Cardiorenal Medicine最新文献

Background: Heart failure (HF) prevalence is increasing, and its prognosis worsens in the presence of other comorbidities. Up to 70% of patients develop cardiorenal syndrome (CRS), which is associated with diuretic resistance or kidney deterioration over time. Peritoneal dialysis (PD) for ultrafiltration (PD-UF) could be a potential therapeutic option in CRS, although its long-term outcomes have not been described.

Methods: Retrospective registry study of the Catalan Renal Registry on patients with PD-UF indication between 2013 and 2022. Baseline clinical characteristics and follow-up until December/2022 was studied.

Results: Of the 1,874 incident patients on PD, 198 (10.6%) were PD-UF, 73.2% of the patients were male, and the mean age was 70.7 ± 9.3 years. Median estimated glomerular filtration rate (eGFR) at start was 22.6 (IQR: 14.8-32.8) mL/min×1.73 m2 and 75.0% have an eGFR above 15 mL/min×1.73 m2. Previous history of ischemic heart disease, arrhythmia, or cardiac surgery was recorded, and 57.6% of patients had ≥2 of these pathologies. The most common HF etiology was ischemic heart disease in 21.7% of patients. Median overall patient survival was 21 (IQR: 17.3-24.3) months. Technique survival at 1 year was 94.8%, and 27 patients were transferred to other renal replacement therapy (hemodialysis or kidney transplantation). In the Cox multivariate analysis, age ≥75 years (HR: 1.76 [95% CI: 1.20-2.59]), mild frailty (HR: 2.18 [95% CI: 1.17-2.59]), severe frailty (HR: 17.62 [95% CI: 1.20-55.48]), and the burden of cardiac disease (2 categories HR: 2.17 [95% CI: 1.05-4.47]; 3 categories HR: 2.26 [95% CI: 1.05-4.89]) were associated with poor overall survival. Technique survival was associated with eGFR (<30 mL/min×1.73 m2 HR: 5.64 [95% CI: 1.32-24.18]) and body mass index (<20 kg/m2 HR: 6.53 [95% CI: 1.06-40.12]) at baseline.

Conclusion: PD-UF is a feasible option in patients with advanced HF and CRS. The complexity of this population increases with older age, frailty, and higher cardiac burden.

Introduction: Chronic kidney disease (CKD) is associated with a high prevalence of cardiovascular complications, including left ventricular hypertrophy (LVH), which significantly increases morbidity and mortality. LVH in CKD results from a complex interplay of hemodynamic, neurohormonal, and metabolic factors. The uric acid-to-high density lipoprotein cholesterol ratio (UHR) has recently been proposed as a potential marker for cardiovascular outcomes, combining the effects of uric acid and HDL-C on inflammation and cardiovascular risk. However, the relationship between UHR and LVH in CKD patients remains unexplored. This study aimed to investigate the association between UHR and LVH in patients with CKD.

Methods: This cross-sectional study included CKD patients admitted to the Division of Nephrology between April 2019 and October 2019. CKD was staged according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. LVH was assessed using transthoracic echocardiography, and left ventricular mass index (LVMI) was calculated. LVH was defined as an LVMI >115 g/m2 for men and >95 g/m2 for women. UHR was calculated by dividing serum uric acid levels (µmol/L) by HDL-C levels (mmol/L). Multivariable logistic regression models were used to assess the association between UHR and LVH, adjusting for covariates including age, gender, BMI, and other relevant clinical factors.

Results: A total of 466 patients were included, of whom 56 had LVH. Patients with LVH had significantly higher UHR levels compared to those without LVH. In multivariable regression analysis, the natural logarithm of UHR (LnUHR) was significantly associated with an increased risk of LVH (OR: 2.04, 95% CI: 1.05-4.12, p = 0.035) after full adjustment for confounders. Further analysis using restricted cubic splines revealed a non-linear relationship between UHR and LVH, with an inflection point at UHR = 0.60. Below this threshold, each increase of one standard deviation in UHR was associated with a 2.11-fold increase in LVH risk (OR: 2.11, 95% CI: 1.51-3.03, p < 0.001), while above this threshold, the association was not significant (OR: 0.82, 95% CI: 0.39-1.47, p = 0.54).

Conclusion: This study provides the first evidence of an association between UHR and LVH in CKD patients, particularly at lower UHR levels. The findings suggest that UHR could serve as a novel marker for cardiovascular risk stratification in CKD, reflecting the balance between pro-inflammatory and protective cardiovascular factors. These results highlight the potential of UHR as a cost-effective tool for identifying CKD patients at increased risk of LVH, warranting further investigation in longitudinal studies to establish causality and explore targeted interventions.

Background: An increased blood pressure variability (BPV) is associated with a high risk of cardiovascular events in the general population. This concept was scarcely tested in patients with chronic kidney disease (CKD). We investigated the behavior of BPV parameters in a large cohort of older patients with CKD.

Methods: This retrospective cohort study included patients ≥75 years old with eGFR ≤60 mL/min. Three systolic and diastolic consecutive blood pressure (BP) measurements were obtained automatically per visit (short term - 3 consecutive measurements) and across visits (long term - across visits). We calculated (1) standard deviation (SD); (2) coefficient of variation (SD divided by the BP average); and (3) variability independent of the mean (VIM). For each BPV parameter, patients were divided into quartiles.

Results: We included 1,063 patients (17,363 measurements). For short BPV, the higher systolic BPV (SD and VIM) was associated with older age, a lower proportion of males, and a higher proportion of patients with pulse pressure (PP) >40 mm Hg. Higher diastolic BPV (SD and VIM) was associated with lower body mass index, lower eGFR, and a higher proportion of PP >40 mm Hg (for SD). Bland-Altman plots revealed comparable results between short- and long-term BPV.

Conclusion: A higher BPV was associated with reduced renal function in older patients with CKD. Our study also suggests that short- and long-term BPV can be used with similar results. Further studies are needed to confirm the association between BPV and outcomes and understand the physiological mechanisms underlying this correlation.

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.

Background: The molecular association between end-stage renal disease (ESRD), arteriovenous fistula (AVF) failure, and cardiovascular disease (CVD) remains unclear. This study aimed to investigate their potential relationship.

Methods: Three datasets were downloaded from the public database. AVF-failure-related differentially expressed genes (DEGs), CVD-related DEGs, and ESRD-related DEGs were identified by differential expression analysis and weighted gene co-expression network analysis. Then, AVF-failure-related, CVD-related, and ESRD-related DEGs were overlapped to obtain the hub genes. The diagnostic values of hub genes were evaluated. Finally, the immune infiltration analysis and drug prediction were performed.

Results: A total of four hub genes (ABCC8, ALPI, FGF11, and OBP2A) were identified, and those genes have excellent diagnostic accuracy. Among them, ABCC8, ALPI, and FGF11 showed good sensitivity and specificity. However, compared to the nondiabetic subgroup, the diagnostic ability of these genes was weaker in the diabetic subgroup for distinguishing AVF failure in ESRD patients. Type 17 T helper cells and gamma delta T cells may be associated with CVD caused by ESRD and AVF. A total of 15 drugs associated with hub genes were predicted.

Conclusion: ABCC8, ALPI, and FGF11 could serve as potential diagnostic biomarkers for AVF failure and CVD in HD-treated ESRD patients. Their robustness needs to be validated in larger cohorts and additional subgroups with comorbidities.

Background: The interaction between the heart and kidneys involves complex mechanisms, leading to a clinical condition known as cardiorenal syndrome (CRS), where dysfunction in one organ leads to impairment of the other. This syndrome can be acute or chronic, affecting both organs simultaneously.

Summary: In 2008, the Acute Dialysis Quality Group classified CRS into two main categories: cardiorenal CRS and renocardiac CRS, based on the primary organ affected. Cardiorenal CRS includes two subtypes where heart failure causes kidney injury (types 1 and 2), while renocardiac CRS (types 3 and 4) refers to kidney injury leading to cardiac dysfunction, either from acute kidney injury or chronic kidney disease. Type 5 CRS is termed as secondary CRS which involves both organ dysfunction due to an acute systemic disease, such as sepsis, infections, or chronic conditions like diabetes mellitus. This review examines the cardiovascular involvement in various nephrological diseases commonly seen in clinical practice, with a focus on types 3-5 CRS in children from a nephrology perspective.

Key messages: CRS is common in pediatric patients with cardiac, renal, or systemic conditions and poses a significant risk of mortality. The lack of longitudinal studies or specific biomarkers for the diagnosis, treatment, and follow-up of CRS in children is evident. Aspects such as the development of new biomarkers, ongoing research into neurohormonal mechanisms, meta-analyses, and introduction of algorithms for the follow-up period may reshape patient management. Specific diagnostic tools or therapeutic interventions for CRS management in children should be implemented. Collaborative efforts among pediatricians, cardiologists, and nephrologists are essential for developing effective treatments. Large-scale studies are needed to better understand CRS and develop targeted therapies to improve outcomes for pediatric patients, reducing morbidity and mortality.

Background: Uncontrolled hypertension is both a driver of chronic kidney disease (CKD) and a complication of the disease, as well as a risk factor for cardiovascular disease (CVD). Therefore, renal protective agents with antihypertensive properties are desirable for management of cardiorenal syndrome in CKD. Sodium-glucose cotransporter-2 (SGLT2) inhibitors are emerging as a new class of renal protective agents, with robust efficacy in delaying progression of CKD and reducing cardiovascular events. Here, we present an overview of SGLT2 inhibitors and discuss the alternative mechanisms contributing to the antihypertensive and cardiorenal benefits of SGLT2 inhibitors, with a focus on people with CKD and concomitant hypertension. We also explore the role of SGLT2 as a central node in the pathways underlying these mechanisms.

Summary: Beyond its well-known renal benefit, SGLT2 inhibitors have shown blood pressure (BP)-lowering effects in people with CKD, with an average reduction of 3-5 mm Hg in systolic BP. Clinical evidence has shown that SGLT2 inhibitors confer cardiorenal protective effects in patients with CKD regardless of diabetes status, and these benefits appear to extend to individuals with hypertensive CKD. The antihypertensive effects of SGLT2 inhibitors were also demonstrated in patients with CKD and hypertension. While osmotic diuresis is thought to be a predominant mechanism underlying the antihypertensive effects of SGLT2 inhibitors in the CKD population, we believe that the underlying mechanisms are likely to be multifactorial, with alternative pathways also involved, particularly in hypertension-associated CKD.

Key messages: Given the rising incidence of hypertension and CKD, the BP-lowering and cardioprotective effects of SGLT2 inhibitors could provide additional value in using this drug class for management of patients with CKD who have hypertension. Further subgroup analyses or larger studies on this specific population will provide more insights into the role of SGLT2 inhibitors in improving cardiorenal outcomes in this setting.

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, neutrophil gelatinase-associated lipocalin (NGAL), and α-Klotho were detected at admission using enzyme-linked immunosorbent assay. 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, brain natriuretic peptide (BNP), troponin-I (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 (area under a receiver operating characteristic curve, 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: Renal function plays a pivotal role in influencing various diseases, particularly cardiovascular conditions. Renal markers show strong associations with coronary artery disease (CAD), aortic valve sclerosis (AVSc), and sarcopenia. The sarcopenia index (SI), a biomarker derived from renal markers, serves a dual purpose: it precisely quantifies muscle mass while also acting as a prognostic indicator for adverse cardiovascular outcomes, especially in patients with concurrent CAD and AVSc.

Methods: A retrospective analysis was performed on consecutive CAD patients treated from 2013 to 2014. The SI was calculated using the formula (serum creatinine [mg/dL]/cystatin C [mg/dL]) × 100. The primary composite endpoint was cardiovascular death or rehospitalization for heart failure or acute coronary syndrome events. The secondary endpoint included the primary endpoint plus all-cause mortality. Kaplan-Meier analysis and Cox proportional hazards modeling was applied to analyze the association between SI and outcomes.

Results: Among the 1,123 CAD patients, 277 had AVSc. Patients with AVSc had significantly lower SI, which was independently associated with AVSc presence (OR = 1.750, p < 0.001). Associations between SI and both endpoints were identified in CAD patients with AVSc rather than in those without AVSc. SI below the median (89.40) was predictive of worse outcomes. Lower SI significantly increased the risk for the primary (HR = 1.883, p = 0.035) and secondary (HR = 1.910, p = 0.021) endpoints in AVSc subgroup.

Conclusion: Lower SI is independently associated with AVSc in CAD patients and was also associated with adverse cardiovascular events and mortality in CAD patients with AVSc.

Background: Fluid/sodium overload is the primary reason for hospital admission for patients with acute decompensated heart failure. Unfortunately, congestion often remains undertreated and is associated with significant adverse outcomes in patients with congestive heart failure (CHF). Potent loop diuretics have long been accepted as the first-line treatment for these patients. However, recurrent hospital admission, due in part to a lack of response to diuretics, becomes common as heart failure progresses.

Summary: While the goal of acute decompensated heart failure (ADHF) therapy has historically been to correct the excess of sodium chloride and water in the body, recent studies in patients with diuretic-resistant CHF have reported a paradoxical role for repletion with hypertonic saline (HS) infusion during continued use of loop diuretics to enhance diuresis. With the increasing use of combined therapy in the intensive care unit and recent trials of combined therapy in ambulatory patients, nephrologists are increasingly involved in its use.

Key messages: Several clinical trials in ADHF have demonstrated a role for HS in the improvement of outcomes such as decongestion, diuresis, kidney function, weight loss, mortality, length of stay, and readmission rates. This is a review for nephrologists of the potential effects of infusion of HS in combination with loop diuretics in patients with ADHF.