1
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Chatur S, Neuen BL, Claggett BL, Beldhuis IE, Mc Causland FR, Desai AS, Rouleau JL, Zile MR, Lefkowitz MP, Packer M, McMurray JJV, Solomon SD, Vaduganathan M. Effects of Sacubitril/Valsartan Across the Spectrum of Renal Impairment in Patients With Heart Failure. J Am Coll Cardiol 2024; 83:2148-2159. [PMID: 38588927 DOI: 10.1016/j.jacc.2024.03.392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The Kidney Disease Improving Global Outcomes (KDIGO) classification integrates both estimated glomerular filtration rate and urine-albumin-creatinine ratio to stratify risk more comprehensively in patients with chronic kidney disease. There are limited data assessing whether this classification system is associated with prognosis and treatment response in heart failure populations. OBJECTIVES The aim of this study was to evaluate the relative treatment effects of sacubitril/valsartan across the KDIGO risk categories in patients with HFrEF. METHODS PARADIGM-HF (Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure) was a global randomized controlled trial evaluating sacubitril/valsartan vs enalapril in patients with heart failure with reduced ejection fraction (HFrEF). Patients were classified according to low, moderate, and high/very high KDIGO risk. Treatment responses were assessed according to baseline KDIGO risk. The primary outcome was a composite of cardiovascular (CV) death or heart failure hospitalization. A renal composite outcome was defined as sustained decline in estimated glomerular filtration rate by ≥40% or end-stage kidney disease. RESULTS Among 1,910 (23% of total) participants with available data, 42%, 32%, and 26% were classified as low, moderate, and high/very high KDIGO risk, respectively. Patients in the highest KDIGO risk categories experienced the highest rates of the primary composite outcome (7.6 per 100 person-years [95% CI: 6.5-9.0 per 100 person-years], 9.4 per 100 person-years [95% CI: 7.9-11.2 per 100 person-years], and 14.9 per 100 person-years [95% CI: 12.7-17.6 per 100 person-years]; P < 0.001). Sacubitril/valsartan had a similar safety profile and demonstrated consistent effects on the risk of both the primary outcome (PInteraction = 0.31) and the renal composite outcome (PInteraction = 0.50) across the spectrum of KDIGO risk. CONCLUSIONS One in 4 patients with HFrEF were classified as at least high KDIGO kidney risk; these individuals faced concordantly the highest risks of CV events. Sacubitril/valsartan exhibited consistent CV and kidney protective benefits as well as safety across the spectrum of baseline kidney risk. These data further support initiation of sacubitril/valsartan in HFrEF across a broad range of kidney risk. (This Study Will Evaluate the Efficacy and Safety of LCZ696 Compared to Enalapril on Morbidity and Mortality of Patients With Chronic Heart Failure [PARADIGM-HF]; NCT01035255).
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Affiliation(s)
- Safia Chatur
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/safchat
| | - Brendon L Neuen
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Iris E Beldhuis
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Finnian R Mc Causland
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - Michael R Zile
- Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina, USA
| | | | - Milton Packer
- Baylor University Medical Center, Dallas, Texas, USA
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/mvaduganathan
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Buryskova Salajova K, Malik J, Valerianova A. Cardiorenal Syndromes and Their Role in Water and Sodium Homeostasis. Physiol Res 2024; 73:173-187. [PMID: 38710052 PMCID: PMC11081188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 11/16/2023] [Indexed: 05/08/2024] Open
Abstract
Sodium is the main osmotically active ion in the extracellular fluid and its concentration goes hand in hand with fluid volume. Under physiological conditions, homeostasis of sodium and thus amount of fluid is regulated by neural and humoral interconnection of body tissues and organs. Both heart and kidneys are crucial in maintaining volume status. Proper kidney function is necessary to excrete regulated amount of water and solutes and adequate heart function is inevitable to sustain renal perfusion pressure, oxygen supply etc. As these organs are bidirectionally interconnected, injury of one leads to dysfunction of another. This condition is known as cardiorenal syndrome. It is divided into five subtypes regarding timeframe and pathophysiology of the onset. Hemodynamic effects include congestion, decreased cardiac output, but also production of natriuretic peptides. Renal congestion and hypoperfusion leads to kidney injury and maladaptive activation of renin-angiotensin-aldosterone system and sympathetic nervous system. In cardiorenal syndromes sodium and water excretion is impaired leading to volume overload and far-reaching negative consequences, including higher morbidity and mortality of these patients. Keywords: Cardiorenal syndrome, Renocardiac syndrome, Volume overload, Sodium retention.
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Affiliation(s)
- K Buryskova Salajova
- 3rd Department of Internal Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University, Prague, Czech Republic.
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3
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Roskvist R, Eggleton K, Arroll B, Stewart R. Non-acute heart failure management in primary care. BMJ 2024; 385:e077057. [PMID: 38580384 DOI: 10.1136/bmj-2023-077057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Affiliation(s)
- Rachel Roskvist
- Department of General Practice and Primary Health Care, School of Population Health, University of Auckland, New Zealand
| | - Kyle Eggleton
- Department of General Practice and Primary Health Care, School of Population Health, University of Auckland, New Zealand
| | - Bruce Arroll
- Department of General Practice and Primary Health Care, School of Population Health, University of Auckland, New Zealand
| | - Ralph Stewart
- Department of Medicine, School of Medicine, University of Auckland, New Zealand
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4
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Arici M, Assaad-Khalil SH, Bertoluci MC, Choo J, Lee YJ, Madero M, Rosa Diez GJ, Sánchez Polo V, Chung S, Thanachayanont T, Pollock C. Results from a cross-specialty consensus on optimal management of patients with chronic kidney disease (CKD): from screening to complications. BMJ Open 2024; 14:e080891. [PMID: 38453198 PMCID: PMC10921537 DOI: 10.1136/bmjopen-2023-080891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 02/14/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) affects around 10% of the global population and has been estimated to affect around 50% of individuals with type 2 diabetes and 50% of those with heart failure. The guideline-recommended approach is to manage with disease-modifying therapies, but real-world data suggest that prescribing rates do not reflect this in practice. OBJECTIVE To develop a cross-specialty consensus on optimal management of the patient with CKD using a modified Delphi method. DESIGN An international steering group of experts specialising in internal medicine, endocrinology/diabetology, nephrology and primary care medicine developed 42 statements on aspects of CKD management including identification and screening, risk factors, holistic management, guidelines, cross-specialty alignment and education. Consensus was determined by agreement using an online survey. PARTICIPANTS The survey was distributed to cardiologists, nephrologists, endocrinologists and primary care physicians across 11 countries. MAIN OUTCOMES AND MEASURES The threshold for consensus agreement was established a priori by the steering group at 75%. Stopping criteria were defined as a target of 25 responses from each country (N=275), and a 4-week survey period. RESULTS 274 responses were received in December 2022, 25 responses from Argentina, Australia, Brazil, Guatemala, Mexico, Singapore, South Korea, Taiwan, Thailand, Turkey and 24 responses from Egypt. 53 responses were received from cardiologists, 52 from nephrologists, 55 from endocrinologists and 114 from primary care physicians. 37 statements attained very high agreement (≥90%) and 5 attained high agreement (≥75% and <90%). Strong alignment between roles was seen across the statements, and different levels of experience (2-5 years or 5+ years), some variation was observed between countries. CONCLUSIONS There is a high degree of consensus regarding aspects of CKD management among healthcare professionals from 11 countries. Based on these strong levels of agreement, the steering group derived 12 key recommendations focused on diagnosis and management of CKD.
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Affiliation(s)
- Mustafa Arici
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Hacettepe Universitesi, Ankara, Türkiye
| | - Samir Helmy Assaad-Khalil
- Unit of Diabetes, Lipidology & Metabolism, Alexandria University Faculty of Medicine, Alexandria, Egypt
| | - Marcello Casaccia Bertoluci
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul Instituto de Biociencias, Porto Alegre, Brazil
| | - Jason Choo
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | | | - Magdalena Madero
- Division of Nephrology, Department of Medicine, National Heart Institute of Mexico, Mexico City, Mexico
| | | | - Vicente Sánchez Polo
- Servicio de Nefrología y Trasplante Renal, Instituto Guatemalteco de Seguridad Social, Guatemala City, Guatemala
| | - Sungjin Chung
- Division of Nephrology, The Catholic University of Korea College of Medicine, Seoul, Korea (the Republic of)
| | | | - Carol Pollock
- Kolling Institute of Medical Research, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Straburzynska-Migaj E, Senni M, Wachter R, Fonseca C, Witte KK, Mueller C, Lonn E, Butylin D, Noe A, Schwende H, Lawrence D, Suryawanshi B, Pascual-Figal D. Early Initiation of Sacubitril/Valsartan in Patients With Acute Heart Failure and Renal Dysfunction: An Analysis of the TRANSITION Study. J Card Fail 2024; 30:425-435. [PMID: 37678704 DOI: 10.1016/j.cardfail.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 08/22/2023] [Accepted: 08/22/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Treatment of patients with heart failure with reduced ejection fraction (HFrEF) and renal dysfunction (RD) is challenging owing to the risk of further deterioration in renal function, especially after acute decompensated HF (ADHF). METHODS AND RESULTS We assessed the effect of RD (estimated glomerular filtration rate of ≥30 to <60 mL/min/1.73 m2) on initiation, up-titration, and tolerability of sacubitril/valsartan in hemodynamically stabilized patients with HFrEF admitted for ADHF (RD, n = 476; non-RD, n = 483). At week 10, the target dose of sacubitril/valsartan (97/103 mg twice daily) was achieved by 42% patients in RD subgroup vs 54% in non-RD patients (P < .001). Sacubitril/valsartan was associated with greater estimated glomerular filtration rate improvements in RD subgroup than non-RD (change from baseline least squares mean 4.1 mL/min/1.73 m2, 95% confidence interval 2.2-6.1, P < .001). Cardiac biomarkers improved significantly in both subgroups; however, compared with the RD subgroup, the improvement was greater in those without RD (N-terminal pro-brain natriuretic peptide, -28.6% vs -44.8%, high-sensitivity troponin T -20.3% vs -33.9%) (P < .001). Patients in the RD subgroup compared with those without RD experienced higher rates of hyperkalemia (16.3% vs 6.5%, P < .001), investigator-reported cardiac failure (9.7% vs 5.6%, P = .029), and renal impairment (6.4% vs 2.1%, P = .002). CONCLUSIONS Most patients with HFrEF and concomitant RD hospitalized for ADHF tolerated early initiation of sacubitril/valsartan and showed significant improvements in estimated glomerular filtration rate and cardiac biomarkers. CLINICAL TRIAL REGISTRATION NCT02661217.
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Affiliation(s)
- Ewa Straburzynska-Migaj
- Poznan University of Medical Sciences, Poznan, University Hospital in Poznan, Poznan, Poland.
| | - M Senni
- Cardiovascular Department and Cardiology Unit, ASST Papa Giovanni XXIII, University of Milano-Bicocca, Bergamo, Italy
| | - R Wachter
- Clinic and polyclinic for cardiology, Leipzig University Hospital, Leipzig, Germany
| | - C Fonseca
- Hospital São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, and NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
| | - K K Witte
- Division of Cardiovascular and Diabetes Research, University of Leeds, Leeds, UK
| | - C Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Heart Center Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - E Lonn
- Department of Medicine and Population Health Research Institute, McMaster University, Hamilton, Canada
| | - D Butylin
- Novartis Pharma AG, Basel, Switzerland
| | - A Noe
- Novartis Pharma AG, Basel, Switzerland
| | | | | | | | - D Pascual-Figal
- Hospital Virgen de la Arrixaca, University of Murcia, Murcia, Spain & Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
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Muraoka M, Nagata H, Yamamura K, Sakamoto I, Ishikita A, Nishizaki A, Eguchi Y, Fukuoka S, Uike K, Nagatomo Y, Hirata Y, Nishiyama K, Tsutsui H, Ohga S. Long-Term Renal Involvement in Association with Fontan Circulation. Pediatr Cardiol 2024; 45:340-350. [PMID: 37966520 DOI: 10.1007/s00246-023-03334-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 10/19/2023] [Indexed: 11/16/2023]
Abstract
Multiorgan dysfunction is a concern of Fontan patients. To clarify the pathophysiology of Fontan nephropathy, we characterize renal disease in the long-term observational study. Medical records of 128 consecutive Fontan patients [median age: 22 (range 15-37) years old] treated between 2009 and 2018 were reviewed to investigate the incidence of nephropathy and its association with other clinical variables. Thirty-seven patients (29%) showed proteinuria (n = 34) or < 90 mL/min/1.73 m2 of estimated glomerular filtration rate (eGFR) (n = 7), including 4 overlapping cases. Ninety-six patients (75%) had liver dysfunction (Forns index > 4.21). Patients with proteinuria received the Fontan procedure at an older age [78 (26-194) vs. 56 (8-292) months old, p = 0.02] and had a higher cardiac index [3.11 (1.49-6.35) vs. 2.71 (1.40-4.95) L/min/m2, p = 0.02], central venous pressure [12 (7-19) vs. 9 (5-19) mmHg, p < 0.001], and proportion with > 4.21 of Forns index (88% vs. 70%, p = 0.04) than those without proteinuria. The mean renal perfusion pressure was lower in patients with a reduced eGFR than those without it [55 (44-65) vs. 65 (45-102) mmHg, p = 0.03], but no other variables differed significantly. A multivariable analysis revealed that proteinuria was associated with an increased cardiac index (unit odds ratio 2.02, 95% confidence interval 1.12-3.65, p = 0.02). Seven patients with severe proteinuria had a lower oxygen saturation than those with no or mild proteinuria (p = 0.01, 0.03). Proteinuria or a decreased eGFR differentially occurred in approximately 30% of Fontan patients. Suboptimal Fontan circulation may contribute to the development of proteinuria and reduced eGFR.
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Affiliation(s)
- Mamoru Muraoka
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Hazumu Nagata
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan.
| | - Kenichiro Yamamura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Ichiro Sakamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ayako Ishikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akiko Nishizaki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshimi Eguchi
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Shoji Fukuoka
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Kiyoshi Uike
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Yusaku Nagatomo
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Yuichiro Hirata
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Kei Nishiyama
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
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Kronk NN, Kronk BK, Robbie AT. A Case Report: Lithium-Induced Neurotoxicity, a Differential to Always Consider. Cureus 2023; 15:e50225. [PMID: 38192942 PMCID: PMC10773538 DOI: 10.7759/cureus.50225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2023] [Indexed: 01/10/2024] Open
Abstract
Lithium, a mood stabilizer commonly prescribed for bipolar disorder, has a narrow therapeutic index that increases the risk of toxicity for patients who are prescribed this medication. Patients presenting with lithium toxicity could have a wide array of symptoms triggered by several factors that mimic other neurological conditions. In this paper, we discuss the case of an 81-year-old male who presented to the emergency department with worsening tremors and visual hallucinations, ataxia, and cognitive decline. He was initially thought to have Parkinson's disease with dementia in the outpatient setting and was later found to have lithium toxicity. Swift identification and management, involving fluid diuresis, led to the complete resolution of the patient's neurological symptoms by the fourth day of hospitalization. This case calls attention to the challenges of diagnosing lithium toxicity due to the variability in presentation as well as precipitating factors that clinicians must be cognizant of when working up patients who are prescribed lithium.
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Affiliation(s)
- Noah N Kronk
- Emergency Medicine, University of Missouri School of Medicine, Columbia, USA
| | - Brooke K Kronk
- Neurology, University of Missouri School of Medicine, Columbia, USA
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8
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Abdelhamid M, Al Ghalayini K, Al‐Humood K, Altun B, Arafah M, Bader F, Ibrahim M, Sabbour H, Shawky Elserafy A, Skouri H, Yilmaz MB. Regional expert opinion: Management of heart failure with preserved ejection fraction in the Middle East, North Africa and Turkey. ESC Heart Fail 2023; 10:2773-2787. [PMID: 37530028 PMCID: PMC10567674 DOI: 10.1002/ehf2.14456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/02/2023] [Accepted: 06/21/2023] [Indexed: 08/03/2023] Open
Abstract
Although epidemiological data on heart failure (HF) with preserved ejection fraction (HFpEF) are scarce in the Middle East, North Africa and Turkey (MENAT) region, Lancet Global Burden of Disease estimated the prevalence of HF in the MENAT region in 2019 to be 0.78%, versus 0.71% globally. There is also a high incidence of HFpEF risk factors and co-morbidities in the region, including coronary artery disease, diabetes, obesity, hypertension, anaemia and chronic kidney disease. For instance, 14.5-16.2% of adults in the region reportedly have diabetes, versus 7.0% in Europe. Together with increasing life expectancy, this may contribute towards a higher burden of HFpEF in the region than currently reported. This paper aims to describe the epidemiology and burden of HFpEF in the MENAT region, including unique risk factors and co-morbidities. It highlights challenges with diagnosing HFpEF, such as the prioritization of HF with reduced ejection fraction (HFrEF), the specific profile of HFpEF patients in the region and barriers to effective management associated with the healthcare system. Guidance is given on the diagnosis, prevention and management of HFpEF, including the emerging role of sodium-glucose co-transporter-2 inhibitors. Given the high burden of HFpEF coupled with the fact that its prevalence is likely to be underestimated, healthcare professionals need to be alert to its signs and symptoms and to manage patients accordingly. Historically, HFpEF treatments have focused on managing co-morbidities and symptoms, but new agents are now available with proven effects on outcomes in patients with HFpEF.
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Affiliation(s)
| | | | | | - Bülent Altun
- Faculty of MedicineHacettepe UniversityAnkaraTurkey
| | | | - Feras Bader
- Cleveland ClinicAbu DhabiUnited Arab Emirates
| | | | | | | | - Hadi Skouri
- Sheikh Shakhbout Medical CityAbu DhabiUnited Arab Emirates
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Xanthopoulos A, Papamichail A, Briasoulis A, Loritis K, Bourazana A, Magouliotis DE, Sarafidis P, Stefanidis I, Skoularigis J, Triposkiadis F. Heart Failure in Patients with Chronic Kidney Disease. J Clin Med 2023; 12:6105. [PMID: 37763045 PMCID: PMC10532148 DOI: 10.3390/jcm12186105] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 09/29/2023] Open
Abstract
The function of the kidney is tightly linked to the function of the heart. Dysfunction/disease of the kidney may initiate, accentuate, or precipitate of the cardiac dysfunction/disease and vice versa, contributing to a negative spiral. Further, the reciprocal association between the heart and the kidney may occur on top of other entities, usually diabetes, hypertension, and atherosclerosis, simultaneously affecting the two organs. Chronic kidney disease (CKD) can influence cardiac function through altered hemodynamics and salt and water retention, leading to venous congestion and therefore, not surprisingly, to heart failure (HF). Management of HF in CKD is challenging due to several factors, including complex interplays between these two conditions, the effect of kidney dysfunction on the metabolism of HF medications, the effect of HF medications on kidney function, and the high risk for anemia and hyperkalemia. As a result, in most HF trials, patients with severe renal impairment (i.e., eGFR 30 mL/min/1.73 m2 or less) are excluded. The present review discusses the epidemiology, pathophysiology, and current medical management in patients with HF developing in the context of CKD.
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Affiliation(s)
- Andrew Xanthopoulos
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
| | - Adamantia Papamichail
- Amyloidosis Center, Department of Clinical Therapeutics, Faculty of Medicine, Alexandra Hospital, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Alexandros Briasoulis
- Amyloidosis Center, Department of Clinical Therapeutics, Faculty of Medicine, Alexandra Hospital, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Konstantinos Loritis
- Amyloidosis Center, Department of Clinical Therapeutics, Faculty of Medicine, Alexandra Hospital, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Angeliki Bourazana
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
| | - Dimitrios E. Magouliotis
- Unit of Quality Improvement, Department of Cardiothoracic Surgery, University of Thessaly, 41110 Larissa, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Ioannis Stefanidis
- Department of Nephrology, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - John Skoularigis
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
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10
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Price N, Wood AF. Acute kidney injury in the critical care setting. Nurs Stand 2023; 38:45-50. [PMID: 37458070 DOI: 10.7748/ns.2023.e12063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2022] [Indexed: 07/18/2023]
Abstract
Acute kidney injury is a sudden reduction in renal function which impairs the kidneys' ability to maintain fluid, electrolyte and acid-base balance. The syndrome often develops secondary to severe illness and is associated with a significant increase in morbidity and mortality rate in critically ill patients. This article gives an overview of the pathophysiology and aetiology of acute kidney injury, as well as the associated complications and clinical diagnostic signs. The authors also describe some common causes of the syndrome in critically ill patients, specifically sepsis, liver failure and cardiac failure, and discuss patient management in the critical care setting, with a focus on haemodynamic support and continuous renal replacement therapy.
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Affiliation(s)
- Natasha Price
- division of nursing and paramedic science, school of health sciences, Queen Margaret University, Edinburgh, Scotland
| | - Alison Fiona Wood
- programme lead for independent prescribing, division of nursing and paramedic science, school of health sciences, Queen Margaret University, Edinburgh, Scotland
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11
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Akbari A, McIntyre CW. Recent Advances in Sodium Magnetic Resonance Imaging and Its Future Role in Kidney Disease. J Clin Med 2023; 12:4381. [PMID: 37445416 PMCID: PMC10342976 DOI: 10.3390/jcm12134381] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
Sodium imbalance is a hallmark of chronic kidney disease (CKD). Excess tissue sodium in CKD is associated with hypertension, inflammation, and cardiorenal disease. Sodium magnetic resonance imaging (23Na MRI) has been increasingly utilized in CKD clinical trials especially in the past few years. These studies have demonstrated the association of excess sodium tissue accumulation with declining renal function across whole CKD spectrum (early- to end-stage), biomarkers of systemic inflammation, and cardiovascular dysfunction. In this article, we review recent advances of 23Na MRI in CKD and discuss its future role with a focus on the skin, the heart, and the kidney itself.
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Affiliation(s)
- Alireza Akbari
- Robarts Research Institute, Western University, London, ON N6A 3K7, Canada;
- Lilibeth Caberto Kidney Clinic Research Unit, London Health Sciences Centre, London, ON N6A 5W9, Canada
| | - Christopher W. McIntyre
- Robarts Research Institute, Western University, London, ON N6A 3K7, Canada;
- Lilibeth Caberto Kidney Clinic Research Unit, London Health Sciences Centre, London, ON N6A 5W9, Canada
- Departments of Medicine, Pediatrics and Medical Biophysics, Western University, London, ON N6A 3K7, Canada
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12
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Weir RAP. Management of hospitalised patients with heart failure admitted to non-cardiology services. Heart 2023; 109:959-965. [PMID: 36849234 DOI: 10.1136/heartjnl-2022-321720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
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13
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Affiliation(s)
- Paul M Haydock
- Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Andrew S Flett
- Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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14
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Buda V, Prelipcean A, Cozma D, Man DE, Negres S, Scurtu A, Suciu M, Andor M, Danciu C, Crisan S, Dehelean CA, Petrescu L, Rachieru C. An Up-to-Date Article Regarding Particularities of Drug Treatment in Patients with Chronic Heart Failure. J Clin Med 2022; 11:2020. [PMID: 35407628 PMCID: PMC8999552 DOI: 10.3390/jcm11072020] [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] [Received: 03/03/2022] [Revised: 03/24/2022] [Accepted: 04/01/2022] [Indexed: 11/17/2022] Open
Abstract
Since the prevalence of heart failure (HF) increases with age, HF is now one of the most common reasons for the hospitalization of elderly people. Although the treatment strategies and overall outcomes of HF patients have improved over time, hospitalization and mortality rates remain elevated, especially in developed countries where populations are aging. Therefore, this paper is intended to be a valuable multidisciplinary source of information for both doctors (cardiologists and general physicians) and pharmacists in order to decrease the morbidity and mortality of heart failure patients. We address several aspects regarding pharmacological treatment (including new approaches in HF treatment strategies [sacubitril/valsartan combination and sodium glucose co-transporter-2 inhibitors]), as well as the particularities of patients (age-induced changes and sex differences) and treatment (pharmacokinetic and pharmacodynamic changes in drugs; cardiorenal syndrome). The article also highlights several drugs and food supplements that may worsen the prognosis of HF patients and discusses some potential drug-drug interactions, their consequences and recommendations for health care providers, as well as the risks of adverse drug reactions and treatment discontinuation, as an interdisciplinary approach to treatment is essential for HF patients.
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Affiliation(s)
- Valentina Buda
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (V.B.); (A.P.); (A.S.); (M.S.); (C.D.); (C.A.D.)
- Research Center for Pharmaco-Toxicological Evaluation, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Andreea Prelipcean
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (V.B.); (A.P.); (A.S.); (M.S.); (C.D.); (C.A.D.)
| | - Dragos Cozma
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (D.E.M.); (M.A.); (S.C.); (L.P.); (C.R.)
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Dana Emilia Man
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (D.E.M.); (M.A.); (S.C.); (L.P.); (C.R.)
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Simona Negres
- Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, Traian Vuia 6, 020956 Bucharest, Romania;
| | - Alexandra Scurtu
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (V.B.); (A.P.); (A.S.); (M.S.); (C.D.); (C.A.D.)
- Research Center for Pharmaco-Toxicological Evaluation, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Maria Suciu
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (V.B.); (A.P.); (A.S.); (M.S.); (C.D.); (C.A.D.)
- Research Center for Pharmaco-Toxicological Evaluation, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Minodora Andor
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (D.E.M.); (M.A.); (S.C.); (L.P.); (C.R.)
| | - Corina Danciu
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (V.B.); (A.P.); (A.S.); (M.S.); (C.D.); (C.A.D.)
- Research Center for Pharmaco-Toxicological Evaluation, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Simina Crisan
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (D.E.M.); (M.A.); (S.C.); (L.P.); (C.R.)
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Cristina Adriana Dehelean
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (V.B.); (A.P.); (A.S.); (M.S.); (C.D.); (C.A.D.)
- Research Center for Pharmaco-Toxicological Evaluation, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Lucian Petrescu
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (D.E.M.); (M.A.); (S.C.); (L.P.); (C.R.)
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Ciprian Rachieru
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (D.E.M.); (M.A.); (S.C.); (L.P.); (C.R.)
- Center for Advanced Research in Cardiovascular Pathology and Hemostasis, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
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15
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Banerjee D, Winocour P, Chowdhury TA, De P, Wahba M, Montero R, Fogarty D, Frankel AH, Karalliedde J, Mark PB, Patel DC, Pokrajac A, Sharif A, Zac-Varghese S, Bain S, Dasgupta I. Management of hypertension and renin-angiotensin-aldosterone system blockade in adults with diabetic kidney disease: Association of British Clinical Diabetologists and the Renal Association UK guideline update 2021. BMC Nephrol 2022; 23:9. [PMID: 34979961 PMCID: PMC8722287 DOI: 10.1186/s12882-021-02587-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 10/28/2021] [Indexed: 12/31/2022] Open
Abstract
People with type 1 and type 2 diabetes are at risk of developing progressive chronic kidney disease (CKD) and end-stage kidney failure. Hypertension is a major, reversible risk factor in people with diabetes for development of albuminuria, impaired kidney function, end-stage kidney disease and cardiovascular disease. Blood pressure control has been shown to be beneficial in people with diabetes in slowing progression of kidney disease and reducing cardiovascular events. However, randomised controlled trial evidence differs in type 1 and type 2 diabetes and different stages of CKD in terms of target blood pressure. Activation of the renin-angiotensin-aldosterone system (RAAS) is an important mechanism for the development and progression of CKD and cardiovascular disease. Randomised trials demonstrate that RAAS blockade is effective in preventing/ slowing progression of CKD and reducing cardiovascular events in people with type 1 and type 2 diabetes, albeit differently according to the stage of CKD. Emerging therapy with sodium glucose cotransporter-2 (SGLT-2) inhibitors, non-steroidal selective mineralocorticoid antagonists and endothelin-A receptor antagonists have been shown in randomised trials to lower blood pressure and further reduce the risk of progression of CKD and cardiovascular disease in people with type 2 diabetes. This guideline reviews the current evidence and makes recommendations about blood pressure control and the use of RAAS-blocking agents in different stages of CKD in people with both type 1 and type 2 diabetes.
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Affiliation(s)
- D Banerjee
- St George's Hospitals NHS Foundation Trust, London, UK
| | - P Winocour
- ENHIDE, East and North Herts NHS Trust, Stevenage, UK
| | | | - P De
- City Hospital, Birmingham, UK
| | - M Wahba
- St Helier Hospital, Carshalton, UK
| | | | - D Fogarty
- Belfast Health and Social Care Trust, Belfast, UK
| | - A H Frankel
- Imperial College Healthcare NHS Trust, London, UK
| | | | - P B Mark
- University of Glasgow, Glasgow, UK
| | - D C Patel
- Royal Free London NHS Foundation Trust, London, UK
| | - A Pokrajac
- West Hertfordshire Hospitals, London, UK
| | - A Sharif
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - S Bain
- Swansea University, Swansea, UK
| | - I Dasgupta
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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16
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Abel AAI, Clark AL. Long-Term Pharmacological Management of Reduced Ejection Fraction Following Acute Myocardial Infarction: Current Status and Future Prospects. Int J Gen Med 2021; 14:7797-7805. [PMID: 34795500 PMCID: PMC8593493 DOI: 10.2147/ijgm.s294896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/26/2021] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) with reduced ejection fraction is common following acute myocardial infarction (MI), and active medical management can have a profound impact on prognosis. Reviewing relevant clinical trials, we focus on the pharmacological management of left ventricular systolic dysfunction (LVSD) following an acute MI, although there is overlap with the pharmacological management of chronic HF due to reduced ejection fraction. Angiotensin converting enzyme (ACE) inhibitors, beta-blockers, and mineralocorticoid receptor antagonists are the mainstay of medical management in patients with LVSD post MI; there may also be a role for anticoagulation. Sacubitril-valsartan (angiotensin receptor neprilysin inhibitor) has not yet been shown to be superior to an ACE inhibitor in reducing cardiovascular mortality and HF events in patients with LVSD post MI. Large randomised trials evaluating sodium glucose transporter 2 (SGLT-2) inhibitors in LVSD post MI are ongoing.
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Affiliation(s)
- Alexandra A I Abel
- Department of Academic Cardiology, Castle Hill Hospital, Kingston Upon Hull, UK
| | - Andrew L Clark
- Department of Academic Cardiology, Castle Hill Hospital, Kingston Upon Hull, UK
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17
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Humphrey TJL, James G, Wittbrodt ET, Zarzuela D, Hiemstra TF. Adverse clinical outcomes associated with RAAS inhibitor discontinuation: analysis of over 400 000 patients from the UK Clinical Practice Research Datalink (CPRD). Clin Kidney J 2021; 14:2203-2212. [PMID: 34804520 PMCID: PMC8598122 DOI: 10.1093/ckj/sfab029] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/11/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Users of guideline-recommended renin-angiotensin-aldosterone system (RAAS) inhibitors may experience disruptions to their treatment, e.g. due to hyperkalaemia, hypotension or acute kidney injury. The risks associated with treatment disruption have not been comprehensively assessed; therefore, we evaluated the risk of adverse clinical outcomes in RAAS inhibitor users experiencing treatment disruptions in a large population-wide database. METHODS This exploratory, retrospective analysis utilized data from the UK's Clinical Practice Research Datalink, linked to Hospital Episodes Statistics and the Office for National Statistics databases. Adults (≥18 years) with first RAAS inhibitor use (defined as angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) between 1 January 2009 and 31 December 2014 were eligible for inclusion. Time to the first occurrence of adverse clinical outcomes [all-cause mortality, all-cause hospitalization, cardiac arrhythmia, heart failure hospitalization, cardiac arrest, advancement in chronic kidney disease (CKD) stage and acute kidney injury] was compared between RAAS inhibitor users with and without interruptions or cessations to treatment during follow-up. Associations between baseline characteristics and adverse clinical outcomes were also assessed. RESULTS Among 434 027 RAAS inhibitor users, the risk of the first occurrence of all clinical outcomes, except advancement in CKD stage, was 8-75% lower in patients without interruptions or cessations versus patients with interruptions/cessations. Baseline characteristics independently associated with increased risk of clinical outcomes included increasing age, smoking, CKD, diabetes and heart failure. CONCLUSIONS These findings highlight the need for effective management of factors associated with RAAS inhibitor interruptions or cessations in patients for whom guideline-recommended RAAS inhibitor treatment is indicated.
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Affiliation(s)
| | - Glen James
- Global Medical Affairs, AstraZeneca, Cambridge, UK
| | - Eric T Wittbrodt
- Biopharmaceuticals Medical Unit, AstraZeneca, Gaithersburg, MD, USA
| | - Donna Zarzuela
- Biopharmaceuticals Medical Unit, AstraZeneca, Gaithersburg, MD, USA
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18
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Damy T, Chouihed T, Delarche N, Berrut G, Cacoub P, Henry P, Lamblin N, Andrès E, Hanon O. Diagnosis and Management of Heart Failure in Elderly Patients from Hospital Admission to Discharge: Position Paper. J Clin Med 2021; 10:jcm10163519. [PMID: 34441815 PMCID: PMC8396904 DOI: 10.3390/jcm10163519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 02/07/2023] Open
Abstract
Multidisciplinary management of worsening heart failure (HF) in the elderly improves survival. To ensure patients have access to adequate care, the current HF and French health authority guidelines advise establishing a clearly defined HF patient pathway. This pathway involves coordinating multiple disciplines to manage decompensating HF. Yet, recent registry data indicate that insufficient numbers of patients receive specialised cardiology care, which increases the risk of rehospitalisation and mortality. The patient pathway in France involves three key stages: presentation with decompensated HF, stabilisation within a hospital setting and transitional care back out into the community. In each of these three phases, HF diagnosis, severity and precipitating factors need to be promptly identified and managed. This is particularly pertinent in older, frail patients who may present with atypical symptoms or coexisting comorbidities and for whom geriatric evaluation may be needed or specific geriatric syndrome management implemented. In the transition phase, multi-professional post-discharge management must be coordinated with community health care professionals. When the patient is discharged, HF medication must be optimised, and patients educated about self-care and monitoring symptoms. This review provides practical guidance to clinicians managing worsening HF in the elderly.
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Affiliation(s)
- Thibaud Damy
- Service de Cardiologie, CHU H. Mondor, 94000 Créteil, France
- Correspondence:
| | - Tahar Chouihed
- Service des SAMU-SMUR-Urgences, Centre d’Investigations Cliniques-1433, INSERM UMR_S 1116, Université de Lorraine, CHRU Nancy, F-CRIN INI-CRCT, 541000 Nancy, France;
| | | | - Gilles Berrut
- CHU Nantes, Pôle Hospitalo-Universitiare de Gérontologie Clinique, 44000 Nantes, France;
| | - Patrice Cacoub
- Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, AP-HP, 75000 Paris, France;
| | - Patrick Henry
- Service de Cardiologie, APHP, Hôpital Lariboisière, 75000 Paris, France;
| | - Nicholas Lamblin
- Service de Cardiologie, Institut Pasteur de Lille, CHU de Lille, Université de Lille, U1167, 59000 Lille, France;
| | - Emmanuel Andrès
- Service Méd. Interne, Diabète, Maladies Métaboliques, Clinique Médicale B, CHU Strasbourg, 67000 Strasbourg, France;
| | - Olivier Hanon
- Service de Gériatrie, APHP, Hôpital Broca, Université de Paris, 54 Rue Pascal, 75013 Paris, France;
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19
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Abstract
CKD is common in patients with heart failure, associated with high mortality and morbidity, which is even higher in people undergoing long-term dialysis. Despite increasing use of evidence-based drug and device therapy in patients with heart failure in the general population, patients with CKD have not benefitted. This review discusses prevalence and evidence of kidney replacement, device, and drug therapies for heart failure in CKD. Evidence for treatment with β-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and sodium-glucose cotransporter inhibitors in mild-to-moderate CKD has emerged from general population studies in patients with heart failure with reduced ejection fraction (HFrEF). β-Blockers have been shown to improve outcomes in patients with HFrEF in all stages of CKD, including patients on dialysis. However, studies of HFrEF selected patients with creatinine <2.5 mg/dl for ACE inhibitors, <3.0 mg/dl for angiotensin-receptor blockers, and <2.5 mg/dl for mineralocorticoid receptor antagonists, excluding patients with severe CKD. Angiotensin receptor neprilysin inhibitor therapy was successfully used in randomized trials in patients with eGFR as low as 20 ml/min per 1.73 m2 Hence, the benefits of renin-angiotensin-aldosterone axis inhibitor therapy in patients with mild-to-moderate CKD have been demonstrated, yet such therapy is not used in all suitable patients because of fear of hyperkalemia and worsening kidney function. Sodium-glucose cotransporter inhibitor therapy improved mortality and hospitalization in patients with HFrEF and CKD stages 3 and 4 (eGFR>20 ml/min per 1.73 m2). High-dose and combination diuretic therapy, often necessary, may be complicated with worsening kidney function and electrolyte imbalances, but has been used successfully in patients with CKD stages 3 and 4. Intravenous iron improved symptoms in patients with heart failure and CKD stage 3; and high-dose iron reduced heart failure hospitalizations by 44% in patients on dialysis. Cardiac resynchronization therapy reduced death and hospitalizations in patients with heart failure and CKD stage 3. Peritoneal dialysis in patients with symptomatic fluid overload improved symptoms and prevented hospital admissions. Evidence suggests that combined cardiology-nephrology clinics may help improve management of patients with HFrEF and CKD. A multidisciplinary approach may be necessary for implementation of evidence-based therapy.
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Affiliation(s)
- Debasish Banerjee
- Renal and Transplantation Unit, St George’s University Hospitals National Health Service Foundation Trust, London, United Kingdom
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St Georges, University of London, London, United Kingdom
| | - Giuseppe Rosano
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St Georges, University of London, London, United Kingdom
| | - Charles A. Herzog
- Cardiology Division, Department of Internal Medicine, Hennepin Healthcare/University of Minnesota, Minneapolis, Minnesota
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20
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Molina Barragan AM, Pardo E, Galichon P, Hantala N, Gianinazzi AC, Darrivere L, Tsai ES, Garnier M, Bonnet F, Fieux F, Verdonk F. SARS-CoV-2 Renal Impairment in Critical Care: An Observational Study of 42 Cases (Kidney COVID). J Clin Med 2021; 10:jcm10081571. [PMID: 33917886 PMCID: PMC8068224 DOI: 10.3390/jcm10081571] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/01/2021] [Accepted: 04/04/2021] [Indexed: 01/08/2023] Open
Abstract
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection leads to 5% to 16% hospitalization in intensive care units (ICU) and is associated with 23% to 75% of kidney impairments, including acute kidney injury (AKI). The current work aims to precisely characterize the renal impairment associated to SARS-CoV-2 in ICU patients. Forty-two patients consecutively admitted to the ICU of a French university hospital who tested positive for SARS-CoV-2 between 25 March 2020, and 29 April 2020, were included and classified in categories according to their renal function. Complete renal profiles and evolution during ICU stay were fully characterized in 34 patients. Univariate analyses were performed to determine risk factors associated with AKI. In a second step, we conducted a logistic regression model with inverse probability of treatment weighting (IPTW) analyses to assess major comorbidities as predictors of AKI. Thirty-two patients (94.1%) met diagnostic criteria for intrinsic renal injury with a mixed pattern of tubular and glomerular injuries within the first week of ICU admission, which lasted upon discharge. During their ICU stay, 24 patients (57.1%) presented AKI which was associated with increased mortality (p = 0.007), hemodynamic failure (p = 0.022), and more altered clearance at hospital discharge (p = 0.001). AKI occurrence was associated with lower pH (p = 0.024), higher PaCO2 (CO2 partial pressure in the arterial blood) (p = 0.027), PEEP (positive end-expiratory pressure) (p = 0.027), procalcitonin (p = 0.015), and CRP (C-reactive protein) (p = 0.045) on ICU admission. AKI was found to be independently associated with chronic kidney disease (adjusted OR (odd ratio) 5.97 (2.1-19.69), p = 0.00149). Critical SARS-CoV-2 infection is associated with persistent intrinsic renal injury and AKI, which is a risk factor of mortality. Mechanical ventilation settings seem to be a critical factor of kidney impairment.
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Affiliation(s)
- Antoine-Marie Molina Barragan
- Department of Anesthesiology and Intensive Care, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 75012 Paris, France; (A.-M.M.B.); (E.P.); (N.H.); (A.-C.G.); (L.D.); (M.G.); (F.B.); (F.F.)
| | - Emmanuel Pardo
- Department of Anesthesiology and Intensive Care, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 75012 Paris, France; (A.-M.M.B.); (E.P.); (N.H.); (A.-C.G.); (L.D.); (M.G.); (F.B.); (F.F.)
- Sorbonne University, GRC 29, DMU DREAM, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France;
| | - Pierre Galichon
- Sorbonne University, GRC 29, DMU DREAM, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France;
- Transplantation and Nephrology Department, Hôpital Pitié-Salpétrière, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France
| | - Nicolas Hantala
- Department of Anesthesiology and Intensive Care, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 75012 Paris, France; (A.-M.M.B.); (E.P.); (N.H.); (A.-C.G.); (L.D.); (M.G.); (F.B.); (F.F.)
- Sorbonne University, GRC 29, DMU DREAM, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France;
| | - Anne-Charlotte Gianinazzi
- Department of Anesthesiology and Intensive Care, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 75012 Paris, France; (A.-M.M.B.); (E.P.); (N.H.); (A.-C.G.); (L.D.); (M.G.); (F.B.); (F.F.)
- Sorbonne University, GRC 29, DMU DREAM, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France;
| | - Lucie Darrivere
- Department of Anesthesiology and Intensive Care, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 75012 Paris, France; (A.-M.M.B.); (E.P.); (N.H.); (A.-C.G.); (L.D.); (M.G.); (F.B.); (F.F.)
- Sorbonne University, GRC 29, DMU DREAM, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France;
| | - Eileen S. Tsai
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - Marc Garnier
- Department of Anesthesiology and Intensive Care, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 75012 Paris, France; (A.-M.M.B.); (E.P.); (N.H.); (A.-C.G.); (L.D.); (M.G.); (F.B.); (F.F.)
- Sorbonne University, GRC 29, DMU DREAM, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France;
| | - Francis Bonnet
- Department of Anesthesiology and Intensive Care, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 75012 Paris, France; (A.-M.M.B.); (E.P.); (N.H.); (A.-C.G.); (L.D.); (M.G.); (F.B.); (F.F.)
- Sorbonne University, GRC 29, DMU DREAM, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France;
| | - Fabienne Fieux
- Department of Anesthesiology and Intensive Care, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 75012 Paris, France; (A.-M.M.B.); (E.P.); (N.H.); (A.-C.G.); (L.D.); (M.G.); (F.B.); (F.F.)
| | - Franck Verdonk
- Department of Anesthesiology and Intensive Care, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 75012 Paris, France; (A.-M.M.B.); (E.P.); (N.H.); (A.-C.G.); (L.D.); (M.G.); (F.B.); (F.F.)
- Sorbonne University, GRC 29, DMU DREAM, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France;
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA;
- Correspondence:
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21
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Brandenburg V, Bauersachs J, Böhm M, Fliser D, Frantz S, Frey N, Hasenfuß G, Kielstein JT. [Symptom control in heart failure patients - how to handle GFR decrease and hyperkalaemia]. Dtsch Med Wochenschr 2021; 146:e47-e55. [PMID: 33482670 PMCID: PMC7972821 DOI: 10.1055/a-1307-8652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Bei Patienten mit Herzinsuffizienz und reduzierter Ejektionsfraktion wird durch eine optimierte medikamentöse Therapie sowohl die Symptomkontrolle verbessert als auch die Mortalität gesenkt. Eckpfeiler der Herzinsuffizienztherapie sind dabei Medikamente mit Einfluss auf das Renin-Angiotensin-Aldosteron-System, sogenannte RAAS-Inhibitoren. Dieser Artikel stellt einen kardiologisch-nephrologischen Konsens zur praxisorientierten Hilfestellung bei abnehmender glomerulärer Filtrationsrate oder Anstieg des Serum-Kaliumspiegels vor. Dies sind die 2 häufigsten Gründe für eine Dosisreduktion oder das Absetzen von prognoseverbessernden Medikamenten bei Herzinsuffizienzpatienten.
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Affiliation(s)
- Vincent Brandenburg
- Klinik für Kardiologie, Nephrologie und Internistische Intensivmedizin, Rhein-Maas-Klinikum, Würselen
| | - Johann Bauersachs
- Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover
| | - Michael Böhm
- Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Danilo Fliser
- Innere Medizin IV - Nieren- und Hochdruckkrankheiten, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Stefan Frantz
- Medizinische Klinik und Poliklinik I (Kardiologie, Endokrinologie, Nephrologie, Pneumologie, Intensiv- und Notfallmedizin) Universitätsklinikum Würzburg
| | - Norbert Frey
- Klinik für Innere Medizin III (Schwerpunkt Kardiologie, Angiologie und Intensivmedizin), Universitätsklinikum Schleswig-Holstein, Kiel
| | - Gerd Hasenfuß
- Herzzentrum, Abt. Kardiologie und Pneumologie, Universitätsmedizin Göttingen
| | - Jan T Kielstein
- Klinik für Nephrologie, Blutreinigung und Rheumatologie, Klinikum Braunschweig
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22
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Bunsawat K, Ratchford SM, Alpenglow JK, Park SH, Jarrett CL, Stehlik J, Smith AS, Richardson RS, Wray DW. Sacubitril-valsartan improves conduit vessel function and functional capacity and reduces inflammation in heart failure with reduced ejection fraction. J Appl Physiol (1985) 2021; 130:256-268. [PMID: 33211601 PMCID: PMC7944927 DOI: 10.1152/japplphysiol.00454.2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 11/11/2020] [Accepted: 11/11/2020] [Indexed: 12/11/2022] Open
Abstract
The Prospective comparison of ARNI with angiotensin-converting enzyme inhibitor to Determine Impact on Global Mortality and morbidity in Heart Failure trial identified a marked reduction in the risk of death and hospitalization for heart failure in patients with heart failure with reduced ejection fraction (HFrEF) treated with sacubitril-valsartan (trade name Entresto), but the physiological processes underpinning these improvements are unclear. We tested the hypothesis that treatment with sacubitril-valsartan improves peripheral vascular function, functional capacity, and inflammation in patients with HFrEF. We prospectively studied patients with HFrEF (n = 11, 10 M/1 F, left ventricular ejection fraction = 27 ± 8%) on optimal, guideline-directed medical treatment who were subsequently prescribed sacubitril-valsartan (open-label, uncontrolled, and unblinded). Peripheral vascular function [brachial artery flow-mediated dilation (FMD, conduit vessel function) and reactive hyperemia (RH, microvascular function)], functional capacity [six-minute walk test (6MWT) distance], and the proinflammatory biomarkers tumor necrosis factor-α (TNF-α) and interleukin-18 (IL-18) were obtained at baseline and at 1, 2, and 3 mo of treatment. %FMD improved after 1 mo of treatment, and this favorable response persisted for months 2 and 3 (baseline: 3.25 ± 1.75%; 1 mo: 5.23 ± 2.36%; 2 mo: 5.81 ± 1.79%; 3 mo: 6.35 ± 2.77%), whereas RH remained unchanged. 6MWT distance increased at months 2 and 3 (baseline: 420 ± 92 m; 1 mo: 436 ± 98 m; 2 mo: 465 ± 115 m; 3 mo: 460 ± 110 m), and there was a sustained reduction in TNF-α (baseline: 2.38 ± 1.35 pg/mL; 1 mo: 2.06 ± 1.52 pg/mL; 2 mo: 1.95 ± 1.34 pg/mL; 3 mo: 1.92 ± 1.37 pg/mL) and a reduction in IL-18 at month 3 (baseline: 654 ± 150 pg/mL; 1 mo: 595 ± 140 pg/mL; 2 mo: 601 ± 176 pg/mL; 3 mo: 571 ± 127 pg/mL). This study provides new evidence for the potential of this new drug class to improve conduit vessel function, functional capacity, and inflammation in patients with HFrEF.NEW & NOTEWORTHY We observed an approximately twofold improvement in conduit vessel function (brachial artery FMD), increased functional capacity (6MWT distance), and a reduction in inflammation (TNF-α and IL-18) following 3 mo of sacubitril-valsartan therapy. These findings provide important new information concerning the physiological mechanisms by which this new drug class provokes favorable changes in HFrEF pathophysiology.
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Affiliation(s)
- Kanokwan Bunsawat
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Stephen M Ratchford
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
- Department of Health & Exercise Science, Appalachian State University, Boone, North Carolina
| | - Jeremy K Alpenglow
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah
| | - Soung Hun Park
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah
| | - Catherine L Jarrett
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
| | - Josef Stehlik
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Adam S Smith
- Department of Pharmacy Services, University of Utah, Salt Lake City, Utah
| | - Russell S Richardson
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah
| | - D Walter Wray
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah
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23
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Howard SJ, Elvey R, Ohrnberger J, Turner AJ, Anselmi L, Martindale AM, Blakeman T. Post-discharge care following acute kidney injury: quality improvement in primary care. BMJ Open Qual 2020; 9:e000891. [PMID: 33328317 PMCID: PMC7745694 DOI: 10.1136/bmjoq-2019-000891] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 10/27/2020] [Accepted: 11/03/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Over the past decade, targeting acute kidney injury (AKI) has become a priority to improve patient safety and health outcomes. Illness complicated by AKI is common and is associated with adverse outcomes including high rates of unplanned hospital readmission. Through national patient safety directives, NHS England has mandated the implementation of an AKI clinical decision support system in hospitals. In order to improve care following AKI, hospitals have also been incentivised to improve discharge summaries and general practices are recommended to establish registers of people who have had an episode of illness complicated by AKI. However, to date, there is limited evidence surrounding the development and impact of interventions following AKI. DESIGN We conducted a quality improvement project in primary care aiming to improve the management of patients following an episode of hospital care complicated by AKI. All 31 general practices within a single NHS Clinical Commissioning Group were incentivised by a locally commissioned service to engage in audit and feedback, education training and to develop an action plan at each practice to improve management of AKI. RESULTS AKI coding in general practice increased from 28% of cases in 2015/2016 to 50% in 2017/2018. Coding of AKI was associated with significant improvements in downstream patient management in terms of conducting a medication review within 1 month of hospital discharge, monitoring kidney function within 3 months and providing written information about AKI to patients. However, there was no effect on unplanned hospitalisation and mortality. CONCLUSION The findings suggest that the quality improvement intervention successfully engaged a primary care workforce in AKI-related care, but that a higher intensity intervention is likely to be required to improve health outcomes. Development of a real-time audit tool is necessary to better understand and minimise the impact of the high mortality rate following AKI.
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Affiliation(s)
- Susan J Howard
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Health Innovation Manchester, Manchester, UK
| | - Rebecca Elvey
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Health Innovation Manchester, Manchester, UK
- Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care; School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK, The University of Manchester, Manchester, UK
| | - Julius Ohrnberger
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Alex J Turner
- Health Organisation, Policy and Economics (HOPE) group, Centre for Primary Care and Health Services Research, The University of Manchester, Manchester, UK
| | - Laura Anselmi
- Health Organisation, Policy and Economics (HOPE) group, Centre for Primary Care and Health Services Research, The University of Manchester, Manchester, UK
| | - Anne-Marie Martindale
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Health Innovation Manchester, Manchester, UK
- Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care; School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK, The University of Manchester, Manchester, UK
| | - Tom Blakeman
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Health Innovation Manchester, Manchester, UK
- Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care; School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK, The University of Manchester, Manchester, UK
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Williams DM, Evans M. Dapagliflozin for Heart Failure with Preserved Ejection Fraction: Will the DELIVER Study Deliver? Diabetes Ther 2020; 11:2207-2219. [PMID: 32852697 PMCID: PMC7509021 DOI: 10.1007/s13300-020-00911-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Indexed: 10/29/2022] Open
Abstract
Drug therapies for people with heart failure and preserved ejection fraction (HFpEF) are often limited to diuretics to improve symptoms as no therapies demonstrate a mortality benefit in this cohort. People with diabetes have a high risk of developing HFpEF and vice versa, suggesting shared pathophysiological mechanisms exist, which in turn engenders the potential for shared treatments. Dapagliflozin is a sodium-glucose co-transporter 2 (SGLT2) inhibitor which has demonstrated significantly improved cardiovascular and hospitalisation for heart failure (HHF) outcomes in previous cardiovascular outcome trials (CVOTs). These CVOTs include the DECLARE-TIMI and DAPA-HF studies which observed significant benefits for people with heart failure and specifically those with heart failure and reduced ejection fraction (HFrEF), respectively. The ongoing DELIVER study is evaluating the use of dapagliflozin specifically in people with HFpEF, which may have enormous implications for treatment and considerable economic consequences. This will complement previous and other ongoing CVOTs evaluating dapagliflozin use. In this review we discuss the use of SGLT2 inhibitors in HFrEF and HFpEF with a focus on the DELIVER study and its potential health and economic implications.
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Affiliation(s)
- David M Williams
- Department of Diabetes and Endocrinology, University Hospital Llandough, Cardiff, UK.
| | - Marc Evans
- Department of Diabetes and Endocrinology, University Hospital Llandough, Cardiff, UK
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Sankaranarayanan R, Douglas H, Wong C. Cardio-nephrology MDT meetings play an important role in the management of cardiorenal syndrome. THE BRITISH JOURNAL OF CARDIOLOGY 2020; 27:26. [PMID: 35747773 PMCID: PMC9205259 DOI: 10.5837/bjc.2020.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Cardiorenal syndrome is a complex condition associated with significant morbidity in the form of symptoms secondary to fluid overload, leading to hospitalisations, and portends increased mortality. Both the diagnosis and management of the conditions are complicated by the fact that there is dysfunction of the heart as well as the kidney, usually with uncertainty with regards to the timing of the first insult. Management in primary care, or in the emergency setting, tends to be predominantly focused on short-term improvement in function of one organ, leading to deleterious effects on the other. A consensus multi-disciplinary approach involving both cardiologists and nephrologists has been advocated in order to devise a unified management plan. Our report presents findings of monthly cardio-nephrology multi-disciplinary team meetings and illustrates that this can be an efficacious approach both in terms of avoiding unnecessary outpatient clinic visits, as well as consensus decision-making.
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Affiliation(s)
- Rajiv Sankaranarayanan
- Consultant Cardiologist, NIHR Research Scholar and Honorary Clinical Lecturer, Aintree University Hospital, Liverpool Centre for Cardiovascular Science, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL
| | - Homeyra Douglas
- Consultant Cardiologist and Clinical Director, Aintree University Hospital, Liverpool Centre for Cardiovascular Science, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL
| | - Christopher Wong
- Consultant Nephrologist and Visiting Professor of Life Sciences (Liverpool Hope University), Aintree University Hospital, Liverpool Centre for Cardiovascular Science, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL
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26
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Williams DM, Evans M. Are SGLT-2 Inhibitors the Future of Heart Failure Treatment? The EMPEROR-Preserved and EMPEROR-Reduced Trials. Diabetes Ther 2020; 11:1925-1934. [PMID: 32710261 PMCID: PMC7434820 DOI: 10.1007/s13300-020-00889-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Indexed: 12/17/2022] Open
Abstract
Heart failure is frequently associated with diabetes, and therapies which reduce mortality in people with heart failure and reduced ejection fraction (HFrEF) are often limited to drugs which modulate the renin-angiotensin-aldosterone system or heart rate control and occasionally to device therapy. Treatment is even more challenging in people with heart failure and preserved ejection fraction (HFpEF), with currently no approved therapy demonstrating a mortality-improving effect, limiting treatment to diuretics for the alleviation of the symptoms of fluid overload and risk factor management. Previous cardiovascular outcome trials for sodium-glucose co-transporter-2 (SGLT-2) inhibitors have demonstrated significant favourable outcomes for cardiovascular disease, heart failure hospitalisation and all-cause mortality. The aim of the nearly completed EMPEROR-preserved and EMPEROR-reduced trials is to determine the impact of empagliflozin on cardiovascular and heart failure outcomes in people with HFpEF or HFrEF with or without diabetes. The trials will add substantially to our understanding of SGLT-2 inhibitors in the treatment of HFrEF and may have major implications for the treatment of people with HFpEF. The study will also be powered to address the impact of empagliflozin on changes in renal function in people with and without diabetes and incident diabetes in the participants without diabetes at baseline. In this article we discuss the rationale for using SGLT-2 inhibitors in people with heart failure and explore the potential findings and importance of the ongoing EMPEROR-preserved and EMPEROR-reduced trials.
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Affiliation(s)
- David M Williams
- Department of Diabetes and Endocrinology, University Hospital Llandough, Cardiff, UK.
| | - Marc Evans
- Department of Diabetes and Endocrinology, University Hospital Llandough, Cardiff, UK
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27
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Tsang JY, Murray J, Kingdon E, Tomson C, Hallas K, Campbell S, Blakeman T. Guidance for post-discharge care following acute kidney injury: an appropriateness ratings evaluation. BJGP Open 2020; 4:bjgpopen20X101054. [PMID: 32546580 PMCID: PMC7465579 DOI: 10.3399/bjgpopen20x101054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 02/10/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is associated with poor health outcomes, including increased mortality and rehospitalisation. National policy and patient safety drivers have targeted AKI as an example to ensure safer transitions of care. AIM To establish guidance to promote high-quality transitions of care for adults following episodes of illness complicated by AKI. DESIGN & SETTING An appropriateness ratings evaluation was undertaken using the RAND/UCLA Appropriateness Method (RAM). The Royal College of General Practitioners (RCGP) AKI working group developed a range of clinical scenarios to help identify the necessary steps to be taken following discharge of a patient from secondary care into primary care in the UK. METHOD A 10-person expert panel was convened to rate 819 clinical scenarios, testing the most appropriate time and action following hospital discharge. Specifically, the scenarios focused on determining the appropriateness and urgency for planning: an initial medication review; monitoring of kidney function; and assessment for albuminuria. RESULTS Taking no action (that is, no medication review; no kidney monitoring; or no albuminuria testing) was rated inappropriate in all cases. In most scenarios, there was consensus that both the initial medication review and kidney function monitoring should take place within 1-2 weeks or 1 month, depending on clinical context. However, patients with heart failure and poor kidney recovery were rated to require expedited review. There was consensus that assessment for albuminuria should take place at 3 months after discharge following AKI. CONCLUSION Systems to support tailored and timely post-AKI discharge care are required, especially in high-risk populations, such as people with heart failure.
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Affiliation(s)
- Jung Yin Tsang
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester, Centre for Primary Care and Health Services Research, Institute of Population Health, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre (PTSRC), University of Manchester, Manchester, UK
| | - Jonathan Murray
- Renal Unit, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
- Academic Health Science Network for the North East and North Cumbria (AHSN NENC), Newcastle upon Tyne, UK
| | - Edward Kingdon
- Brighton & Sussex University Hospitals NHS Trust, Brighton, UK
- Kent Surrey Sussex Academic Health Science Network (KSS AHSN), Crawley, UK
| | - Charlie Tomson
- Department of Renal Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Kyle Hallas
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester, Centre for Primary Care and Health Services Research, Institute of Population Health, University of Manchester, Manchester, UK
| | - Stephen Campbell
- NIHR Greater Manchester Patient Safety Translational Research Centre (PTSRC), University of Manchester, Manchester, UK
| | - Tom Blakeman
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester, Centre for Primary Care and Health Services Research, Institute of Population Health, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre (PTSRC), University of Manchester, Manchester, UK
- RCGP Clinical Champion for Kidney Care, Royal College of General Practitioners, London, UK
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28
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Bidulka P, Fu EL, Leyrat C, Kalogirou F, McAllister KSL, Kingdon EJ, Mansfield KE, Iwagami M, Smeeth L, Clase CM, Bhaskaran K, van Diepen M, Carrero JJ, Nitsch D, Tomlinson LA. Stopping renin-angiotensin system blockers after acute kidney injury and risk of adverse outcomes: parallel population-based cohort studies in English and Swedish routine care. BMC Med 2020; 18:195. [PMID: 32723383 PMCID: PMC7389346 DOI: 10.1186/s12916-020-01659-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 06/08/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The safety of restarting angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB) after acute kidney injury (AKI) is unclear. There is concern that previous users do not restart ACEI/ARB despite ongoing indications. We sought to determine the risk of adverse events after an episode of AKI, comparing prior ACEI/ARB users who stop treatment to those who continue. METHODS We conducted two parallel cohort studies in English and Swedish primary and secondary care, 2006-2016. We used multivariable Cox regression to estimate hazard ratios (HR) for hospital admission with heart failure (primary analysis), AKI, stroke, or death within 2 years after hospital discharge following a first AKI episode. We compared risks of admission between people who stopped ACEI/ARB treatment to those who were prescribed ACEI/ARB within 30 days of AKI discharge. We undertook sensitivity analyses, including propensity score-matched samples, to explore the robustness of our results. RESULTS In England, we included 7303 people with AKI hospitalisation following recent ACEI/ARB therapy for the primary analysis. Four thousand three (55%) were classified as stopping ACEI/ARB based on no prescription within 30 days of discharge. In Sweden, we included 1790 people, of whom 1235 (69%) stopped treatment. In England, no differences were seen in subsequent risk of heart failure (HR 1.10; 95% confidence intervals (CI) 0.93-1.30), AKI (HR 0.90; 95% CI 0.77-1.05), or stroke (HR 0.99; 95% CI 0.71-1.38), but there was an increased risk of death (HR 1.27; 95% CI 1.15-1.41) in those who stopped ACEI/ARB compared to those who continued. Results were similar in Sweden: no differences were seen in risk of heart failure (HR 0.91; 95% CI 0.73-1.13) or AKI (HR 0.81; 95% CI 0.54-1.21). However, no increased risk of death was seen (HR 0.94; 95% CI 0.78-1.13) and stroke was less common in people who stopped ACEI/ARB (HR 0.56; 95% CI 0.34-0.93). Results were similar across all sensitivity analyses. CONCLUSIONS Previous ACEI/ARB users who continued treatment after an episode of AKI did not have an increased risk of heart failure or subsequent AKI compared to those who stopped the drugs.
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Affiliation(s)
- Patrick Bidulka
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Edouard L Fu
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef, Leiden, 2333ZA, The Netherlands
| | - Clémence Leyrat
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Fotini Kalogirou
- Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - Katherine S L McAllister
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Edward J Kingdon
- Sussex Kidney Unit, Royal Sussex County Hospital, Brighton, BN2 5BE, UK
| | - Kathryn E Mansfield
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Masao Iwagami
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Catherine M Clase
- Department of Medicine, Department of Health Research, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Krishnan Bhaskaran
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef, Leiden, 2333ZA, The Netherlands
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12, Stockholm, Sweden
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Laurie A Tomlinson
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Changes in Respiratory Muscle Strength Following Cardiac Rehabilitation for Prognosis in Patients with Heart Failure. J Clin Med 2020; 9:jcm9040952. [PMID: 32235491 PMCID: PMC7230659 DOI: 10.3390/jcm9040952] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 03/25/2020] [Accepted: 03/27/2020] [Indexed: 12/28/2022] Open
Abstract
Respiratory muscle weakness, frequently observed in patients with heart failure (HF), is reported as a predictor for poor prognosis. Although increased respiratory muscle strength ameliorates exercise tolerance and quality of life in HF patients, the relationship between changes in respiratory muscle strength and patient prognosis remains unclear. A total of 456 patients with HF who continued a 5-month cardiac rehabilitation (CR) were studied. We measured maximal inspiratory pressure (PImax) at hospital discharge as the baseline and five months thereafter to assess the respiratory muscle strength. Changes in PImax during the 5-month observation period (⊿PImax) were examined. We investigated the composite multiple incidence of all-cause death or unplanned readmission after 5-month CR. The relationship between ⊿PImax and the incidence of clinical events was analyzed. Over a median follow-up of 1.8 years, 221 deaths or readmissions occurred, and their rate of incidence was 4.3/100 person-years. The higher ⊿PImax was significantly associated with lower incidence of clinical event. In multivariate Poisson regression model after adjustment for clinical confounding factors, ⊿PImax remained a significant and independent predictor for all-cause death/readmission (adjusted incident rate ratio for ⊿PImax increase of 10 cmH2O: 0.77, 95% confidence interval: 0.70–0.86). In conclusion, the changes in respiratory muscle strength independently predict the incidence of clinical events in patients with HF.
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30
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Chahal RS, Chukwu CA, Kalra PR, Kalra PA. Heart failure and acute renal dysfunction in the cardiorenal syndrome. Clin Med (Lond) 2020; 20:146-150. [PMID: 32188648 PMCID: PMC7081827 DOI: 10.7861/clinmed.2019-0422] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Just under 1 million people in the UK have symptomatic heart failure. Decompensated heart failure is associated with a particularly poor prognosis with in-hospital mortality at around 10%. Over the last 30 years renin-angiotensin-aldosterone system antagonists have been shown to have incremental benefit on improved quality of life, reduced hospitalisation and mortality rates in those with heart failure with reduced ejection fraction. Concomitant chronic kidney disease and 'acute kidney injury' are common and associated with adverse outcomes.In patients with decompensated heart failure, congestion is a key driver of deterioration in renal function. Decongestion is fundamental to successful management. Yet it is not uncommon to see prognostically important medication (such as angiotensin converting enzyme inhibitors and mineralocorticoid antagonists) inappropriately stopped, along with under-diuresis of the patient. This leaves the patient still in a state of congestion without the prognostic medication at discharge, with resultant adverse outcome. The British Society for Heart Failure and the Renal Association have produced consensus guidance to help guide management in a more consistent fashion based on heart failure classification, whether the patient is congested and the degree of renal impairment. Early heart failure specialist review is associated with improved patient outcomes.
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Affiliation(s)
| | | | - Paul R Kalra
- Portsmouth Hospitals NHS Trust, Portsmouth, UK and honorary professor, University of Portsmouth, Portsmouth, UK
| | - Philip A Kalra
- Salford Royal NHS Foundation Trust, Salford, UK and University of Manchester, Manchester, UK
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Abstract
Purpose of Review To provide an overview of the potential iatrogenic causes of acute decompensated heart failure (AHF) and an evidence-based management strategy to address this. Recent Findings As the heart failure (HF) population continues to age and become burdened with greater comorbidities and polypharmacy, patients become more susceptible to the iatrogenic precipitants of HF. The following clinical scenarios are familiar to clinicians, but the sequelae to AHF are often unanticipated: HF medications withdrawn during an intercurrent illness and not restarted, cardiotoxic therapy prescribed for cancer without timely and regular monitoring of left ventricular function, excessive intravenous fluids administered for sepsis or postoperatively, a blood transfusion volume not adjusted for body weight, iatrogenic anaemia that goes unnoticed or an inappropriate type of pacemaker implanted in a patient with underlying left ventricular systolic dysfunction. Summary Iatrogenic decompensated HF is a phenomenon that is infrequently documented in the literature but increasingly confronted by clinicians of all specialties. It is associated with a high mortality and morbidity rate. By having greater awareness of these triggers, iatrogenic AHF should be one that is prevented rather than managed when it occurs.
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32
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McCoy IE, Chertow GM. AKI-A Relevant Safety End Point? Am J Kidney Dis 2020; 75:508-512. [PMID: 32037098 DOI: 10.1053/j.ajkd.2019.11.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 11/25/2019] [Indexed: 12/22/2022]
Abstract
Acute kidney injury (AKI) is a common outcome evaluated in clinical studies, often as a safety end point in a variety of cardiovascular, kidney disease, and other clinical trials. AKI end points that include modest increases in serum creatinine levels from baseline may not associate with patient-centered outcomes such as initiation of dialysis, sustained decline in kidney function, or death. Surprisingly, data from several randomized controlled trials have suggested that in certain settings, the development of AKI may be associated with favorable outcomes. AKI safety end points that are nonspecific and may not associate with patient-centered outcomes could result in beneficial therapies being inappropriately withheld or never developed for commercial use. We review several issues related to commonly used AKI definitions and suggest that future work in AKI use more patient-centered AKI end points such as major adverse kidney events at 30 days or other later time points.
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Affiliation(s)
- Ian E McCoy
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA.
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
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Tomson C, Tomlinson LA. Stopping RAS Inhibitors to Minimize AKI: More Harm than Good? Clin J Am Soc Nephrol 2019; 14:617-619. [PMID: 30814113 PMCID: PMC6450359 DOI: 10.2215/cjn.14021118] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Charles Tomson
- Department of Renal Medicine, Freeman Hospital, Newcastle upon Tyne, United Kingdom; and
| | - Laurie A Tomlinson
- London School of Hygiene and Tropical Medicine Non-Communicable Disease Epidemiology, London, United Kingdom
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