalence of frailty (p < 0.001). Furthermore, they exhibited a heightened probability of moderate or severe mitral regurgitation (p < 0.001), tricuspid regurgitation (p < 0.001), and pulmonary hypertension (p < 0.001) compared to those with a low SIC. In terms of perioperative complications, acute kidney injury (10.1% vs. 3.9%, p = 0.008) and bleeding (13.6% vs. 6.7%, p = 0.014) were more prevalent in patients with a high SIC. The RCS demonstrated a positive correlation between SIC and all-cause mortality rate. Furthermore, incorporating high SIC into the STS score improved its predictive value for 1-year all-cause mortality (AUC: 0.731 vs. 0.649, p = 0.01).

Conclusion: Patients with a high SIC are more likely to experience frailty and cardiac damage and exhibit an increased in-hospital and mid-term mortality rate. SIC may provide additional information for risk stratification of patients undergoing TAVR.

Introduction: Chronic heart failure (HF) has high rates of mortality and hospitalization in patients with advanced chronic kidney disease (aCKD). However, randomized clinical trials have systematically excluded aCKD population. We have investigated current HF therapy in patients receiving clinical care in specialized aCKD units.

Methods: The Heart And Kidney Audit (HAKA) was a cross-sectional and retrospective real-world study including outpatients with aCKD and HF from 29 Spanish centers. The objective was to evaluate how the treatment of HF in patients with aCKD complied with the recommendations of the European Society of Cardiology Guidelines for the diagnosis and treatment of HF, especially regarding the foundational drugs: renin-angiotensin system inhibitors (RASi), angiotensin receptor blocker/neprilysin inhibitors (ARNI), beta-blockers (BBs), mineralocorticoid receptor antagonists (MRAs), and sodium-glucose cotransporter-2 inhibitors (SGLT2i).

Results: Among 5,012 aCKD patients, 532 (13%) had a diagnosis of HF. Of them, 20% had reduced ejection fraction (HFrEF), 13% mildly reduced EF (HFmrEF), and 67% preserved EF (HFpEF). Only 9.3% of patients with HFrEF were receiving quadruple therapy with RASi/ARNI, BB, MRA, and SGLT2i, but the majority were not on the maximum recommended doses. None of the patients with HFrEF and CKD G5 received quadruple therapy. Among HFmrEF patients, approximately half and two-thirds were receiving RASi and/or BB, respectively, while less than 15% received ARNI, MRA, or SGLT2i. Less than 10% of patients with HFpEF were receiving SGLT2i.

Conclusions: Under real-world conditions, HF in aCKD patients is sub-optimally treated. Increased awareness of current guidelines and pragmatic trials specifically enrolling these patients represent unmet medical needs.

Introduction: There is limited evidence as to the effect of sex on the outcomes of patients admitted for ST-elevation myocardial infarction (STEMI) who have a concomitant diagnosis of chronic kidney disease (CKD) and end-stage renal disease (ESRD). We aimed to determine if there are differences in the outcomes between males and females in these patient populations.

Methods: Data were obtained from the National Inpatient Sample database and patients were selected using the International Classification of Diseases, Ninth and Tenth Revision (ICD-9 and -10) codes. Hospitalizations for patients with CKD who had STEMI from 2012 to 2020 were included. The primary outcome of interest was in-hospital mortality. Secondary outcomes evaluated included ischemic stroke, major bleeding complications, pressor requirement, permanent pacemaker implantation, percutaneous coronary intervention, coronary artery bypass grafting, surgery, pericardiocentesis, mechanical circulatory support, and mechanical ventilation.

Results: A total of 1,283,255 STEMI patients without CKD, 158,715 STEMI patients with CKD, and 22,690 STEMI patients with ESRD were identified and analyzed. Among patients with STEMI and CKD, females demonstrated higher in-hospital mortality compared to male counterparts (16.7% vs. 12.7%, aOR = 1.13, 95% CI: 1.05-1.21, p < 0.01). While there was no sex difference in the in-hospital mortality among STEMI patients with ESRD, female patients in this group were less likely to receive coronary artery bypass grafting and mechanical circulatory support.

Conclusion: Increased in-hospital mortality rates were shown for females admitted for STEMI with CKD. Among patients with ESRD who had STEMI, females were less likely to receive coronary artery bypass grafting and mechanical circulatory support. Further research needs to be conducted to better explain this said difference in outcomes.

Introduction: The role of curcuminoids, a striking antioxidant, in prevention of contrast-induced acute kidney injury (CI-AKI) remains unknown. We aimed to evaluate the efficacy and safety of curcuminoids in preventing CI-AKI in patients undergoing elective coronary angiography (CAG) and/or percutaneous coronary intervention (PCI).

Methods: We randomized 114 patients who were undergoing elective CAG and/or PCI to receive curcuminoids, 4 g/day (1 day before and 1 day after the procedure, n = 56), or placebo (n = 58). Serum creatinine was assessed at baseline, 12, 24, and 48 h after contrast exposure. The primary endpoint was development of CI-AKI defined as serum creatinine increase ≥0.3 mg/dL within 48 h after contrast exposure. The secondary endpoint was the occurrence of kidney injury defined by >30% increase in urine neutrophil gelatinase-associated lipocalin (NGAL).

Results: Baseline characteristics were comparable between the two groups. Seven (12.7%) in curcuminoids group and eight (14.0%) in placebo group developed CI-AKI (p = 0.84). The incidence of increased urine NGAL was comparable in the placebo and curcuminoids group (39.6% vs. 50%, respectively; p = 0.34). None in both groups had drug-related adverse events.

Conclusion: This is a pilot study to demonstrate the safety and tolerability of curcuminoids in patients undergoing elective CAG and/or PCI. Curcuminoids have no protective effects against kidney injury after elective CAG and/or PCI.

Background: Some patients with cardiorenal syndrome 1 and congestion exhibit resistance to diuretics. This scenario complicates management and is associated with a worse prognosis. In some cases, rescue treatment may be considered by starting kidney replacement therapies or ultrafiltration. This decision is complex and necessitates a profound understanding of these techniques and the pathophysiology of this syndrome. These modalities are classified into continuous, intermittent, and ultrafiltration therapies, each with its own advantages and disadvantages that are pertinent in selecting the optimal treatment.

Summary: In patients with diuretic-resistant cardiorenal syndrome, extracorporeal ultrafiltration and kidney replacement therapies have the potential to relieve congestion, restore the neurohormonal system, and improve quality of life.

Key messages: (i) In cardiorenal syndrome, the resistance to diuretics is common. (ii) Extracorporeal ultrafiltration and renal replacement therapies are rescue options that may improve the management of these patients. (iii) Better understanding of these modalities will help the development of new devices which are friendlier, safer, and more affordable for patients in these clinical settings.

Introduction: Cardiac implantable electrical devices are able to affect kidney function through hemodynamic improvements. The cardiac contractility modulation (CCM) is a device-based therapy option for patients with symptomatic chronic heart failure (HF) despite optimized medical treatment. The long-term cardiorenal interactions for CCM treated patients are yet to be described.

Methods: CCM recipients (n = 187) from the Mannheim Cardiac Contractility Modulation Observational Study (MAINTAINED) were evaluated in the long-term (up to 60 months) for changes in serum creatinine, estimated glomerular filtration rate (eGFR), other surrogate markers of kidney function, and the chronic kidney disease (CKD) stage distribution. With regard to kidney function at baseline, the patients were furthermore grouped to either advanced CKD (aCKD, CKD stage ≥3, eGFR≤59 mL/min/1.73 m2, n = 107) or preserved kidney function and mild CKD (pCKD, CKD stages 1-2, eGFR≥60 mL/min/1.73 m2, n = 80). The groups were compared for differences regarding kidney function, New York Heart Association classification (NYHA), biventricular systolic function, HF hospitalizations and other parameters in the long-term (60 months).

Results: CKD stage distribution remained stable during the entire follow-up (p = 0.65). An increase in serum creatinine (1.47 ± 1 vs. 1.6±1 mg/dL) with a corresponding decline of eGFR (58.2 ± 23.4 vs. 54.2 ± 24.4 mL/min/1.73 m2, both p < 0.05) were seen after 60 months but not before for the total cohort, which was only significant in pCKD patients in terms of group comparison. Mean survival (54.3 ± 1.3 vs. 55.3 ± 1.2 months, p = 0.53) was comparable in both groups. Improvements in NYHA (3.11 ± 0.46 vs. 2.94 ± 0.41-2.28 ± 0.8 vs. 1.94 ± 0.6) and LVEF (24.8 ± 7.1 vs. 22.9 ± 6.6-31.1 ± 11.4 vs. 35.5 ± 11.1%) were likewise similar after 60 months (both p < 0.05). The aCKD patients suffered from more HF hospitalizations and ventricular tachycardias during the entire follow-up period (both p < 0.05).

Conclusions: The kidney function parameters and CKD stage distribution might remain stable in CCM treated HF patients in the long-term, who experience improvements in LVEF and functional status, regardless of their kidney function before. An impaired kidney function might be associated with further cardiovascular comorbidities and more advanced HF before CCM, and could be an additional risk factor of HF complications afterward.