Association of Cardiac Biomarkers With the Kansas City Cardiomyopathy Questionnaire in Patients With Chronic Kidney Disease Without Heart Failure

Early Serum Biomarkers of Cardiovascular Disease in Elderly Patients with Chronic Kidney Disease

BACKGROUND

The global population is aging. It is estimated that by 2050, the proportion of the elderly population will reach 16%. Various studies have suggested that elderly people have a greater incidence of CKD. These elderly patients are also susceptible to cardiovascular disease (CVD), which is the leading cause of death, resulting in poor prognosis in this population. However, CVD in such patients is often insidious and lacks early markers for effective evaluation. Fortunately, several studies have recently proposed biomarkers associated with this process.

SUMMARY

This study aimed to summarize the early biomarkers of CVD in elderly patients with CKD to provide a basis for its prevention and treatment.

KEY MESSAGES

This review outlines four categories of potential early biomarkers. All of them have been shown to have some clinical value for these patients, but more research is still needed.

Management of Chronic Heart Failure in Dialysis Patients: A Challenging but Rewarding Path

Chronic heart failure (CHF) is a common complication and cause of death in dialysis patients. Although several clinical guidelines and expert consensus on heart failure (HF) in the general population have been issued in China and abroad, due to abnormal renal function or even no residual renal function (RRF) in dialysis patients, the high number of chronic complications, as well as the specificity, variability, and limitations of hemodialysis (HD) and peritoneal dialysis (PD) treatments, there are significant differences between dialysis patients and the general population in terms of the treatment and management of HF. The current studies are not relevant to all dialysis-combined HF populations, and there is an urgent need for high-quality studies on managing HF in dialysis patients to guide and standardize treatment. After reviewing the existing guidelines and literature, we focused on the staging and diagnosis of HF, management of risk factors, pharmacotherapy, and dialysis treatment in patients on dialysis. Based on evidence-based medicine and clinical trial data, this report reflects new perspectives and future trends in the diagnosis and treatment of HF in dialysis patients, which will further enhance the clinicians' understanding of HF in dialysis patients.

Vascular endothelial growth factor-D plasma levels in fluid overload and cardiac function evaluation of elderly patients with cardiovascular disease

This study aimed to investigate the clinical significance of vascular endothelial growth factor (VEGF) subtypes and growth differentiation factor-15 (GDF-15) plasma levels in evaluating the fluid overload and cardiac function of elderly patients with cardiovascular disease. The plasma levels of VEGF-C, VEGF-D, and GDF-15 were measured using ELISA. Their correlations with N-terminal pro B-type natriuretic peptide (NT-Pro BNP) and echocardiography data were analyzed. 1. Higher plasma levels of VEGF-D and GDF-15 were observed in elderly patients with cardiovascular disease and heart failure(P < .01). VEGF-D plasma levels were higher in patients with chronic heart failure than those with acute myocardial infarction (P < .01). VEGF-D plasma levels were positively correlated with amino-terminal pro-B type natriuretic peptide (NT-pro BNP) (P < .001). VEGF-D plasma levels were positively correlated with echocardiographic parameters, including left atrial diameter, left ventricular end-diastolic diameter and left ventricular ejection fraction, in patients with cardiovascular disease (P < .01). 2. VEGF-C plasma levels were higher in acute myocardial infarction group (P < .05). The plasma levels of VEGF-C were not correlated with either VEGF-D or NT-pro BNP plasma levels. VEGF-C plasma levels had no correlation with echocardiographic parameters. 3. GDF-15 plasma levels were positively correlated with sera biomarkers of cardiac injury (creatine kinase isoenzyme MB and cardiac troponin I). GDF-15 plasma levels were positively correlated with urinary biomarkers of tubular injury (N-acetyl-β-galactosidase and α1-microglobulin). Both GDF-15 and NT-pro BNP plasma levels were correlated with age, estimated glomerular filtration rate (eGFR), and nutritional biomarkers (albumin and hemoglobin plasma levels). VEGF-D plasma levels is a potential biomarker of fluid overload and cardiac function in elderly patients with cardiovascular disease. Age, nutrition, and kidney injury are factors influencing both GDF-15 and NT-pro BNP plasma levels in estimating cardiac function and fluid overload.

Reliability and Validity of Kansas City Cardiomyopathy Questionnaire in Arabic Patients with Chronic Heart Failure

Background: The Kansas City Cardiomyopathy Questionnaire (KCCQ) is the most specific and widely used questionnaire for assessing health-related quality of life (HRQoL) in chronic heart failure (CHF). This study aimed to examine reliability and validity of the KCCQ in Arabic patients with CHF. Material and Methods: Patients with CHF filled out the Arabic versions of the Minnesota Living with Heart Failure (MLHF) and KCCQ questionnaire, and performed a six-minute walk test (6MWT) on their first visit. On the return, the patients filled out the KCCQ along with the global rating of change (GRC) scale. Internal consistency, test-retest reliability, and construct validity were examined. Results: A total of 101 Arabic patients with CHF, with a mean (SD) age of 55 (11) years old, completed the study. The Cronbach's alpha was 0.97, and the ICC2,1 = 0.95 (95%CI: 0.92 to 0.97, p < 0.001). The Arabic version of KCCQ was correlated with the MLHF (r = -0.57, p = 0.01) and with the 6MWT (r = 0.70, p < 0.001). Conclusions: The Arabic version of KCCQ is a reliable and valid measure of HRQoL, which could be utilized in routine clinical practice for Arabic-speaking patients with CHF.

Inflammageing and Cardiovascular System: Focus on Cardiokines and Cardiac-Specific Biomarkers

The term "inflammageing" was introduced in 2000, with the aim of describing the chronic inflammatory state typical of elderly individuals, which is characterized by a combination of elevated levels of inflammatory biomarkers, a high burden of comorbidities, an elevated risk of disability, frailty, and premature death. Inflammageing is a hallmark of various cardiovascular diseases, including atherosclerosis, hypertension, and rapid progression to heart failure. The great experimental and clinical evidence accumulated in recent years has clearly demonstrated that early detection and counteraction of inflammageing is a promising strategy not only to prevent cardiovascular disease, but also to slow down the progressive decline of health that occurs with ageing. It is conceivable that beneficial effects of counteracting inflammageing should be most effective if implemented in the early stages, when the compensatory capacity of the organism is not completely exhausted. Early interventions and treatments require early diagnosis using reliable and cost-effective biomarkers. Indeed, recent clinical studies have demonstrated that cardiac-specific biomarkers (i.e., cardiac natriuretic peptides and cardiac troponins) are able to identify, even in the general population, the individuals at highest risk of progression to heart failure. However, further clinical studies are needed to better understand the usefulness and cost/benefit ratio of cardiac-specific biomarkers as potential targets in preventive and therapeutic strategies for early detection and counteraction of inflammageing mechanisms and in this way slowing the progressive decline of health that occurs with ageing.

Chimeric galectin-3 and collagens: Biomarkers and potential therapeutic targets in fibroproliferative diseases

Fibrosis, stiffening and scarring of an organ/tissue due to genetic abnormalities, environmental factors, infection, and/or injury, is responsible for > 40% of all deaths in the industrialized world, and to date, there is no cure for it despite extensive research and numerous clinical trials. Several biomarkers have been identified, but no effective therapeutic targets are available. Human galectin-3 is a chimeric gene product formed by the fusion of the internal domain of the collagen alpha gene [N-terminal domain (ND)] at the 5'-end of galectin-1 [C-terminal domain (CRD)] that appeared during evolution together with vertebrates. Due to the overlapping structural similarities between collagen and galectin-3 and their shared susceptibility to cleavage by matrix metalloproteases to generate circulating collagen-like peptides, this review will discuss present knowledge on the role of collagen and galectin-3 as biomarkers of fibrosis. We will also highlight the need for transformative approaches targeting both the ND and CRD domains of galectin-3, since glycoconjugate binding by the CRD is triggered by ND-mediated oligomerization and the therapies targeted only at the CRD have so far achieved limited success.

Cardiac Biomarkers and Risk of Atherosclerotic Cardiovascular Disease in Patients with CKD

Background

Several cardiac biomarkers of cardiac stress, inflammation, and fibrosis (N-terminal pro brain-type natriuretic peptide [NT-proBNP], high-sensitivity troponin T [hsTnT], growth differentiation factor 15 [GDF-15], and soluble ST2 [sST2]) have been associated with atherosclerotic disease in the general population. We hypothesized that these cardiac biomarkers may also be associated with the atherosclerotic cardiovascular disease in patients with CKD.

Methods

We analyzed levels of NT-proBNP, hsTnT, GDF-15, and sST2 in a cohort of 2732 participants with mild to moderate CKD from the Chronic Renal Insufficiency Cohort (CRIC) study. Outcomes included incident atherosclerotic disease, defined as the first instance of myocardial infarction, stroke, or peripheral vascular disease. We used Cox proportional hazard models to the test the association of each cardiac biomarker with risk of incident atherosclerotic disease, adjusting for multiple possible confounders.

Results

When modeled continuously (per SD increase in the log-transformed biomarker), NT-proBNP, hsTnT, GDF-15, and sST2 were significantly associated with incident atherosclerotic disease after adjustment for multiple potential confounders: (NT-proBNP HR, 1.51; 95% CI, 1.27 to 1.81; hsTnT HR, 1.61; 95% CI, 1.38 to 1.89; GDF-15 HR, 1.44; 95% CI, 1.19 to 1.73; and sST2 HR, 1.19; 95% CI, 1.04 to 1.36).

Conclusions

NT-proBNP, hsTnT, GDF-15, and sST2 were significantly associated with incident atherosclerotic cardiovascular disease in patients with CKD. These associations may highlight important mechanisms for the development of atherosclerotic disease in CKD.

Patient-Reported Symptoms and Subsequent Risk of Myocardial Infarction in Chronic Kidney Disease

BACKGROUND AND OBJECTIVES

Although patient-reported symptoms often precede acute presentations of cardiovascular disease, patients with nondialysis-requiring CKD are less likely to have typical symptoms of atherosclerotic disease when presenting with acute myocardial infarction. However, the associations between typical atherosclerotic symptoms and subsequent risk of myocardial infarction are unknown in ambulatory patients with CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

To determine whether typical atherosclerotic symptoms are associated with risk for subsequent myocardial infarction in people with CKD, we examined participants from the Chronic Renal Insufficiency Cohort Study. Chest pain, shortness of breath, and inability to climb stairs were evaluated annually using the Kidney Disease Quality of Life Instrument. Associations between categorical time-updated symptoms and physician-adjudicated incident myocardial infarction were assessed using Cox regression models.

RESULTS

Among 3910 participants (mean age of 58±11 years; mean eGFR =44±15 ml/min per 1.73 m2), there were 476 incident myocardial infarctions over a median follow-up period of 10.4 years (interquartile range, 5.36-12.6 years). Median time from symptom assessment to incident myocardial infarction was 213 days (interquartile range, 111-333 days). Compared with no symptoms, mild, and moderate or worse, symptoms of chest pain (hazard ratio, 1.30; 95% confidence interval, 1.01 to 1.67; and hazard ratio, 1.70; 95% confidence interval, 1.27 to 2.27, respectively) and shortness of breath (hazard ratio, 1.37; 95% confidence interval, 1.10 to 1.70; and hazard ratio, 1.33; 95% confidence interval, 1.05 to 1.69, respectively) were significantly associated with greater risks for subsequent myocardial infarction. Participants reporting mild and severe limitations in climbing stairs (versus no limitation) had significantly higher adjusted risk of myocardial infarction (hazard ratio, 1.44; 95% confidence interval, 1.10 to 1.89; and hazard ratio, 1.89; 95% confidence interval, 1.44 to 2.49, respectively).

CONCLUSIONS

In a large ambulatory cohort of adults with CKD, symptoms of atherosclerotic cardiovascular disease were strongly associated with a higher risk for subsequent myocardial infarction.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_03_17_CJN12080921.mp3.

Galectin-3 in Cardiovascular Diseases

Galectin-3 (Gal-3) is a β-galactoside-binding protein belonging to the lectin family with pleiotropic regulatory activities and several physiological cellular functions, such as cellular growth, proliferation, apoptosis, differentiation, cellular adhesion, and tissue repair. Inflammation, tissue fibrosis and angiogenesis are the main processes in which Gal-3 is involved. It is implicated in the pathogenesis of several diseases, including organ fibrosis, chronic inflammation, cancer, atherosclerosis and other cardiovascular diseases (CVDs). This review aims to explore the connections of Gal-3 with cardiovascular diseases since they represent a major cause of morbidity and mortality. We herein discuss the evidence on the pro-inflammatory role of Gal-3 in the atherogenic process as well as the association with plaque features linked to lesion stability. We report the biological role and molecular mechanisms of Gal-3 in other CVDs, highlighting its involvement in the development of cardiac fibrosis and impaired myocardium remodelling, resulting in heart failure and atrial fibrillation. The role of Gal-3 as a prognostic marker of heart failure is described together with possible diagnostic applications to other CVDs. Finally, we report the tentative use of Gal-3 inhibition as a therapeutic approach to prevent cardiac inflammation and fibrosis.

Association of Cardiac Biomarkers With the Kansas City Cardiomyopathy Questionnaire in Patients With Chronic Kidney Disease Without Heart Failure

Background The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a measure of heart failure (HF) health status. Worse KCCQ scores are common in patients with chronic kidney disease (CKD), even without diagnosed heart failure (HF). Elevations in the cardiac biomarkers GDF-15 (growth differentiation factor-15), galectin-3, sST2 (soluble suppression of tumorigenesis-2), hsTnT (high-sensitivity troponin T), and NT-proBNP (N-terminal pro-B-type natriuretic peptide) likely reflect subclinical HF in CKD. Whether cardiac biomarkers are associated with low KCCQ scores is not known. Methods and Results We studied participants with CKD without HF in the multicenter prospective CRIC (Chronic Renal Insufficiency Cohort) Study. Outcomes included (1) low KCCQ score <75 at year 1 and (2) incident decline in KCCQ score to <75. We used multivariable logistic regression and Cox regression models to evaluate the associations between baseline cardiac biomarkers and cross-sectional and longitudinal KCCQ scores. Among 2873 participants, GDF-15 (adjusted odds ratio 1.42 per SD; 99% CI, 1.19-1.68) and galectin-3 (1.28; 1.12-1.48) were significantly associated with KCCQ scores <75, whereas sST2, hsTnT, and NT-proBNP were not significantly associated with KCCQ scores <75 after multivariable adjustment. Of the 2132 participants with KCCQ ≥75 at year 1, GDF-15 (adjusted hazard ratio, 1.36 per SD; 99% CI, 1.12-1.65), hsTnT (1.20; 1.01-1.44), and NT-proBNP (1.30; 1.08-1.56) were associated with incident decline in KCCQ to <75 after multivariable adjustment, whereas galectin-3 and sST2 did not have significant associations with KCCQ decline. Conclusions Among participants with CKD without clinical HF, GDF-15, galectin-3, NT-proBNP, and hsTnT were associated with low KCCQ either at baseline or during follow-up. Our findings show that elevations in cardiac biomarkers reflect early symptomatic changes in HF health status in CKD patients.