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Faucon AL, Fu EL, Stengel B, Mazhar F, Evans M, Carrero JJ. A nationwide cohort study comparing the effectiveness of diuretics and calcium channel blockers on top of renin-angiotensin system inhibitors on chronic kidney disease progression and mortality. Kidney Int 2023; 104:542-551. [PMID: 37330214 DOI: 10.1016/j.kint.2023.05.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 05/07/2023] [Accepted: 05/18/2023] [Indexed: 06/19/2023]
Abstract
It is unknown whether initiating diuretics on top of renin-angiotensin system inhibitors (RASi) is superior to alternative antihypertensive agents such as calcium channel blockers (CCBs) in patients with chronic kidney disease (CKD). For this purpose, we emulated a target trial in the Swedish Renal Registry 2007-2022 that included nephrologist-referred patients with moderate-advanced CKD and treated with RASi, who initiated diuretics or CCB. Using propensity score-weighted cause-specific Cox regression, we compared risks of major adverse kidney events (MAKE; composite of kidney replacement therapy [KRT], experiencing over a 40% eGFR decline from baseline, or an eGFR under 15 ml/min per 1.73m2), major cardiovascular events (MACE; composite of cardiovascular death, myocardial infarction or stroke), and all-cause mortality. We identified 5875 patients (median age 71 years, 64% men, median eGFR 26 ml/min per 1.73m2), of whom 3165 started a diuretic and 2710 a CCB. After a median follow-up of 6.3 years, 2558 MAKE, 1178 MACE and 2299 deaths occurred. Compared to CCB, diuretic use was associated with a lower risk of MAKE (weighted hazard ratio 0.87 [95% confidence interval: 0.77-0.97]), consistent across single components (KRT: 0.77 [0.66-0.88], over 40% eGFR decline: 0.80 [0.71-0.91] and eGFR under 15ml/min/1.73m2: 0.84 [0.74-0.96]). The risks of MACE (1.14 [0.96-1.36]) and all-cause mortality (1.07 [0.94-1.23]) did not differ between therapies. Results were consistent when modeling the total time drug exposure, across sub-groups and a broad range of sensitivity analyses. Thus, our observational study suggests that in patients with advanced CKD, using a diuretic rather than a CCB on top of RASi may improve kidney outcomes without compromising cardioprotection.
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Affiliation(s)
- Anne-Laure Faucon
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; INSERM UMR 1018, Department of Clinical Epidemiology, Centre for Epidemiology and Population Health, Paris-Saclay University, Villejuif, France.
| | - Edouard L Fu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bénédicte Stengel
- INSERM UMR 1018, Department of Clinical Epidemiology, Centre for Epidemiology and Population Health, Paris-Saclay University, Villejuif, France
| | - Faizan Mazhar
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Marie Evans
- Division of Nephrology, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Juan-Jesús Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Division of Nephrology, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
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Lorenzo M, Miñana G, Palau P, Amiguet M, Seller J, Garcia Pinilla JM, Domínguez E, Villar S, DE LA Espriella R, Núñez E, Górriz JL, Valle A, Bodí V, Sanchis J, Bayés-Genis A, Núñez J. Short-term Changes in Hemoglobin and Changes in Functional Status, Quality of Life, and Natriuretic Peptides after initiation of Dapagliflozin in Heart Failure with Reduced Ejection Fraction. J Card Fail 2023; 29:849-854. [PMID: 36871614 DOI: 10.1016/j.cardfail.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND We aimed to evaluate the effect of dapagliflozin on short-term changes in hemoglobin in patients with stable heart failure with reduced ejection fraction (HFrEF) and whether these changes mediated the effect of dapagliflozin on functional capacity, quality of life, and NT-proBNP. METHODS It is an exploratory analysis of a randomized, double-blinded clinical trial in which 90 stable patients with HFrEF were randomly allocated to dapagliflozin or placebo to evaluate short-term changes in peak oxygen consumption (peak VO2) (NCT04197635). This substudy evaluated 1 and 3-month changes in hemoglobin and whether these changes mediated the effects of dapagliflozin on peak VO2, Minnesota Living-With-Heart-Failure test (MLHFQ), and NT-proBNP. RESULTS At baseline, mean hemoglobin was 14.3 ± 1.7 g/dL. Hemoglobin significantly increased in those on dapagliflozin [1-month: +0.45 g/dL (p=0.037), and 3-month:+0.55 g/dL, (p=0.012)]. Changes in hemoglobin positively mediated the changes in peak VO2 at 3-month (59.5%, p<0.001). Changes in hemoglobin significantly mediated the effect of dapagliflozin in MLHFQ at 3-month (-53.2% and -48.7%, p=0.017) and NT-proBNP at 1 and 3-month (-68.0%, p=0.048 and -62.7%, p=0.029, respectively). CONCLUSIONS In patients with stable HFrEF, dapagliflozin caused a short-term increase in hemoglobin, identifying patients with a greater improvement in maximal functional capacity, QoL, and reduction of NT-proBNP.
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Affiliation(s)
- Miguel Lorenzo
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain
| | - Gema Miñana
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain
| | - Patricia Palau
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain
| | - Martina Amiguet
- Fundación para Fomento de Investigación Sanitaria y Biomédica CV-Fisabio, Valencia, Spain
| | - Julia Seller
- Fundación para Fomento de Investigación Sanitaria y Biomédica CV-Fisabio, Valencia, Spain; Cardiology Department, Hospital de Dénia-MarinaSalud, Alicante, Spain
| | - Jose Manuel Garcia Pinilla
- CIBER Cardiovascular, Madrid, Spain; Cardiology Department, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - Eloy Domínguez
- Fundación para Fomento de Investigación Sanitaria y Biomédica CV-Fisabio, Valencia, Spain; Universitat Jaume I, Castellón, Spain
| | - Sandra Villar
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain
| | - Rafael DE LA Espriella
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain
| | - Eduardo Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain
| | - Jose Luis Górriz
- Nephrology Department, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain
| | | | - Vicent Bodí
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain
| | - Juan Sanchis
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain
| | - Antoni Bayés-Genis
- CIBER Cardiovascular, Madrid, Spain; Cardiology Department, Hospital Germans Trias i Pujol, Universitat de Barcelona, Barcelona, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain.
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McCallum W, Sarnak MJ. Cardiorenal Syndrome in the Hospital. Clin J Am Soc Nephrol 2023; 18:01277230-990000000-00026. [PMID: 36787124 PMCID: PMC10356127 DOI: 10.2215/cjn.0000000000000064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 12/22/2022] [Indexed: 01/22/2023]
Abstract
The cardiorenal syndrome refers to a group of complex, bidirectional pathophysiological pathways involving dysfunction in both the heart and kidney. Upward of 60% of patients admitted for acute decompensated heart failure have CKD, as defined by an eGFR of <60 ml/min per 1.73 m2. CKD, in turn, is one of the strongest risk factors for mortality and cardiovascular events in acute decompensated heart failure. Although not well understood, the mechanisms in the cardiorenal syndrome include venous congestion, arterial underfilling, neurohormonal activation, inflammation, and endothelial dysfunction. Arterial underfilling may lead to activation of the renin-angiotensin-aldosterone system and sympathetic nervous system, leading to sodium reabsorption and vasoconstriction. Venous congestion likely also mediates and perpetuates these maladaptive pathways. To rule out intrinsic kidney disease that is distinct from the cardiorenal syndrome, one should obtain a careful history, review longitudinal eGFR trends, assess albuminuria and proteinuria, and review the urine sediment and kidney imaging. The hallmark of the cardiorenal syndrome is intense sodium avidity and diuretic resistance, often requiring a combination of diuretics with varying pharmacological targets, and monitoring of urinary response to guide escalations in therapy. Invasive means of decongestion may be required including ultrafiltration or kidney RRT such as peritoneal dialysis, which is often better tolerated from a hemodynamic perspective than intermittent hemodialysis. Strategies for increasing forward perfusion in states of low cardiac output and cardiogenic shock may include afterload reduction and inotropes and, in the most severe cases, mechanical circulatory support devices, many of which have kidney-specific considerations.
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Affiliation(s)
- Wendy McCallum
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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Reis T, Ronco F, Ostermann M. Diuretics and Ultrafiltration in Heart Failure. Cardiorenal Med 2023; 13:56-65. [PMID: 36630939 DOI: 10.1159/000529068] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/15/2022] [Indexed: 01/12/2023] Open
Abstract
Fluid overload is a risk factor for increased morbidity and mortality, especially in patients with heart disease. The treatment options are limited to diuretics and mechanical fluid removal using ultrafiltration or renal replacement therapy. This paper provides an overview of the challenges of managing fluid overload, outlines the risks and benefits of different pharmacological options and extracorporeal techniques, and provides guidance for clinical practice.
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Affiliation(s)
- Thiago Reis
- Division of Kidney Transplantation, D'Or Institute for Research and Education (IDOR), DF Star Hospital, Brasília, Brazil
- Laboratory of Molecular Pharmacology, Faculty of Health Sciences, University of Brasília, Asa Norte, Campus Darcy Ribeiro, Brasília, Brazil
| | - Federico Ronco
- Interventional Cardiology, Ospedale dell'Angelo, Mestre, Venezia, Italy
| | - Marlies Ostermann
- Department of Critical Care and Nephrology, King's College London, Guy's and St Thomas' Hospital, London, UK
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Chávez-Íñiguez JS, Ivey-Miranda JB, De la Vega-Mendez FM, Borges-Vela JA. How to interpret serum creatinine increases during decongestion. Front Cardiovasc Med 2023; 9:1098553. [PMID: 36684603 PMCID: PMC9846337 DOI: 10.3389/fcvm.2022.1098553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/12/2022] [Indexed: 01/06/2023] Open
Abstract
During decongestion in acute decompensated heart failure (ADHF), it is common to observe elevations in serum creatinine (sCr) values due to vascular congestion, a mechanism that involves increased central venous pressure that has a negative impact on the nephron, promoting greater absorption of water and sodium, increased interstitial pressure in an encapsulated organ developing "renal tamponade" which is one of main physiopathological mechanism associated with impaired kidney function. For the treatment of this syndrome, it is recommended to use diuretics that generate a high urinary output and natriuresis to decongest the venous system, during this process the sCr values can rise, a phenomenon that may bother some cardiologist and nephrologist, since raise the suspicion of kidney damage that could worsen the prognosis of these patients. It is recommended that increases of up to 0.5 mg/dL from baseline are acceptable, but some patients have higher increases, and we believe that an arbitrary number would be impractical for everyone. These increases in sCr may be related to changes in glomerular hemodynamics and true hypovolemia associated with decongestion, but it is unlikely that they are due to structural injury or truly hypoperfusion and may even have a positive connotation if accompanied by an effective decongestion and be associated with a better prognosis in the medium to long term with fewer major cardiovascular and renal events. In this review, we give a comprehensive point of view on the interpretation of creatinine elevation during decongestion in patients with ADHF.
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Affiliation(s)
- Jonathan S. Chávez-Íñiguez
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico,University of Guadalajara Health Sciences Center, Guadalajara, Mexico,*Correspondence: Jonathan S. Chávez-Íñiguez, ; @JonathanNefro; orcid.org/0000-0003-2786-6667
| | - Juan B. Ivey-Miranda
- Heart Failure and Heart Transplant Clinic, Hospital de Cardiología, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Frida M. De la Vega-Mendez
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Julian A. Borges-Vela
- Heart Failure and Heart Transplant Clinic, Hospital de Cardiología, Instituto Mexicano del Seguro Social, Mexico City, Mexico
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Sawatani T, Shirakabe A, Okazaki H, Matsushita M, Shibata Y, Shigihara S, Nishigoori S, Sasamoto N, Kiuchi K, Kobayashi N, Shimizu W, Asai K. Time-Dependent Changes in N-Terminal Pro-Brain Natriuretic Peptide and B-Type Natriuretic Peptide Ratio During Hospitalization for Acute Heart Failure. Int Heart J 2023; 64:213-222. [PMID: 37005316 DOI: 10.1536/ihj.22-350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
The time-dependent changes in the simultaneous evaluation of B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) levels during hospitalization for acute heart failure (AHF) remain obscure.A total of 356 AHF patients were analyzed. Blood samples were collected within 15 minutes of admission (Day 1), 48-120 hours (Day 2-5) and between days 7 and 21 (Before-discharge). Plasma BNP and serum NT-proBNP were significantly decreased on Days 2-5 and Before-discharge in comparison to Day 1, but the NT-proBNP/BNP ratio was not changed. Patients were divided into 2 groups according to the median NT-proBNP/BNP (N/B) ratio on Day 2-5 (Low-N/B versus High-N/B). A multivariate logistic regression model showed that age (per 1-year increase), serum creatinine (per 1.0-mg/dL increase), and serum albumin (per 1.0-mg/dL decrease) were independently associated with High-N/B (odds ratio [OR]: 1.071, 95%confidence interval [CI]: 1.036-1.108, OR: 1.190, 95%CI: 1.121-1.264 and OR: 2.410, 95%CI: 1.121-5.155, respectively). Kaplan-Meier curve analysis showed that the High-N/B group had a significantly poorer prognosis than the Low-N/B group, and a multivariate Cox regression model revealed that High-N/B was an independent predictor of 365-day mortality (hazard ratio [HR]: 1.796, 95%CI: 1.041-3.100) and HF events (HR: 1.509, 95%CI: 1.007-2.263). The same trend in prognostic impact was significantly observed in both low and high delta-BNP cohorts (< 55% and ≥ 55% BNP value on the start date/BNP value at 2-5-days).A high NT-proBNP/BNP ratio on Day 2-5 was associated with non-cardiac conditions and was associated with adverse outcomes even if BNP was adequately decreased by the treatment of AHF.
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Affiliation(s)
- Tomofumi Sawatani
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital
| | - Akihiro Shirakabe
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital
| | - Hirotake Okazaki
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital
| | - Masato Matsushita
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital
| | - Yusaku Shibata
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital
| | - Shota Shigihara
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital
| | - Suguru Nishigoori
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital
| | - Nozomi Sasamoto
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital
| | - Kazutaka Kiuchi
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital
| | - Nobuaki Kobayashi
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Kuniya Asai
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital
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Rodríguez-Espinosa D, Guzman-Bofarull J, De La Fuente-Mancera JC, Maduell F, Broseta JJ, Farrero M. Multimodal Strategies for the Diagnosis and Management of Refractory Congestion. An Integrated Cardiorenal Approach. Front Physiol 2022; 13:913580. [PMID: 35874534 PMCID: PMC9304751 DOI: 10.3389/fphys.2022.913580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/20/2022] [Indexed: 01/12/2023] Open
Abstract
Refractory congestion is common in acute and chronic heart failure, and it significantly impacts functional class, renal function, hospital admissions, and survival. In this paper, the pathophysiological mechanisms involved in cardiorenal syndrome and the interplay between heart failure and chronic kidney disease are reviewed. Although the physical exam remains key in identifying congestion, new tools such as biomarkers or lung, vascular, and renal ultrasound are currently being used to detect subclinical forms and can potentially impact its management. Thus, an integrated multimodal diagnostic algorithm is proposed. There are several strategies for treating congestion, although data on their efficacy are scarce and have not been validated. Herein, we review the optimal use and monitorization of different diuretic types, administration route, dose titration using urinary volume and natriuresis, and a sequential diuretic scheme to achieve a multitargeted nephron blockade, common adverse events, and how to manage them. In addition, we discuss alternative strategies such as subcutaneous furosemide, hypertonic saline, and albumin infusions and the available evidence of their role in congestion management. We also discuss the use of extracorporeal therapies, such as ultrafiltration, peritoneal dialysis, or conventional hemodialysis, in patients with normal or impaired renal function. This review results from a multidisciplinary view involving both nephrologists and cardiologists.
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Affiliation(s)
- Diana Rodríguez-Espinosa
- Department of Nephrology and Renal Transplantation, Hospital Clínic of Barcelona, Barcelona, Spain
| | | | | | - Francisco Maduell
- Department of Nephrology and Renal Transplantation, Hospital Clínic of Barcelona, Barcelona, Spain
| | - José Jesús Broseta
- Department of Nephrology and Renal Transplantation, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Marta Farrero
- Department of Cardiology, Hospital Clínic of Barcelona, Barcelona, Spain
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