Kidney Function, Albuminuria, and Risk of Incident Atrial Fibrillation: A Systematic Review and Meta-Analysis

CLLAF SCORE-A New Risk Score for Predicting Atrial Fibrillation in Treatment-Naive CLL Patients Initiating First- and Second-Generation BTK Inhibitor Therapy

BACKGROUND

One of the limiting toxicities of BTKi is the development of atrial fibrillation (AF), with an incidence of 3%-16%.

AIM

This study aimed to identify patients with chronic lymphocytic leukemia (CLL) starting both first- and second-generation BTKis who are at high risk of developing AF using a machine learning approach.

METHODS

The CLL cohort is based on data obtained from electronic medical records from Maccabi, the second-largest healthcare organization in Israel. The optimal scoring model was determined using the Risk-calibrated Supersparse Linear Integer Model (RiskSLIM) algorithm.

RESULTS

A total of 3964 patients with a CLL diagnosis were available in the database. Of these, 208 patients started BTKi during the study period (125 on ibrutinib and 83 on acalabrutinib), and 16 patients developed AF during follow-up. In addition to well-established factors such as age, sex, and hypertension, the algorithm detected other factors associated with a high risk for AF: type of BTKi used, low eGFR, elevated absolute monocytes (> 1100/μL), elevated CRP, elevated CK, and elevated B2MG (> 2.5 mg/L). Based on the total AF-free survival (AFS), we identified three main risk groups: low (0-6), intermediate (7-11) and high (≥ 12). The median AF-free survival (AFS) was 28 and 56 months for the high-risk and intermediate-risk groups, respectively, and was not reached for the low-risk group. The difference between the groups was statistically significant (p = 0.0013).

CONCLUSION

Our novel score has a high concordance index for predicting the development of AF in patients with CLL treated with first- and second-generation BTKis. It combines age, sex, medical history, and laboratory tests associated with inflammatory status and disease burden and can be applied in clinical settings worldwide.

Clinical Practice Guideline for detection and management of diabetic kidney disease: A consensus report by the Spanish Society of Nephrology

To address all the changes in the management of people with diabetes (DM) and chronic kidney disease (CKD), under the auspices of the Spanish Society of Nephrology (SEN), the Spanish Diabetic Nephropathy Study Group (GEENDIAB) decided to publish an updated Clinical Practice Guideline for detection and management of diabetic kidney disease (DKD). It is aimed at a wide audience of clinicians treating diabetes and CKD. The terminology of kidney disease in diabetic patients has evolved toward a more inclusive nomenclature that avoids underdiagnosis of this entity. Thus, the terms "diabetes and kidney disease" and "diabetic kidney disease" are those proposed in the latest KDIGO 2022 guidelines to designate the whole spectrum of patients who can benefit from a comprehensive therapeutic approach only differentiated according to eGFR range and albuminuria. Recommendations have been divided into five main areas of interest: Chapter 1: Screening and diagnosis of diabetic kidney disease, Chapter 2: Metabolic control in people with diabetes and CKD, Chapter 3: Blood pressure control in people with diabetic kidney disease, Chapter 4: Treatment targeting progression of CKD in people with diabetic kidney disease, and Chapter 5: Antiplatelet or anticoagulant therapy in people with diabetes and CKD. World Health Organization (WHO) recommendations for guideline development were followed to report this guideline. Systematic reviews were carried out, with outcome ratings and summaries of findings, and we reported the strength of recommendations following the "Grading of Recommendations Assessment, Development and Evaluation" GRADE evidence profiles.

Albuminuria in Cardiovascular, Kidney, and Metabolic Disorders: A State-of-the-Art Review

Albuminuria-increased urine albumin excretion-is associated with cardiovascular mortality among patients with diabetes, hypertension, chronic kidney disease, or heart failure, as well as among adults with few cardiovascular risk factors. Many authors have hypothesized that albuminuria reflects widespread endothelial dysfunction, but additional work is needed to uncover whether albuminuria is directly pathologic or causative of cardiovascular disease. Urinary albumin-to-creatinine ratio is an attractive, unifying biomarker of cardiovascular, kidney, and metabolic conditions that may be useful for identifying and monitoring disease trajectory. However, albuminuria may develop through unique mechanisms across these distinct clinical phenotypes. This state-of-the-art review discusses the role of albuminuria in cardiovascular, kidney, and metabolic conditions; identifies potential pathways linking albuminuria to adverse outcomes; and provides practical approaches to screening and managing albuminuria for clinical cardiologists. Future research is needed to determine how broadly and how frequently to screen patients for albuminuria, whether it is cost-effective to treat low-grade albuminuria (10-30 mg/g), and how to equitably offer newer antiproteinuric therapies across the spectrum of cardiovascular-kidney-metabolic diseases.

Association of Estimated Glomerular Filtration Rate (eGFR) and High-Sensitivity C-Reactive Protein (Hs-CRP) with the Risk of New-Onset Atrial Fibrillation in Patients with Diabetes

BACKGROUND

Both renal function decline and systemic inflammation may synergistically increase the risk of atrial fibrillation (AF). This study investigates the association between estimated glomerular filtration rate (eGFR) and high-sensitivity C-reactive protein (hs-CRP) levels with the risk of new-onset AF in patients with diabetes mellitus.

METHODS

We included diabetic patients without AF who participated in physical exams in the Kailuan Study from 2006 to 2010. Participants were categorized into four groups based on baseline eGFR and hs-CRP levels: 1) high eGFR (≥60 mL/min/1.73m²) and low hs-CRP (<3 mg/L) (n=6,915), 2) high eGFR and high hs-CRP (≥3 mg/L) (n=3,154), 3) low eGFR (<60 mL/min/1.73m²) and low hs-CRP (n=4,638), 4) low eGFR and high hs-CRP (n=1,809). We employed multivariable Cox regression analysis to evaluate the relationships between eGFR, hs-CRP, and new-onset AF, adjusting for confounders including smoking status, alcohol consumption, blood pressure, fasting blood glucose (FBG), heart rate, lipid levels, body mass index (BMI), and medication usage. Competing risk analysis was also performed.

RESULTS

Among 16,516 patients, 222 developed new-onset AF over a mean follow-up of 12.6 years. After adjusting for confounders, elevated hs-CRP and reduced eGFR were significantly associated with higher risk of new-onset AF compared to the high eGFR/low hs-CRP group. These findings remained consistent after excluding AF cases within the first 2-year. No significant interaction between eGFR and hs-CRP was observed (P=0.227). Subgroup analysis revealed that the combination of eGFR and hs-CRP had predictive value primarily in males under 60 years of age, individuals with FBG <9 mmol/L, hypertension, and those not on hypoglycemic medications.

CONCLUSION

In diabetic patients, decreased eGFR and elevated hs-CRP were independently linked to an increased risk of new-onset AF, emphasizing the importance of monitoring these factors for early detection and prevention of AF.

Albuminuria, Forgotten No More: Underlining the Emerging Role in CardioRenal Crosstalk

Kidneys have an amazing ability to adapt to adverse situations, both acute and chronic. In the presence of injury, the kidney is able to activate mechanisms such as autoregulation or glomerular hyperfiltration to maintain the glomerular filtration rate (GFR). While these adaptive mechanisms can occur in physiological situations such as pregnancy or high protein intake, they can also occur as an early manifestation of diseases such as diabetes mellitus or as an adaptive response to nephron loss. Although over-activation of these mechanisms can lead to intraglomerular hypertension and albuminuria, other associated mechanisms related to the activation of inflammasome pathways, including endothelial and tubular damage, and the hemodynamic effects of increased activity of the renin-angiotensin-aldosterone system, among others, are recognized pathways for the development of albuminuria. While the role of albuminuria in the progression of chronic kidney disease (CKD) is well known, there is increasing evidence of its negative association with cardiovascular events. For example, the presence of albuminuria is associated with an increased likelihood of developing heart failure (HF), even in patients with normal GFR, and the role of albuminuria in atherosclerosis has recently been described. Albuminuria is associated with adverse outcomes such as mortality and HF hospitalization. On the other hand, it is increasingly known that the systemic effects of congestion are mainly preceded by increased central venous pressure and transmitted retrogradely to organs such as the liver or kidney. With regard to the latter, a new entity called congestive nephropathy is emerging, in which increased renal venous pressure can lead to albuminuria. Fortunately, the presence of albuminuria is modifiable and new treatments are now available to reverse this common risk factor in the cardiorenal interaction.