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Maxacalcitol (22-Oxacalcitriol (OCT)) Retards Progression of Left Ventricular Hypertrophy with Renal Dysfunction Through Inhibition of Calcineurin-NFAT Activity. Cardiovasc Drugs Ther 2020; 35:381-397. [PMID: 33206298 DOI: 10.1007/s10557-020-07111-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE Left ventricular hypertrophy (LVH) is a cardiovascular complication highly prevalent in patients with chronic kidney disease (CKD). Previous studies analyzing 1α-hydroxylase or vitamin D receptor (Vdr) knockout mice revealed active vitamin D as a promising agent inhibiting LVH progression. Paricalcitol, an active vitamin D analog, failed to suppress the progression of LV mass index (LVMI) in pre-dialysis patients with CKD. As target genes of activated VDR differ depending on its agonists, we examined the effects of maxacalcitol (22-oxacalcitriol: OCT), a less calcemic active vitamin D analog, on LVH in hemodialysis patients and animal LVH models with renal insufficiency. METHODS In retrospective cohort study, patients treated with OCT who underwent hemodialysis were enrolled. Using cardiac echocardiography, LV mass was evaluated by the area-length method. In animal study, angiotensin II (Ang II)-infused Wister rats with heminephrectomy or Ang II-stimulated neonatal rat ventricular myocytes (NRVM) were treated with OCT. RESULTS OCT significantly inhibited the progression of LVMI in hemodialysis patients. In Ang II-infused heminephrectomized rats, OCT suppressed the progression of LVH in a blood pressure-independent manner. OCT also suppressed the activity of calcineurin in the left ventricle of model rats. Specifically, OCT reduced the protein levels of calcineurin A, but not the mRNA levels of Ppp3ca (calcineurin Aα). Luciferase assays showed that OCT increased the promoter activity of Fbxo32 (atrogin1), an E3 ubiquitin ligase targeting calcineurin A. Finally, OCT promoted ubiquitination and degradation of calcineurin A. CONCLUSION Our works indicated that OCT retards progression of LVH through calcineurin-NFAT pathway, which reveal a novel aspect of OCT in attenuating pathological LVH.
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Microvascular disease in chronic kidney disease: the base of the iceberg in cardiovascular comorbidity. Clin Sci (Lond) 2020; 134:1333-1356. [PMID: 32542397 PMCID: PMC7298155 DOI: 10.1042/cs20200279] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/29/2020] [Accepted: 06/08/2020] [Indexed: 02/07/2023]
Abstract
Chronic kidney disease (CKD) is a relentlessly progressive disease with a very high mortality mainly due to cardiovascular complications. Endothelial dysfunction is well documented in CKD and permanent loss of endothelial homeostasis leads to progressive organ damage. Most of the vast endothelial surface area is part of the microcirculation, but most research in CKD-related cardiovascular disease (CVD) has been devoted to macrovascular complications. We have reviewed all publications evaluating structure and function of the microcirculation in humans with CKD and animals with experimental CKD. Microvascular rarefaction, defined as a loss of perfused microvessels resulting in a significant decrease in microvascular density, is a quintessential finding in these studies. The median microvascular density was reduced by 29% in skeletal muscle and 24% in the heart in animal models of CKD and by 32% in human biopsy, autopsy and imaging studies. CKD induces rarefaction due to the loss of coherent vessel systems distal to the level of smaller arterioles, generating a typical heterogeneous pattern with avascular patches, resulting in a dysfunctional endothelium with diminished perfusion, shunting and tissue hypoxia. Endothelial cell apoptosis, hypertension, multiple metabolic, endocrine and immune disturbances of the uremic milieu and specifically, a dysregulated angiogenesis, all contribute to the multifactorial pathogenesis. By setting the stage for the development of tissue fibrosis and end organ failure, microvascular rarefaction is a principal pathogenic factor in the development of severe organ dysfunction in CKD patients, especially CVD, cerebrovascular dysfunction, muscular atrophy, cachexia, and progression of kidney disease. Treatment strategies for microvascular disease are urgently needed.
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Feldreich T, Nowak C, Carlsson AC, Östgren CJ, Nyström FH, Sundström J, Carrero-Roig JJ, Leppert J, Hedberg P, Giedraitis V, Lind L, Cordeiro A, Ärnlöv J. The association between plasma proteomics and incident cardiovascular disease identifies MMP-12 as a promising cardiovascular risk marker in patients with chronic kidney disease. Atherosclerosis 2020; 307:11-15. [PMID: 32702535 DOI: 10.1016/j.atherosclerosis.2020.06.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/19/2020] [Accepted: 06/18/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS Previous proteomics efforts in patients with chronic kidney disease (CKD) have predominantly evaluated urinary protein levels. Therefore, our aim was to investigate the association between plasma levels of 80 cardiovascular disease-related proteins and the risk of major adverse cardiovascular events (MACE) in patients with CKD. METHODS Individuals with CKD stages 3-5 (eGFR below 60 ml min-1 [1.73 m]-2) from three community-based cohorts (PIVUS, ULSAM, SAVA), one diabetes cohort (CARDIPP) and one cohort with peripheral artery disease patients (PADVA) with information on 80 plasma protein biomarkers, assessed with a proximity extension assay, and follow-up data on incident MACE, were used as discovery sample. To validate findings and to asses generalizability to patients with CKD in clinical practice, an outpatient CKD-cohort (Malnutrition, Inflammation and Vascular Calcification (MIVC)) was used as replication sample. RESULTS In the discovery sample (total n = 1316), 249 individuals experienced MACE during 7.0 ± 2.9 years (range 0.005-12.9) of follow-up, and in the replication sample, 71 MACE events in 283 individuals over a mean ± SD change of 2.9 ± 1.2 years (range 0.1-4.0) were documented. Applying Bonferroni correction, 18 proteins were significantly associated with risk of MACE in the discovery cohort, adjusting for age and sex in order of significance, GDF-15, FGF-23, REN, FABP4, IL6, TNF-R1, AGRP, MMP-12, AM, KIM-1, TRAILR2, TNFR2, CTSL1, CSF1, PlGF, CA-125, CCL20 and PAR-1 (p < 0.000625 for all). Only matrix metalloproteinase 12 (MMP-12) was significantly associated with an increased risk of MACE in the replication sample (hazard ratio (HR) per SD increase, 1.36, 95% CI (1.07-1.75), p = 0.013). CONCLUSIONS Our proteomics analyses identified plasma MMP-12 as a promising cardiovascular risk marker in patients with CKD.
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Affiliation(s)
- Tobias Feldreich
- Education, Health and Social Studies, Dalarna University, Falun, Sweden.
| | - Christoph Nowak
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Alfred Nobels Allé 23, SE 14183, Huddinge, Sweden
| | - Axel C Carlsson
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Alfred Nobels Allé 23, SE 14183, Huddinge, Sweden
| | - Carl-Johan Östgren
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Fredrik H Nyström
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Juan-Jesus Carrero-Roig
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jerzy Leppert
- Centre for Clinical Research, Uppsala University, Västerås, Sweden
| | - Pär Hedberg
- Centre for Clinical Research, Uppsala University, Västerås, Sweden
| | - Vilmantas Giedraitis
- Department of Public Health and Caring Sciences, Geriatrics, Uppsala University, Uppsala, Sweden
| | - Lars Lind
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Antonio Cordeiro
- Department of Hypertension and Nephrology, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | - Johan Ärnlöv
- Education, Health and Social Studies, Dalarna University, Falun, Sweden; Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Alfred Nobels Allé 23, SE 14183, Huddinge, Sweden
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Nelson AJ, Raggi P, Wolf M, Gold AM, Chertow GM, Roe MT. Targeting Vascular Calcification in Chronic Kidney Disease. JACC Basic Transl Sci 2020; 5:398-412. [PMID: 32368697 PMCID: PMC7188874 DOI: 10.1016/j.jacbts.2020.02.002] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 01/24/2020] [Accepted: 02/03/2020] [Indexed: 12/22/2022]
Abstract
Cardiovascular (CV) disease remains an important cause of morbidity and mortality for patients with chronic kidney disease (CKD). Although clustering of traditional risk factors with CKD is well recognized, kidney-specific mechanisms are believed to drive the disproportionate burden of CV disease. One perturbation that is frequently observed at high rates in patients with CKD is vascular calcification, which may be a central mediator for an array of CV sequelae. This review summarizes the pathophysiological bases of intimal and medial vascular calcification in CKD, current strategies for diagnosis and management, and posits vascular calcification as a risk marker and therapeutic target.
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Key Words
- CAC, coronary artery calcification
- CI, confidence interval
- CKD, chronic kidney disease
- CT, computed tomography
- CV, cardiovascular
- CVD, cardiovascular disease
- ESKD, end-stage kidney disease
- FGF, fibroblast growth factor
- HR, hazard ratio
- LDL-C, low-density lipoprotein cholesterol
- MGP, matrix Gla protein
- PTH, parathyroid hormone
- VSMC, vascular smooth muscle cell
- chronic kidney disease
- dialysis
- eGFR, estimated glomerular filtration rate
- medial calcification
- vascular calcification
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Affiliation(s)
- Adam J. Nelson
- Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina
| | - Paolo Raggi
- Division of Cardiology, Department of Medicine, University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Alexander M. Gold
- Research and Development, Sanifit Therapeutics, San Diego, California
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Glenn M. Chertow
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Matthew T. Roe
- Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina
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Godino C, Melillo F, Rubino F, Arrigoni L, Cappelletti A, Mazzone P, Mattiello P, Della Bella P, Colombo A, Salerno A, Cera M, Margonato A. Real-world 2-year outcome of atrial fibrillation treatment with dabigatran, apixaban, and rivaroxaban in patients with and without chronic kidney disease. Intern Emerg Med 2019; 14:1259-1270. [PMID: 31073827 DOI: 10.1007/s11739-019-02100-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 04/29/2019] [Indexed: 01/05/2023]
Abstract
Patients with non-valvular atrial fibrillation (NVAF) and chronic kidney disease (CKD) are at increased risk of stroke and bleeding. Although direct oral anticoagulant (DOAC) trials excluded patients with severe CKD, a growing portion of CKD patients have been starting DOACs and limited data from real-world outcome in this high-risk setting are available. The INSigHT registry included 632 consecutive NVAF patients that started apixaban (256 patients, 41%), dabigatran (245, 39%) and rivaroxaban (131, 20%) between 2012 and 2015. Based on creatinine clearance, two sub-cohorts were defined: (1) non-CKD group (CrCl 60-89 mL/min, 413 patients) and (2) CKD group (15-59 ml/min, 219). Compared to non-CKD patients, those with CKD, were at higher ischemic (CHA2DS2-VASc 4.5 vs 2.9, p < 0.001) and hemorrhagic risk (HAS-BLED 2.4 vs 1.8, p < 0.001). At 2-year follow-up, the overall ISTH-major bleeding and thromboembolic event rates were 5.2% and 2.3% and no significant difference between non-CKD and CKD patients for both efficacy and safety endpoints were observed. In non-CKD patients, the 2-year ISTH-major bleeding rates were higher in rivaroxaban group (HR 2.9, 95% CI 1.1-7.3; p = 0.047) while dabigatran showed non-significant excess in thromboembolic events (HR 4.3, 95% CI 0.9-20.8; p = 0.068). In CKD patients, a significantly higher rate of thromboembolic events was observed in rivaroxaban (HR 6.3, 95% CI 1.1-38.1; p = 0.044). This real-world, non-insurance database registry shows remarkable 2-year safety and efficacy profile of DOACs even in patients with moderate to severe CKD. Head to head differences between DOACs are exploratory, hypothesis generating and warrant further investigation in larger studies.
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Affiliation(s)
- Cosmo Godino
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| | - Francesco Melillo
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Francesca Rubino
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Luca Arrigoni
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Alberto Cappelletti
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Patrizio Mazzone
- Arrhythmia and Electrophysiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Mattiello
- Information Systems Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Della Bella
- Arrhythmia and Electrophysiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Colombo
- Interventional Cardiovascular Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Anna Salerno
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Michela Cera
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Alberto Margonato
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
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Hung TW, Huang JY, Jong GP. Long-term outcomes of dialysis in patients with chronic kidney disease and new-onset atrial fibrillation: A population-based cohort study. PLoS One 2019; 14:e0222656. [PMID: 31536566 PMCID: PMC6752795 DOI: 10.1371/journal.pone.0222656] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 09/03/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is associated with substantial cardiovascular morbidity. Atrial fibrillation (AF) is a prevalent arrhythmia that increases the risk of both stroke and cardiovascular mortality. Information about the mortality risk among patients with advanced CKD and new-onset AF (NAF) in the presence and absence of dialysis is important. However, the association between advanced CKD and NAF in patients with and without dialysis is unclear. OBJECTIVE To investigate long-term outcomes of the association between advanced CKD and NAF in patients with and without dialysis. METHODS We conducted a nested case-control study based on the National Health Insurance Program in Taiwan. Each participant aged 20 years and older who had CKD with dialysis from 2000 to 2013 was assigned to the dialysis group, whereas sex-, age-, CKD duration-, and index date-matched participants without dialysis were randomly selected and assigned to the non-dialysis group. We used the Cox regression model to estimate the hazard ratio (HR) with the 95% confidence interval (CI) for mortality in CKD patients with combined dialysis and NAF. Patients with neither NAF nor dialysis served as the reference group. RESULTS We identified 3,673 dialysis cases and 7,346 Non-dialysis matched controls for enrolment in the study. The crude mortality rates were 3.3 (95% CI: 3.1-3.5), 10.98 (95% CI: 9.3-13.0), 9.2 (95% CI: 8.7-10.0), and 18.0 (95% CI: 15.4-21.2) in the [Non-dialysis, non-NAF], [Non-dialysis, NAF], [Dialysis, non-NAF], and [Dialysis, NAF] groups, respectively. After adjustment for age, gender, and co-morbidities, the aHRs were 2.0 (95% CI: 1.7-2.3), 2.7 (95% CI: 2.5-2.9), and 3.5 (95% CI: 2.9-4.1) in the [Non-Dialysis, NAF], [Dialysis, non-NAF], and [Dialysis, NAF] groups compared with the [Non-Dialysis, non-NAF] group, respectively. The Kaplan-Meier survival curves showed the highest mortality risk in the [Dialysis, NAF] group among the study groups. Patients with concurrent peritoneal dialysis and AF had the highest mortality risk: aHR = 4.3 (95% CI: 2.3-8.0). However, there was a relatively lower effect of NAF on mortality in patients on dialysis than in patients who were not. CONCLUSIONS Patients with advanced CKD and NAF had a significantly increased risk of mortality. Dialysis is not risky for patients with concurrent CKD and NAF. Dialysis offers a sufficient survival benefit to be considered as a standard treatment, as indicated by the superior physical status of patients on dialysis.
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Affiliation(s)
- Tung-Wei Hung
- Division of Nephrology, Department of Internal Medicine, Chung Shan Medical University Hospital and Chung Shan Medical University, Taichung, Taiwan, ROC
| | - Jing-Yang Huang
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan, ROC
| | - Gwo-Ping Jong
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital and Chung Shan Medical University, Taichung, Taiwan, ROC
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Nakamura S, Kawano Y, Nakajima K, Hase H, Joki N, Hatta T, Nishimura S, Moroi M, Nakagawa S, Kasai T, Kusuoka H, Takeishi Y, Momose M, Takehana K, Nanasato M, Yoda S, Nishina H, Matsumoto N, Nishimura T. Prognostic study of cardiac events in Japanese patients with chronic kidney disease using ECG-gated myocardial Perfusion imaging: Final 3-year report of the J-ACCESS 3 study. J Nucl Cardiol 2019; 26:431-440. [PMID: 28439760 PMCID: PMC6430747 DOI: 10.1007/s12350-017-0880-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 03/23/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Myocardial perfusion imaging (MPI) is considered useful for risk stratification among patients with chronic kidney disease (CKD), without renal deterioration by contrast media. METHODS AND RESULTS The Japanese Assessment of Cardiac Events and Survival Study by Quantitative Gated SPECT (J-ACCESS 3) is a multicenter, prospective cohort study investigating the ability of MPI to predict cardiac events in 529 CKD patients without a definitive coronary artery disease. All patients were assessed by stress and rest MPI with 99mTc-tetrofosmin and data were analyzed using a defect scoring method and QGS software. Major cardiac events were analyzed for 3 years after registration. The mean eGFR was 29.0 ± 12.8 (mL/minute/1.73 m2). The mean summed stress/rest/difference (SSS, SRS, SDS) scores were 1.9 ± 3.8, 1.1 ± 3.0, and 0.8 ± 1.8, respectively. A total of 60 cardiac events (three cardiac deaths, six sudden deaths, five nonfatal myocardial infarctions, 46 hospitalization cases for heart failure) occurred. The event-free survival rate was lower among patients with kidney dysfunction, higher SSS, and higher CRP values. Multivariate Cox regression analysis independently associated SSS ≥8, eGFR <15 (mL/minute/1.73 m2), and CRP ≥0.3 (mg/dL) with cardiac events. CONCLUSIONS Together with eGFR and CRP, MPI can predict cardiac events in patients with CKD.
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Affiliation(s)
- Satoko Nakamura
- Division of Hypertension and Nephrology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuhei Kawano
- Division of Hypertension and Nephrology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenichi Nakajima
- Department of Nuclear Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Hiroki Hase
- Department of Nephrology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Nobuhiko Joki
- Department of Nephrology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Tsuguru Hatta
- Division of Nephrology, Department of Medicine, Ohmihachiman Community Medical Center, Ohmihachiman, Japan
| | | | - Masao Moroi
- Department of Cardiology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Susumu Nakagawa
- Department of Cardiology, Saiseikai Central Hospital, Tokyo, Japan
| | - Tokuo Kasai
- Department of Cardiology, Jikei Medical University Aoto Hospital, Tokyo, Japan
| | - Hideo Kusuoka
- National Hospital Organization Osaka National Hospital, Osaka, Japan
| | | | - Mitsuru Momose
- Department of Radiology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Kazuya Takehana
- Department of Cardiology, Kansai Medical University, Hirakata, Japan
| | - Mamoru Nanasato
- Department of Cardiology, Nagoya Daini Red-Cross Hospital, Nagoya, Japan
| | - Syunichi Yoda
- Department of Cardiology, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Hidetaka Nishina
- Department of Cardiology, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Naoya Matsumoto
- Department of Cardiology, Suruga-dai Nihon University Hospital, Tokyo, Japan
| | - Tsunehiko Nishimura
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawara-machi Hirokoji, Kamigyo-ku, 602-8566 Kyoto, Japan
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Novel oral anticoagulants in chronic kidney disease: ready for prime time? Curr Opin Nephrol Hypertens 2018; 27:201-208. [PMID: 29570468 DOI: 10.1097/mnh.0000000000000410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Patients with chronic kidney disease (CKD) are at increased risk of atrial fibrillation, stroke, and bleeding posing unique clinical challenges. Novel oral anticoagulants (NOACs) including dabigatran, rivaroxaban, and apixaban have become recognized as alternative therapy to Vitamin K Antagonists (VKA) regarding the prevention of venous thromboembolism (VTE) and reduce the risk of stroke in atrial fibrillation. However, the understanding of NOACs in CKD is still underdeveloped. This review summarizes recent literature on the efficacy and safety of NOACs in patients with CKD. RECENT FINDINGS Studies focusing on patients with moderate kidney disease were drawn from post hoc analyses from three major NOAC trials, meta-analyses, and postmarketing surveillance studies. Cumulatively, these studies continue to demonstrate NOACs as equivalent if not superior therapies to VKAs in regards to both efficacy and safety. These studies are limited by small sample sizes as well as a lack of direct comparison between NOACs. SUMMARY The role of NOACs in managing VTE and atrial fibrillation is increasing. Current research suggests that NOACs are at least as efficacious and well tolerated as VKAs. More research is required to elucidate which NOAC is preferable in the clinical setting.
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Afshinnia F, Zeng L, Byun J, Gadegbeku CA, Magnone MC, Whatling C, Valastro B, Kretzler M, Pennathur S. Myeloperoxidase Levels and Its Product 3-Chlorotyrosine Predict Chronic Kidney Disease Severity and Associated Coronary Artery Disease. Am J Nephrol 2017; 46:73-81. [PMID: 28668952 DOI: 10.1159/000477766] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 03/09/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND The role of myeloperoxidase in chronic kidney disease (CKD) and its association with coronary artery disease (CAD) is controversial. In this study, we compared myeloperoxidase and protein-bound 3-chlorotyrosine (ClY) levels in subjects with varying degrees of CKD and tested their associations with CAD. METHODS From Clinical Phenotyping Resource and Biobank Core, 111 patients were selected from CKD stages 1 to 5. Plasma myeloperoxidase level was measured using enzyme-linked-immunosorbent assay. Plasma protein-bound 3-ClY, a specific product of hypochlorous acid generated by myeloperoxidase was measured by liquid chromatography mass spectrometry. RESULTS We selected 29, 20, 24, 22, and 16 patients from stages 1 to 5 CKD, respectively. In a sex-adjusted general linear model, mean ± SD of myeloperoxidase levels decreased from 18.1 ± 12.3 pmol in stage 1 to 10.9 ± 4.7 pmol in stage 5 (p = 0.011). In patients with and without CAD, the levels were 19.1 ± 10.1 and 14.8 ± 8.7 pmol (p = 0.036). There was an increase in 3-ClY mean from 0.81 ± 0.36 mmol/mol-tyrosine in stage 1 to 1.42 ± 0.41 mmol/mol-tyrosine in stage 5 (p < 0.001). The mean 3-ClY levels in patients with and without CAD were 1.25 ± 0.44 and 1.04 ± 0.42 mmol/mol-tyrosine (p = 0.023), respectively. C-statistic of ClY when added to myeloperoxidase level to predict CKD stage 5 was 0.86, compared to 0.79 for the myeloperoxidase level alone (p = 0.0097). CONCLUSION The myeloperoxidase levels decrease from stages 1 to 5, whereas activity increases. In contrast, both myeloperoxidase and ClY levels rise in the presence of CAD at various stages of CKD. Measuring both plasma myeloperoxidase and 3-CLY levels provide added value to determine the burden of myeloperoxidase-mediated oxidative stress.
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Affiliation(s)
- Farsad Afshinnia
- University of Michigan, Department of Internal Medicine-Nephrology, Ann Arbor, MI, USA
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Baloglu I, Turkmen K, Zeki Tonbul H, Yılmaz Selcuk N. The relationship between coronary artery calcium scores and left atrium size in hemodialysis patients. Int Urol Nephrol 2017; 49:1661-1666. [PMID: 28523594 DOI: 10.1007/s11255-017-1620-0] [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: 02/23/2017] [Accepted: 05/15/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Hemodialysis patients have extremely increased cardiovascular mortality. The coronary artery calcification score (CACS) in uremic patients receiving hemodialysis reflects the severity of atherosclerotic vascular disease and predicts the cardiovascular events. In cardiac conditions, left atrial (LA) size has a prognostic importance. In this study, relationship between coronary artery calcification and left atrial size was investigated. METHODS This was a cross-sectional study involving 32 hemodialysis patients (16 females, 16 males; mean age, 52.4 ± 14.1 years) receiving HD for ≥6 months. Coronary artery calcium scoring was performed by a 16-MDCT scanner, and CACS was calculated by Agatston score. A calcification was defined as a minimum of two adjacent pixels (>0.52 mm2) with a density over 130 Hounsfield units. Patients were divided into two subgroups (group 1: CACS ≤ 45.85, n = 16 and group 2: CACS > 45.85, n = 16) according to median CACS value. RESULTS Mean CACS value of 32 hemodialysis patients was 245.57 ± 373.91. LA size was significantly higher in patients with CACS > 45.85 (group 2) than in patients with CACS ≤ 45.85 (group 1). In the bivariate correlation analysis, total CACS was positively correlated with left atrium size (r = 0.47, p = 0.006). Total CACS was positively correlated with age (r = 0.43, p = 0.014). LA size was positively correlated with diastolic blood pressure (r = 0.42, p = 0.016) and negatively correlated with ejection fraction (r = -0.42, p = 0.016). The clinical parameters such as BMI, duration of dialysis, blood pressure, ejection fraction, serum levels of calcium, phosphorus, uric acid, albumin, CRP, triglyceride, cholesterol, hemoglobin and ferritin were not independently associated with total CACS. CONCLUSIONS We found a positive relationship between the CACS and LA size measured by echocardiography in hemodialysis patients. Therefore; echocardiography, which is cheaper and non-invasive than tomographic examinations, might be considered for the risk stratification of coronary artery disease in hemodialysis patients.
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Affiliation(s)
- Ismail Baloglu
- Division of Nephrology, Department of Internal Medicine, Necmettin Erbakan University, Konya, Turkey.
| | - Kultigin Turkmen
- Division of Nephrology, Department of Internal Medicine, Necmettin Erbakan University, Konya, Turkey
| | - H Zeki Tonbul
- Division of Nephrology, Department of Internal Medicine, Necmettin Erbakan University, Konya, Turkey
| | - N Yılmaz Selcuk
- Division of Nephrology, Department of Internal Medicine, Necmettin Erbakan University, Konya, Turkey
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McCullough PA, Ball T, Cox KM, Assar MD. Use of Oral Anticoagulation in the Management of Atrial Fibrillation in Patients with ESRD: Pro. Clin J Am Soc Nephrol 2016; 11:2079-2084. [PMID: 27797888 PMCID: PMC5108189 DOI: 10.2215/cjn.02680316] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Warfarin has had a thin margin of benefit over risk for the prevention of stroke and systemic embolism in patients with ESRD because of higher bleeding risks and complications of therapy. The successful use of warfarin has been dependent on the selection of patients with nonvalvular atrial fibrillation at relatively high risk of stroke and systemic embolism and lower risks of bleeding over the course of therapy. Without such selection strategies, broad use of warfarin has not proven to be beneficial to the broad population of patients with ESRD and nonvalvular atrial fibrillation. In a recent meta-analysis of use of warfarin in patients with nonvalvular atrial fibrillation and ESRD, warfarin had no effect on the risks of stroke (hazard ratio, 1.12; 95% confidence interval, 0.69 to 1.82; P=0.65) or mortality (hazard ratio, 0.96; 95% confidence interval, 0.81 to 1.13; P=0.60) but was associated with increased risk of major bleeding (hazard ratio, 1.30; 95% confidence interval, 1.08 to 1.56; P<0.01). In pivotal trials, novel oral anticoagulants were generally at least equal to warfarin for efficacy and safety in nonvalvular atrial fibrillation and mild to moderate renal impairment. Clinical data for ESRD are limited, because pivotal trials excluded such patients. Given the very high risk of stroke and systemic embolism and the early evidence of acceptable safety profiles of novel oral anticoagulants, we think that patients with ESRD should be considered for treatment with chronic anticoagulation provided that there is an acceptable bleeding profile. Apixaban is currently indicated in ESRD for this application and may be preferable to warfarin given the body of evidence for warfarin and its difficulty of use and attendant adverse events.
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Affiliation(s)
- Peter A. McCullough
- Department of Internal Medicine, Cardiology Division, Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas
- The Heart Hospital Baylor Plano, Plano, Texas; and
| | - Timothy Ball
- Department of Internal Medicine, Cardiology Division, Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas
| | - Katy Mathews Cox
- Department of Clinical Pharmacology, Baylor University Medical Center, Dallas, Texas
| | - Manish D. Assar
- Department of Internal Medicine, Cardiology Division, Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas
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Lopez-Vargas PA, Tong A, Howell M, Craig JC. Educational Interventions for Patients With CKD: A Systematic Review. Am J Kidney Dis 2016; 68:353-70. [PMID: 27020884 DOI: 10.1053/j.ajkd.2016.01.022] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 01/22/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Preventing progression from earlier stages of chronic kidney disease (CKD) to end-stage kidney disease and minimizing the risk for cardiovascular events and other complications is central to the management of CKD. Patients' active participation in their own care is critical, but may be limited by their lack of awareness and understanding of CKD. We aimed to evaluate educational interventions for primary and secondary prevention of CKD. STUDY DESIGN Systematic review. Electronic databases were searched to December 2015, with study quality assessed using the Cochrane Collaboration risk-of-bias tool. SETTING & POPULATION People with CKD stages 1 to 5 in community and hospital settings (studies with only patients with CKD stage 5, kidney transplant recipients irrespective of glomerular filtration rate, or patients receiving dialysis were excluded). SELECTION CRITERIA FOR STUDIES Randomized controlled trials and nonrandomized studies of educational interventions. INTERVENTIONS Educational strategies in people with CKD. OUTCOMES Knowledge, self-management, quality-of-life, and clinical end points. RESULTS 26 studies (12 trials, 14 observational studies) involving 5,403 participants were included. Risk of bias was high in most studies. Interventions were multifaceted, including face-to-face teaching (26 studies), written information (20 studies), and telephone follow-up (13 studies). 20 studies involved 1-on-1 patient/educator interaction and 14 incorporated group sessions. 9 studies showed improved outcomes for quality of life, knowledge, and self-management; 9 had improved clinical end points; and 2 studies showed improvements in both patient-reported and clinical outcomes. Characteristics of effective interventions included teaching sessions that were interactive and workshops/practical skills (13/15 studies); integrated negotiated goal setting (10/13 studies); involved groups of patients (12/14 studies), their families (4/4 studies), and a multidisciplinary team (6/6 studies); and had frequent (weekly [4/5 studies] or monthly [7/7 studies]) participant/educator encounters. LIMITATIONS A meta-analysis was not possible due to heterogeneity of the interventions and outcomes measured. CONCLUSIONS Well-designed, interactive, frequent, and multifaceted educational interventions that include both individual and group participation may improve knowledge, self-management, and patient outcomes.
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Affiliation(s)
- Pamela A Lopez-Vargas
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia.
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Martin Howell
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
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14
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Wilson JAS, Goralski KB, Soroka SD, Morrison M, Mossop P, Sleno L, Wang Y, Anderson DR. An evaluation of oral dabigatran etexilate pharmacokinetics and pharmacodynamics in hemodialysis. J Clin Pharmacol 2014; 54:901-9. [PMID: 24846496 DOI: 10.1002/jcph.335] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 05/20/2014] [Indexed: 11/10/2022]
Abstract
Dabigatran etexilate represents a possible improved alternative to warfarin for anticoagulation in hemodialysis patients with atrial fibrillation (AF). The objective was to determine dabigatran plasma concentrations and anticoagulant effects following administration of a single 110 mg oral dose of dabigatran etexilate to 10 adult patients immediately prior to starting hemodialysis. Mass spectrometry and the Hemoclot® assay were used, respectively, to determine free (unconjugated) dabigatran concentrations and thrombin time (TT) in plasma samples collected intermittently over 48 hours. The median time (tmax ) to reach the maximum plasma-free dabigatran concentration (Cmax ) was 2 hours (range 1-3 hours). The mean free dabigatran Cmax was 95.5 ± 33.4 ng/mL. The mean elimination half-lives on and off hemodialysis were, respectively, 2.6 ± 1.3 and 30.2 ± 7.8 hours. Hemodialysis effectively removed dabigatran with an extraction ratio of 0.63 ± 0.07. The maximal TT ratio was 2.1 and the TT ratio demonstrated a strong linear dependence on free dabigatran concentration (r(2) = 0.741). A 110 mg oral dabigatran dose prior to hemodialysis was rapidly absorbed and achieved therapeutic concentrations. Hemodialysis effectively removed dabigatran from the plasma and may be an effective means of accelerating the elimination of dabigatran in circumstances of excessive anticoagulation.
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Affiliation(s)
- Jo-Anne S Wilson
- College of Pharmacy, Faculty of Health Professions, Dalhousie University, Halifax, Nova Scotia, Canada; Division of Nephrology, Department of Medicine, Capital District Health Authority, Halifax, Nova Scotia, Canada
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Narala KR, Hassan S, LaLonde TA, McCullough PA. Management of coronary atherosclerosis and acute coronary syndromes in patients with chronic kidney disease. Curr Probl Cardiol 2013; 38:165-206. [PMID: 23590761 DOI: 10.1016/j.cpcardiol.2012.12.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Atherosclerosis of the coronary arteries is common, extensive, and more unstable among patients with chronic renal impairment or chronic kidney disease (CKD). The initial presentation of coronary disease is often acute coronary syndrome (ACS) that tends to be more complicated and has a higher risk of death in this population. Medical treatment of ACS includes antianginal agents, antiplatelet therapy, anticoagulants, and pharmacotherapies that modify the natural history of ventricular remodeling after injury. Revascularization, primarily with percutaneous coronary intervention and stenting, is critical for optimal outcomes in those at moderate and high risk for reinfarction, the development of heart failure, and death in predialysis patients with CKD. The benefit of revascularization in ACS may not extend to those with end-stage renal disease because of competing sources of all-cause mortality. In stable patients with CKD and multivessel coronary artery disease, observational studies have found that bypass surgery is associated with a reduced mortality as compared with percutaneous coronary intervention when patients are followed for several years. This article will review the guidelines-recommended therapeutic armamentarium for the treatment of stable coronary atherosclerosis and ACS and give specific guidance on benefits, hazards, dose adjustments, and caveats concerning patients with baseline CKD.
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Zoghbi WA, Arend TE, Oetgen WJ, May C, Bradfield L, Keller S, Ramadhan E, Tomaselli GF, Brown N, Robertson RM, Whitman GR, Bezanson JL, Hundley J. 2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. Circulation 2013; 127:e663-828. [DOI: 10.1161/cir.0b013e31828478ac] [Citation(s) in RCA: 181] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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17
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Smith DH, Thorp ML, Gurwitz JH, McManus DD, Goldberg RJ, Allen LA, Hsu G, Sung SH, Magid DJ, Go AS. Chronic kidney disease and outcomes in heart failure with preserved versus reduced ejection fraction: the Cardiovascular Research Network PRESERVE Study. Circ Cardiovasc Qual Outcomes 2013; 6:333-42. [PMID: 23685625 DOI: 10.1161/circoutcomes.113.000221] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is scant evidence on the effect that chronic kidney disease (CKD) confers on clinically meaningful outcomes among patients with heart failure with preserved left ventricular ejection fraction (HF-PEF). METHODS AND RESULTS We identified a community-based cohort of patients with HF. Electronic medical record data were used to divide into HF-PEF and reduced left ventricular EF on the basis of quantitative and qualitative estimates. Level of CKD was assessed by estimated glomerular filtration rate (eGFR) and by dipstick proteinuria. We followed patients for a median of 22.1 months for outcomes of death and hospitalization (HF-specific and all-cause). Multivariable Cox regression estimated the adjusted relative-risk of outcomes by level of CKD, separately for HF-PEF and HF with reduced left ventricular EF. We identified 14 579 patients with HF-PEF and 9762 with HF with reduced left ventricular EF. When compared with patients with eGFR between 60 and 89 mL/min per 1.73 m(2), lower eGFR was associated with an independent graded increased risk of death and hospitalization. For example, among patients with HF-PEF, the risk of death was nearly double for eGFR 15 to 29 mL/min per 1.73 m(2) and 7× higher for eGFR<15 mL/min per 1.73 m(2), with similar findings in those with HF with reduced left ventricular EF. CONCLUSIONS CKD is common and an important independent predictor of death and hospitalization in adults with HF across the spectrum of left ventricular systolic function. Our study highlights the need to develop new and effective interventions for the growing number of patients with HF complicated by CKD.
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Affiliation(s)
- David H Smith
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR 97227, USA.
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18
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Jneid H, Ettinger SM, Ganiats TG, Philippides GJ, Jacobs AK, Halperin JL, Albert NM, Creager MA, DeMets D, Guyton RA, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; 61:e179-347. [PMID: 23639841 DOI: 10.1016/j.jacc.2013.01.014] [Citation(s) in RCA: 373] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Thet Z, Vilayur E. Atrial fibrillation and warfarin use in haemodialysis patients: An individualized holistic approach is important in stroke prevention. Nephrology (Carlton) 2013; 18:331-9. [DOI: 10.1111/nep.12057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2013] [Indexed: 12/24/2022]
Affiliation(s)
- Zaw Thet
- Department of Nephrology; John Hunter Hospital; Newcastle; New South Wales; Australia
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Abbasnezhad M, Tayyebi-Khosroshahi H, Ghanbarpour A, Habibzadeh A. Is There any Time Dependant Echocardiographical Finding in Chronic Hemodialysis Patients? Cardiol Res 2012; 3:271-276. [PMID: 28352416 PMCID: PMC5358301 DOI: 10.4021/cr241e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2012] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Cardiac disease is the main cause of death in hemodialysis patients. In hemodialysis patients cardiovascular complications are great clinical challenge, and function, shape and left ventricle abnormalities are present in 70 - 80 percent of dialysis patients. Changes in heart function occur in hemodialysis period and are effective in patient's prognosis. In this study we aim to evaluate time dependant clinical and echocardiographical findings in chronic hemodialysis patients. METHODS In a cross-sectional study, 100 adult hemodialysis patients (51% male and 49% female with mean age 52.13 ± 12.69 years) visiting dialysis unit in Imam Reza and Madani hospitals between years 2010 and 2011 were studied in group 1 (hemodialysis ≤ 6 months), group 2 (hemodialysis for 6 months to 3 years) and group 3 (hemodialysis ≥ 3 years). Demographic, laboratory and echocardiographic findings were compared between groups. RESULTS Among demographic findings, group 3 had significantly higher diastolic blood pressure and weight gain and was older than other two groups (P < 0.05). By increase in hemodialysis period, patients had higher blood urea nitrogen and lower serum albumin levels (P < 0.05). Potassium level in group 2 was significantly higher than group 3 and that was higher than group 1. There was no difference between groups in left ventricular hypertrophy (LVH), left atrium dilatation, ejection fraction and mitral insufficiency. Diastolic dysfunction increased in line with increase in hemodialysis period (P = 0.007). Hemodialysis period was higher in patients with LVH than those without (34.80 ± 9.2 months versus 18.51 ± 2.22 months, P = 0.01). CONCLUSION In hemodialysis patients, diastolic dysfunction increases by the hemodialysis time (years). LVH and LA dilation also increase during time, but not significantly.
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Affiliation(s)
- Mohsen Abbasnezhad
- Dept. of Cardiology, Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Amin Ghanbarpour
- Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Afshin Habibzadeh
- Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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McManus DD, Saczynski JS, Ward JA, Jaggi K, Bourrell P, Darling C, Goldberg RJ. The Relationship Between Atrial Fibrillation and Chronic Kidney Disease : Epidemiologic and Pathophysiologic Considerations for a Dual Epidemic. J Atr Fibrillation 2012; 5:442. [PMID: 28496745 DOI: 10.4022/jafib.442] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Revised: 03/23/2012] [Accepted: 04/17/2012] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation (AF) presently affects over 2 million Americans, and the magnitude and population burden from AF continues to increase concomitant with the aging of the U.S. POPULATION Chronic kidney disease (CKD) is present in 13% of individuals in the U.S., and the prevalence of CKD is also rapidly increasing. The increasing population burden of CKD and AF will profoundly affect the clinical and public health, since CKD and AF are both associated with lower quality of life, increased hospitalization rates, and a greater risk of heart failure, stroke, and total mortality. AF and CKD often co-exist, each condition predisposes to the other, and the co-occurrence of these disorders worsens prognosis relative to either disease alone. The shared epidemiology of CKD and AF may be explained by the strong pathophysiologic connections between these diseases. In order to promote a better understanding of CKD and AF, we have reviewed their shared epidemiology and pathophysiology and described the natural history of patients affected by both diseases.
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Affiliation(s)
- David D McManus
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, University of Massachusetts Medical Center, Worcester, MA, USA.,Department of Quantitative Health Sciences, University of Massachusetts Medical School
| | - Jane S Saczynski
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, University of Massachusetts Medical Center, Worcester, MA, USA.,Department of Quantitative Health Sciences, University of Massachusetts Medical School
| | - Jeanine A Ward
- Department of Emergency Medicine, University of Massachusetts Medical Center
| | - Khushleen Jaggi
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Peter Bourrell
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Chad Darling
- Department of Emergency Medicine, University of Massachusetts Medical Center
| | - Robert J Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School
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Engelbertz C, Reinecke H. Atrial Fibrillation and Oral Anticoagulation in Chronic Kidney Disease. J Atr Fibrillation 2012; 4:445. [PMID: 28496732 DOI: 10.4022/jafib.445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 04/03/2012] [Accepted: 04/03/2012] [Indexed: 12/21/2022]
Abstract
Due to several unfavorable epidemiological changes, chronic kidney disease (CKD) and treatment of its associated cardiovascular morbidity have become a worldwide problem. Thus, atrial fibrillation (AF) is the most common arrhythmia and frequently associated with renal impairment: prevalence for AF is up to 27% in long-term hemodialysis patients and in general more than 25% in all CKD patients 70 years and older. Thromboembolism and stroke are the major complications of AF. Two-year death rates for CKD patients after stroke range between 55% and 74%. Although treatment of AF in the general population is well defined, patients with CKD and AF are often undertreated due to lack of studies and guidelines. In this review recent data concerning incidence and prevalence of AF, stroke, and major bleedings in CKD patients are presented. Particular attention is paid to the available data about the different types of oral anticoagulation therapy with regard to CKD stage, including the new oral anticoagulant drugs dabigatran, rivaroxaban, and apixaban. Stratification algorithms for stroke risk in general, and individualized risk stratification for oral anticoagulation in CKD patients are discussed in detail.
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Affiliation(s)
| | - Holger Reinecke
- Department fur Kardiologie und Angiologie, Universitatsklinikum Munster, Münster
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Herzog CA, Asinger RW, Berger AK, Charytan DM, Díez J, Hart RG, Eckardt KU, Kasiske BL, McCullough PA, Passman RS, DeLoach SS, Pun PH, Ritz E. Cardiovascular disease in chronic kidney disease. A clinical update from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2011; 80:572-86. [PMID: 21750584 DOI: 10.1038/ki.2011.223] [Citation(s) in RCA: 611] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Cardiovascular morbidity and mortality in patients with chronic kidney disease (CKD) is high, and the presence of CKD worsens outcomes of cardiovascular disease (CVD). CKD is associated with specific risk factors. Emerging evidence indicates that the pathology and manifestation of CVD differ in the presence of CKD. During a clinical update conference convened by the Kidney Disease: Improving Global Outcomes (KDIGO), an international group of experts defined the current state of knowledge and the implications for patient care in important topic areas, including coronary artery disease and myocardial infarction, congestive heart failure, cerebrovascular disease, atrial fibrillation, peripheral arterial disease, and sudden cardiac death. Although optimal strategies for prevention, diagnosis, and management of these complications likely should be modified in the presence of CKD, the evidence base for decision making is limited. Trials targeting CVD in patients with CKD have a large potential to improve outcomes.
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Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP, Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Zidar JP. 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the American Academy of Family Physicians, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 57:e215-367. [PMID: 21545940 DOI: 10.1016/j.jacc.2011.02.011] [Citation(s) in RCA: 301] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC. 2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 123:e426-579. [PMID: 21444888 DOI: 10.1161/cir.0b013e318212bb8b] [Citation(s) in RCA: 349] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Marinigh R, Lane DA, Lip GYH. Severe Renal Impairment and Stroke Prevention in Atrial Fibrillation. J Am Coll Cardiol 2011; 57:1339-48. [PMID: 21414530 DOI: 10.1016/j.jacc.2010.12.013] [Citation(s) in RCA: 157] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2010] [Accepted: 12/09/2010] [Indexed: 01/10/2023]
Affiliation(s)
- Ricarda Marinigh
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
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Lai HM, Aronow WS, Kalen P, Adapa S, Patel K, Goel A, Vinnakota R, Chugh S, Garrick R. Incidence of thromboembolic stroke and of major bleeding in patients with atrial fibrillation and chronic kidney disease treated with and without warfarin. Int J Nephrol Renovasc Dis 2009; 2:33-7. [PMID: 21694919 PMCID: PMC3108764 DOI: 10.2147/ijnrd.s7781] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Indexed: 11/23/2022] Open
Abstract
The objective was to investigate the incidence of thromboembolic stroke in patients with chronic kidney disease (CKD) and atrial fibrillation (AF) treated with and without warfarin. We investigated the incidence of thromboembolic stroke and of major bleeding in 399 unselected patients with CKD and AF treated with warfarin to maintain an international normalized ratio (INR) between 2.0 and 3.0 (N = 232) and without warfarin (N = 167). Of the 399 patients, 93 (23%) were receiving hemodialysis, and 132 (33%) had an estimated glomerular filtration rate (GFR) of <15 mL/min/1.73 m2 At the 31-month follow-up of patients treated with warfarin and 23-month follow-up of patients not treated with warfarin, thromboembolic stroke developed in 21 of 232 patients (9%) treated with warfarin and in 43 of 167 patients (26%) not treated with warfarin (P < 0.001). Major bleeding occurred in 32 of 232 patients (14%) treated with warfarin and in 15 of 167 patients (9%) not treated with warfarin (P not significant). Stepwise Cox regression analysis showed that significant independent predictors of thromboembolic stroke were use of warfarin (odds ratio, 0.28; P < 0.0001) and prior stroke or transient ischemic attack (odds ratio, 2.9; P < 0.05). In conclusion, this observational study showed that CKD patients with AF treated with warfarin to maintain an INR between 2.0 and 3.0 had a significant reduction in thromboembolic stroke and an insignificant increase in major bleeding.
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Affiliation(s)
- Hoang M Lai
- Divisions of General Medicine, Nephrology, and Cardiology, Department of Medicine, New York Medical College, Valhalla, NY, USA
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Chou CY, Kuo HL, Wang SM, Liu JH, Lin HH, Liu YL, Huang CC. Outcome of atrial fibrillation among patients with end-stage renal disease. Nephrol Dial Transplant 2009; 25:1225-30. [DOI: 10.1093/ndt/gfp589] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Galil AGS, Pinheiro HS, Chaoubah A, Costa DMN, Bastos MG. Chronic kidney disease increases cardiovascular unfavourable outcomes in outpatients with heart failure. BMC Nephrol 2009; 10:31. [PMID: 19843342 PMCID: PMC2771010 DOI: 10.1186/1471-2369-10-31] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Accepted: 10/21/2009] [Indexed: 11/15/2022] Open
Abstract
Background Chronic heart failure (CHF) has a high morbidity and mortality. Chronic kidney disease (CKD) has consistently been found to be an independent risk factor for unfavorable cardiovascular (CV) outcomes. Early intervention on CKD reduces the progression of CHF, hospitalizations and mortality, yet there are very few studies about CKD as a risk factor in the early stages of CHF. The aims of our study were to assess the prevalence and the prognostic importance of CKD in patients with systolic CHF stages B and C. Methods This is a prospective cohort study, dealing with prognostic markers for CV endpoints in patients with systolic CHF (ejection fraction ≤ 45%). Results CKD was defined as estimated glomerular filtration rate <60 mL/min/1.73 m2 and CV endpoints as death or hospitalization due to CHF, in 12 months follow-up. Eighty three patients were studied, the mean age was 62.7 ± 12 years, and 56.6% were female. CKD was diagnosed in 49.4% of the patients, 33% of patients with CHF stage B and 67% in the stage C. Cardiovascular endpoints were observed in 26.5% of the patients. When the sample was stratified into stages B and C of CHF, the occurrence of CKD was associated with 100% and 64.7%, respectively, of unfavorable CV outcomes. After adjustments for all other prognostic factors at baseline, it was observed that the diagnosis of CKD increased in 3.6 times the possibility of CV outcomes (CI 95% 1.04-12.67, p = 0.04), whereas higher ejection fraction (R = 0.925, IC 95% 0.862-0.942, p = 0.03) and serum sodium (R = 0.807, IC 95% 0.862-0.992, p = 0.03) were protective. Conclusion In this cohort of patients with CHF stages B and C, CKD was prevalent and independently associated with increased risk of hospitalization and death secondary to cardiac decompensation, especially in asymptomatic patients.
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Affiliation(s)
- Arise G S Galil
- NIEPEN - Interdisciplinary Nucleus of Study and Research in Nephrology, Federal University of Juiz de Fora, Center for Control of Hypertension, Diabetes and Obesity, Juiz de Fora, Brasil.
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Holden RM, Clase CM. Use of Warfarin in People with Low Glomerular Filtration Rate or on Dialysis. Semin Dial 2009; 22:503-11. [DOI: 10.1111/j.1525-139x.2009.00632.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Aronow WS. Acute and Chronic Management of Atrial Fibrillation in Patients With Late-Stage CKD. Am J Kidney Dis 2009; 53:701-10. [PMID: 19324248 DOI: 10.1053/j.ajkd.2009.01.257] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Accepted: 01/26/2009] [Indexed: 11/11/2022]
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López B, González A, Hermida N, Laviades C, Díez J. Myocardial fibrosis in chronic kidney disease: potential benefits of torasemide. Kidney Int 2008:S19-23. [DOI: 10.1038/ki.2008.512] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Pan NH, Tsao HM, Chang NC, Lee CM, Chen YJ, Chen SA. Dilated left atrium and pulmonary veins in patients with calcified coronary artery: a potential contributor to the genesis of atrial fibrillation. J Cardiovasc Electrophysiol 2008; 20:153-8. [PMID: 18803575 DOI: 10.1111/j.1540-8167.2008.01290.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Coronary artery disease (CAD) is an important etiology of atrial fibrillation (AF). Coronary artery calcification is a marker of coronary atherosclerosis and coronary events. The purpose of this study was to investigate whether larger left atrium (LA) and pulmonary veins (PVs) were seen by multidetector computed tomography (MDCT) scans in those patients with higher coronary calcium scores. METHODS AND RESULTS A total of 166 patients undergoing MDCT for general check-up (n = 128, 77%) or suspected CAD (n = 38, 23%) were enrolled and divided into a control (calcium score = 0, n = 60), medium calcium score (calcium score = 100 approximately 400, n = 47), and high calcium score (calcium score >400, n = 59) groups. Diameters and areas of the LA, left atrial appendage (LAA), and PVs were measured by MDCT. The high calcium score group had significantly larger PVs diameters, LAA orifice area (1.9 +/- 1.4 cm(2), 0.9 +/- 0.5 cm(2), 0.8 +/- 0.4 cm(2), P < 0.005), LA anterior-posterior distance (32.2 +/- 6.8 mm, 30.4 +/- 6.5 mm, 27.3 +/- 6.0 mm, P < 0.05), and transverse distance (52.6 +/- 7.3 mm, 50.2 +/- 9 mm, 49.5 +/- 4.6 mm, P < 0.05) than the medium calcium score and control groups. Six (3.6%) patients with paroxysmal AF had higher calcium scores and larger diameters of LA, LAA, and PVs than those (96.4%) without paroxysmal AF. Two patients in the high calcium score group had calcified PVs localized to the right upper and left upper PVs. The incidence of calcified PVs was 1.2% for the total patients and 3.3% for the high calcium score patients. CONCLUSION In the presence of high calcium scores in this patient population, the LA, LAA, and PVs were enlarged.
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Affiliation(s)
- Nan-Hung Pan
- Division of Cardiovascular Medicine, Taipei Medical University Hospital, Taipei, Taiwan
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Prevalence of Moderate and Severe Renal Insufficiency in Older Persons With Hypertension, Diabetes Mellitus, Coronary Artery Disease, Peripheral Arterial Disease, Ischemic Stroke, or Congestive Heart Failure in an Academic Nursing Home. J Am Med Dir Assoc 2008; 9:257-9. [PMID: 18457801 DOI: 10.1016/j.jamda.2008.01.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2007] [Revised: 12/25/2007] [Accepted: 01/04/2008] [Indexed: 10/22/2022]
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Korantzopoulos P, Kokkoris S, Liu T, Protopsaltis I, Li G, Goudevenos JA. Atrial fibrillation in end-stage renal disease. Pacing Clin Electrophysiol 2008; 30:1391-7. [PMID: 17976105 DOI: 10.1111/j.1540-8159.2007.00877.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
End-stage renal disease (ESRD) is associated with increased cardiovascular morbidity and mortality. Recent studies indicate that atrial fibrillation (AF) is prevalent among ESRD patients while it adversely affects the clinical outcome. Despite these considerations, AF management in this population is problematic. Notably, most ESRD patients with AF are deprived of the benefits of anticoagulation therapy because of the fear of hemorrhagic complications. This article provides a concise and critical overview of the complex pathophysiology, epidemiology, and discusses the clinical issues regarding the emerging association between ESRD and AF.
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol 2007; 50:e1-e157. [PMID: 17692738 DOI: 10.1016/j.jacc.2007.02.013] [Citation(s) in RCA: 1285] [Impact Index Per Article: 75.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Abstract
The biopsychosocial model has been used to describe the intertwined factors that may act as mechanisms in cardiovascular disease, as well as those found in pain conditions. This model may also prove useful in understanding a diagnosis that overlaps these two areas, angina. This article reviews the literature related to biological, psychological, and social mechanisms of painful ischemic episodes and discusses the interactions of those variables. We propose an integrated model that incorporates the biopsychosocial mechanisms that may be responsible for the variability in pain reporting with ischemic episodes. We show how sex differences manifested in various biopsychosocial factors may interact to influence the presence of painful versus silent myocardial ischemia. We present a plan for future research to elucidate this interaction.
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Affiliation(s)
- Susan E Hofkamp
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 193, Baltimore, MD 21287, USA.
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Abstract
Calcification of the cardiovascular system is now well recognized to be a common feature of patients with chronic kidney disease. It is increasingly prevalent in patients with more severe uremia, particularly those receiving dialysis. Furthermore, it is progressive in terms of both severity and associated functional cardiovascular consequences. Although well recognized to be associated with a markedly increased mortality rate, the pathophysiological processes that result in these poor outcomes are less well understood. This article attempts to review calcification of the cardiovascular system as a whole entity and how the structural and functional changes may translate to the observed patterns of disease seen in these patients.
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Affiliation(s)
- Christopher W McIntyre
- Division of Vascular Medicine, School of Medical and Surgical Sciences, University of Nottingham Medical School at Derby , Derby Hospitals NHS Foundation Trust, Derby, United Kingdom.
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation 2007; 116:e148-304. [PMID: 17679616 DOI: 10.1161/circulationaha.107.181940] [Citation(s) in RCA: 813] [Impact Index Per Article: 47.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Chen-Scarabelli C, Scarabelli TM. Chronic Renal Insufficiency Is an Independent Predictor of Mortality in Implantable Cardioverter-Defibrillator Recipients. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 30:371-6. [PMID: 17367356 DOI: 10.1111/j.1540-8159.2007.00677.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Chronic renal insufficiency (CRI) has been associated with increased risk of cardiovascular morbidity and mortality. However, there is limited knowledge regarding this association and the effect of renal dysfunction on survival benefit in patients with implantable cardioverter-defibrillators (ICDs). METHODS We investigated whether there was an association between CRI (defined as serum creatinine levels >or=1.5 mg/dL) and increased risk of mortality in ICD recipients. We retrospectively studied all patients (n = 336) followed within our ICD clinic in a 2.5-year period. CRI, ventricular tachycardia (VT), cardiomyopathy (CM), and mortality were recorded. Ischemic CM was defined as the presence of coronary artery disease (CAD) and left ventricular ejection fraction <or= 30%. RESULTS Despite no significant difference in CAD and VT occurrence between CRI and non-CRI groups in the overall population, there was a significantly higher mortality rate in the CRI group (P < 0.0001). CONCLUSION CRI is a significant independent predictor of mortality in ICD recipients. Further investigation is needed to determine whether prevention, early detection, and more aggressive intervention in the treatment of CRI will reduce the incidence of mortality in this population.
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Komukai K, Ogawa T, Yagi H, Date T, Suzuki K, Sakamoto H, Miyazaki H, Takatsuka H, Shibayama K, Ogawa K, Kanzaki Y, Kosuga T, Kawai M, Hongo K, Yoshida S, Taniguchi I, Mochizuki S. Renal Insufficiency is Related to Painless Myocardial Infarction. Circ J 2007; 71:1366-9. [PMID: 17721012 DOI: 10.1253/circj.71.1366] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Acute myocardial infarction (MI) sometimes occurs without painful symptoms and in such cases, prognosis is worsened by delays in diagnosis and revascularization. Renal insufficiency induces many types of neuropathy, but the relation between renal insufficiency and painless MI remains unclear. METHODS AND RESULTS Patients with MI and elevated creatine kinase levels were retrospectively analyzed. Renal insufficiency (serum creatinine concentration > or =1.5 mg/dl) and other characteristics (age, sex, body mass index, hypertension, smoking, diabetes mellitus, dyslipidemia, history of stroke, previous MI, hemodialysis, and atrial fibrillation) were compared between patients who had MI with painful symptoms (painful MI, n=131) and patients who had MI without painful symptoms (painless MI, n=18). Other variables compared were the time from symptom onset to admission, peak creatine kinase concentration, Killip class, site of MI, emergency coronary angiography, postprocedural Thrombolysis In Myocardial Infarction grade III flow, and in-hospital death. Univariate analysis identified older age, renal insufficiency, and previous MI as predictors of painless MI. Patients with painless MI showed higher rates of Killip class > or =II and in-hospital death and a longer time from symptom onset to admission. However, multivariate analysis identified only renal insufficiency as an independent predictor of painless MI. CONCLUSIONS MI without painful symptoms frequently develops in patients who have renal insufficiency, so the possibility of painless MI should be evaluated in such patients to ensure early diagnosis and treatment.
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Affiliation(s)
- Kimiaki Komukai
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.
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Bhaskaran M, Radhakrishnan N, Patni H, Singh P, Chaudhary AN, Singhal PC. Dialysis Membrane-Induced Oxidative Stress: Role of Heme Oxygenase-1. ACTA ACUST UNITED AC 2006; 105:e24-32. [PMID: 17108707 DOI: 10.1159/000097016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2006] [Accepted: 07/24/2006] [Indexed: 11/19/2022]
Abstract
Dialysis membranes have been reported to induce monocyte apoptosis. We studied the role of oxidative stress in the induction of dialysis membrane-induced monocyte apoptosis. Superoxide dismutase, a superoxide scavenger, prevented dialysis membrane-induced monocyte apoptosis. Similarly, other antioxidants also inhibited dialysis membrane- induced apoptosis. In addition, the interaction of dialysis membranes with monocytes was associated with the generation of molecules leading to oxidative stress such as superoxide and TBARS. Interestingly, pre-induction of heme oxygenase (HO)-1 by hemin prevented dialysis membrane-induced monocyte apoptosis, whereas inhibition of HO-1 activity (treatment with tin protoporphyrin, SN-P) enhanced dialysis membrane-induced monocyte apoptosis. We suggest that oxidative injury associated with dialysis membrane and monocyte interaction plays a role in monocyte injury. Pre-induction of HO-1 may attenuate dialysis membrane-induced monocyte apoptosis.
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Affiliation(s)
- Madhu Bhaskaran
- Division of Kidney Diseases and Hypertension, North Shore University Hospital, Manhasset and Long Island Jewish Medical Center, New Hyde Park, NY, USA
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