1
|
Ayton SL, Yeo JL, Gulsin GS, Dattani A, Bilak J, Deshpande A, Arnold JR, Singh A, Graham-Brown MPM, Ng L, Jones D, Slomka P, Dey D, Moss AJ, Brady EM, McCann GP. Association of epicardial adipose tissue with early structural and functional cardiac changes in Type 2 diabetes. Eur J Radiol 2024; 174:111400. [PMID: 38458143 DOI: 10.1016/j.ejrad.2024.111400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/29/2024] [Accepted: 02/27/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Dysregulated epicardial adipose tissue (EAT) may contribute to the development of heart failure in Type 2 diabetes (T2D). This study aimed to evaluate the associations between EAT volume and composition with imaging markers of subclinical cardiac dysfunction in people with T2D and no prevalent cardiovascular disease. METHODS Prospective case-control study enrolling participants with and without T2D and no known cardiovascular disease. Two hundred and fifteen people with T2D (median age 63 years, 60 % male) and thirty-nine non-diabetics (median age 59 years, 62 % male) were included. Using computed tomography (CT), total EAT volume and mean CT attenuation, as well as, low attenuation (Hounsfield unit range -190 to -90) EAT volume were quantified by a deep learning method and volumes indexed to body surface area. Associations with cardiac magnetic resonance-derived left ventricular (LV) volumes and strain indices were assessed using linear regression. RESULTS T2D participants had higher LV mass/volume ratio (median 0.89 g/mL [0.82-0.99] vs 0.79 g/mL [0.75-0.89]) and lower global longitudinal strain (GLS; 16.1 ± 2.3 % vs 17.2 ± 2.2 %). Total indexed EAT volume correlated inversely with mean CT attenuation. Low attenuation indexed EAT volume was 2-fold higher (18.8 cm3/m2 vs. 9.4 cm3/m2, p < 0.001) in T2D and independently associated with LV mass/volume ratio (ß = 0.002, p = 0.01) and GLS (ß = -0.03, p = 0.03). CONCLUSIONS Higher EAT volumes seen in T2D are associated with a lower mean CT attenuation. Low attenuation indexed EAT volume is independently, but only weakly, associated with markers of subclinical cardiac dysfunction in T2D.
Collapse
Affiliation(s)
- Sarah L Ayton
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Jian L Yeo
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Gaurav S Gulsin
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Abhishek Dattani
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Joanna Bilak
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Aparna Deshpande
- Department of Imaging Services, Glenfield Hospital, University Hospitals of Leicester, Leicester UK
| | - J Ranjit Arnold
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Anvesha Singh
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Leong Ng
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK; Leicester van Geest Multi-Omics Facility, University of Leicester, Leicester, UK
| | - Donald Jones
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK; Leicester van Geest Multi-Omics Facility, University of Leicester, Leicester, UK
| | - Piotr Slomka
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Damini Dey
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alastair J Moss
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK; Leicester van Geest Multi-Omics Facility, University of Leicester, Leicester, UK
| | - Emer M Brady
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK.
| |
Collapse
|
2
|
Graham-Brown MPM, Casula A, Savino M, Humphrey T, Pyart R, Amaran M, Williams J, Crowe K, Medcalf JF. A National audit of the care of patients with acute kidney injury in England and Wales in 2019 and the association with patient outcomes. Clin Med (Lond) 2024; 24:100028. [PMID: 38387536 DOI: 10.1016/j.clinme.2024.100028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication of hospitalisations. This national audit assessed the care received by patients with AKI in hospital Trusts in England and Wales. METHODS Twenty four hospital Trusts across England and Wales took part. Patients with AKI stage2/3 were identified using the UK Renal Registry AKI master patient index. Data was returned through a secure portal with linkage to hospital episode statistic mortality and hospitalisation data. Completion rates of AKI care standards and regional variations in care were established. RESULTS 989 AKI episodes were included in the analyses. In-hospital 30-day mortality was 31-33.1% (AKI 2/3). Standard AKI interventions were completed in >80% of episodes. Significant inter-hospital variation remained in attainment of AKI care standards after adjustment for age and sex. Recording of urinalysis (41.9%) and timely imaging (37.2%) were low. Information on discharge summaries relating to medication changes/re-commencement and follow-up blood tests associated with reduced mortality. No quality indicators relating to clinical management associated with mortality. Better communication on discharge summaries associated with reduced mortality. CONCLUSIONS Outcomes for patients with AKI in hospital remain poor. Regional variation in care exists. Work is needed to assess whether improving and standardising care improves patient outcomes.
Collapse
Affiliation(s)
- M P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, LE1 9HN, United Kingdom; NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester NHS Trust, United Kingdom.
| | - A Casula
- UK Renal Registry, United Kingdom
| | - M Savino
- UK Renal Registry, United Kingdom; Bristol Royal Infirmary, Division of Acute Medicine
| | - T Humphrey
- Department of Renal Medicine, Cambridge University Hospitals NHS Foundation Trust, United Kingdom
| | - R Pyart
- UK Renal Registry, United Kingdom
| | - M Amaran
- Renal Unit, St George's Hospital, London, United Kingdom
| | - J Williams
- School of Medicine, University of Exeter, United Kingdom
| | - K Crowe
- Glasgow Renal & Transplant Unit, NHS Greater Glasgow & Clyde, United Kingdom
| | - J F Medcalf
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester NHS Trust, United Kingdom; UK Renal Registry, United Kingdom
| |
Collapse
|
3
|
Lightfoot CJ, Wilkinson TJ, Vadaszy N, Graham-Brown MPM, Davies MJ, Yates T, Smith AC. Improving self-management behaviour through a digital lifestyle intervention: An internal pilot study. J Ren Care 2024. [PMID: 38296833 DOI: 10.1111/jorc.12488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/07/2023] [Accepted: 01/12/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Self-management is a key component of successful chronic kidney disease (CKD) management. Here, we present the findings from the internal pilot of a multicentre randomised controlled trial (RCT) aimed to test the effect of a digital self-management programme ('My Kidneys & Me' (MK&M)). METHODS Participants (aged ≥18 years and CKD stages 3-4) were recruited from hospital kidney services across England. Study processes were completed virtually. Participants were randomised 2:1 to either intervention (MK&M) or control group. The first 60 participants recruited were included in a 10-week internal pilot which assessed study feasibility and acceptability against pre-specified progression criteria: 1) eligibility and recruitment, acceptability of 2) randomisation and 3) outcomes, 4) MK&M activation, and 5) retention and attrition rates. Semi-structured interviews further explored views on trial participation. RESULTS Of the 60 participants recruited, 41 were randomised to MK&M and 19 to control. All participants completed baseline measures and 62% (n=37) completed post-intervention outcome measures. All progression criteria met the minimum thresholds to proceed. Nine participants were interviewed. The themes identified were satisfaction with study recruitment processes (openness to participate, reading and agreeing to "terms and conditions"), acceptability of study design (remote study participation, acceptability of randomisation, completion of online assessment(s)), and methods to improve recruitment and retention (personalised approach, follow-up communication). CONCLUSION This internal pilot demonstrated the feasibility and acceptability of a virtually run RCT. Progression criteria thresholds to proceed to the definitive RCT were met. Areas for improvement were identified and protocol amendments were made to improve trial delivery.
Collapse
Affiliation(s)
- Courtney J Lightfoot
- Leicester Kidney Lifestyle Team, Department of Population Health Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Thomas J Wilkinson
- Leicester Kidney Lifestyle Team, Department of Population Health Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Noemi Vadaszy
- Leicester Kidney Lifestyle Team, Department of Population Health Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Matthew P M Graham-Brown
- NIHR Leicester Biomedical Research Centre, Leicester, UK
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Department of Renal Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Melanie J Davies
- NIHR Leicester Biomedical Research Centre, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Thomas Yates
- NIHR Leicester Biomedical Research Centre, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Alice C Smith
- Leicester Kidney Lifestyle Team, Department of Population Health Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester, UK
| |
Collapse
|
4
|
Adenwalla SF, O'Halloran P, Faull C, Murtagh FEM, Graham-Brown MPM. Advance care planning for patients with end-stage kidney disease on dialysis: narrative review of the current evidence, and future considerations. J Nephrol 2024:10.1007/s40620-023-01841-3. [PMID: 38236475 DOI: 10.1007/s40620-023-01841-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/18/2023] [Indexed: 01/19/2024]
Abstract
Patients with end-stage kidney disease (ESKD) have a high symptom-burden and high rates of morbidity and mortality. Despite this, evidence has shown that this patient group does not have timely discussions to plan for deterioration and death, and at the end of life there are unmet palliative care needs. Advance care planning is a process that can help patients share their personal values and preferences for their future care and prepare for declining health. Earlier, more integrated and holistic advance care planning has the potential to improve access to care services, communication, and preparedness for future decision-making and changing circumstances. However, there are many barriers to successful implementation of advance care planning in this population. In this narrative review we discuss the current evidence for advance care planning in patients on dialysis, the data around the barriers to advance care planning implementation, and interventions that have been trialled. The review explores whether the concepts and approaches to advance care planning in this population need to be updated to encompass current and future care. It suggests that a shift from a problem-orientated approach to a goal-orientated approach may lead to better engagement, with more patient-centred and satisfying outcomes.
Collapse
Affiliation(s)
- S F Adenwalla
- Department of Cardiovascular Sciences, University of Leicester, Leicester, LE1 9HN, UK.
- NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK.
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK.
| | - P O'Halloran
- School of Nursing and Midwifery, Medical Biology Centre, Queen's University Belfast, Belfast, UK
| | - C Faull
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - F E M Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - M P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, LE1 9HN, UK
- NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK
| |
Collapse
|
5
|
Parke KS, Brady EM, Alfuhied A, Motiwale RS, Razieh CS, Singh A, Arnold JR, Graham-Brown MPM, Bilak JM, Ayton SL, Dattani A, Yeo JL, McCann GP, Gulsin GS. Ethnic differences in cardiac structure and function assessed by MRI in healthy South Asian and White European people: A UK Biobank Study. J Cardiovasc Magn Reson 2024; 26:100001. [PMID: 38218434 DOI: 10.1016/j.jocmr.2023.100001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 12/03/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Echocardiographic studies indicate South Asian people have smaller ventricular volumes, lower mass and more concentric remodelling than White European people, but there are no data using cardiac MRI (CMR). We aimed to compare CMR quantified cardiac structure and function in White European and South Asian people. METHODS Healthy White European and South Asian participants in the UK Biobank Imaging CMR sub-study were identified by excluding those with a history of cardiovascular disease, hypertension, obesity or diabetes. Ethnic groups were matched by age and sex. Cardiac volumes, mass and feature tracking strain were compared. RESULTS 121 matched pairs (77 male/44 female, mean age 58 ± 8 years) of South Asian and White European participants were included. South Asian males and females had smaller absolute but not indexed left ventricular (LV) volumes, and smaller absolute and indexed right ventricular volumes, with lower absolute and indexed LV mass and lower LV mass:volume than White European participants. Although there were no differences in ventricular or atrial ejection fractions, LV global longitudinal strain was higher in South Asian females than White European females but not males, and global circumferential strain was higher in both male and South Asian females than White European females. Peak early diastolic strain rates were higher in South Asian versus White European males, but not different between South Asian and White European females. CONCLUSIONS Contrary to echocardiographic studies, South Asian participants in the UK Biobank study had less concentric remodelling and higher global circumferential strain than White European subjects. These findings emphasise the importance of sex- and ethnic- specific normal ranges for cardiac volumes and function.
Collapse
Affiliation(s)
- Kelly S Parke
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Emer M Brady
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Aseel Alfuhied
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Rishabh S Motiwale
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Cameron S Razieh
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, UK; Leicester Real World Evidence Unit, Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, UK
| | - Anvesha Singh
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Jayanth R Arnold
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Joanna M Bilak
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Sarah L Ayton
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Abhishek Dattani
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Jian L Yeo
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK.
| | - Gaurav S Gulsin
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| |
Collapse
|
6
|
Young HML, Castle EM, Briggs J, Walklin C, Billany RE, Asgari E, Bhandari S, Bishop N, Bramham K, Burton JO, Campbell J, Chilcot J, Cooper N, Deelchand V, Graham-Brown MPM, Haggis L, Hamilton A, Jesky M, Kalra PA, Koufaki P, Macdonald J, McCafferty K, Nixon AC, Noble H, Saynor ZL, Taal MW, Tollitt J, Wheeler DC, Wilkinson TJ, Greenwood SA. The development and internal pilot trial of a digital physical activity and emotional well-being intervention (Kidney BEAM) for people with chronic kidney disease. Sci Rep 2024; 14:700. [PMID: 38184737 PMCID: PMC10771473 DOI: 10.1038/s41598-023-50507-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/20/2023] [Indexed: 01/08/2024] Open
Abstract
This trial assessed the feasibility and acceptability of Kidney BEAM, a physical activity and emotional well-being self-management digital health intervention (DHI) for people with chronic kidney disease (CKD), which offers live and on-demand physical activity sessions, educational blogs and videos, and peer support. In this mixed-methods, multicentre randomised waitlist-controlled internal pilot, adults with established CKD were recruited from five NHS hospitals and randomised 1:1 to Kidney BEAM or waitlist control. Feasibility outcomes were based upon a priori progression criteria. Acceptability was primarily explored via individual semi-structured interviews (n = 15). Of 763 individuals screened, n = 519 (68%, 95% CI 65 to 71%) were eligible. Of those eligible, n = 303 (58%, 95% CI 54-63%) did not respond to an invitation to participate by the end of the pilot period. Of the 216 responders, 50 (23%, 95% CI 18-29%) consented. Of the 42 randomised, n = 22 (10 (45%) male; 49 ± 16 years; 14 (64%) White British) were allocated to Kidney BEAM and n = 20 (12 (55%) male; 56 ± 11 years; 15 (68%) White British) to the waitlist control group. Overall, n = 15 (30%, 95% CI 18-45%) withdrew during the pilot phase. Participants completed a median of 14 (IQR 5-21) sessions. At baseline, 90-100% of outcome data (patient reported outcome measures and a remotely conducted physical function test) were completed and 62-83% completed at 12 weeks follow-up. Interview data revealed that remote trial procedures were acceptable. Participants' reported that Kidney BEAM increased their opportunity and motivation to be physically active, however, lack of time remained an ongoing barrier to engagement with the DHI. An randomised controlled trial of Kidney BEAM is feasible and acceptable, with adaptations to increase recruitment, retention and engagement.Trial registration NCT04872933. Date of first registration 05/05/2021.
Collapse
Affiliation(s)
- Hannah M L Young
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK.
- Diabetes Research Centre, University of Leicester, Leicester, UK.
- National Institute of Health Research Leicester Biomedical Research Centre, Leicester, UK.
| | - Ellen M Castle
- School of Physiotherapy, Department of Health Sciences, Brunel University, London, UK
| | - Juliet Briggs
- Renal Department, King's College Hospital, London, UK
| | | | - Roseanne E Billany
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Elham Asgari
- Department of Nephrology, Guys and St Thomas's Hospital, London, UK
| | - Sunil Bhandari
- Department of Nephrology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Nicolette Bishop
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Kate Bramham
- Renal Department, King's College Hospital, London, UK
| | - James O Burton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Jackie Campbell
- Faculty of Health, Education and Society, University of Northampton, Northampton, UK
| | - Joseph Chilcot
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Nicola Cooper
- Department of Population Health Science, University of Leicester, Leicester, UK
| | | | | | - Lynda Haggis
- Renal Department, King's College Hospital, London, UK
| | - Alexander Hamilton
- Department of Nephrology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Mark Jesky
- Department of Nephrology, Nottingham NHS Trust, Nottingham, UK
| | - Philip A Kalra
- Department of Nephrology Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Pelagia Koufaki
- Dietetics, Nutrition & Biological Sciences, Physiotherapy, Podiatry & Radiography Division, Queen Margaret University, Edinburgh, UK
| | - Jamie Macdonald
- Institute for Applied Human Physiology, Bangor University, Bangor, UK
| | | | - Andrew C Nixon
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
| | - Helen Noble
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Zoe L Saynor
- School of Sport, Health and Exercise Science, University of Portsmouth, Portsmouth, UK
| | - Maarten W Taal
- Centre for Kidney Research and Innovation, University of Nottingham, Nottingham, UK
| | - James Tollitt
- Department of Nephrology Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - Thomas J Wilkinson
- National Institute of Health Research Leicester Biomedical Research Centre, Leicester, UK
| | | |
Collapse
|
7
|
Brady EM, Cao TH, Moss AJ, Athithan L, Ayton SL, Redman E, Argyridou S, Graham-Brown MPM, Maxwell CB, Jones DJL, Ng L, Yates T, Davies MJ, McCann GP, Gulsin GS. Circulating sphingolipids and relationship to cardiac remodelling before and following a low-energy diet in asymptomatic Type 2 Diabetes. BMC Cardiovasc Disord 2024; 24:25. [PMID: 38172712 PMCID: PMC10765891 DOI: 10.1186/s12872-023-03623-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/19/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Heart failure with preserved ejection fraction (HFpEF) is a heterogenous multi-system syndrome with limited efficacious treatment options. The prevalence of Type 2 diabetes (T2D) continues to rise and predisposes patients to HFpEF, and HFpEF remains one of the biggest challenges in cardiovascular medicine today. Novel therapeutic targets are required to meet this important clinical need. Deep phenotyping studies including -OMIC analyses can provide important pathogenic information to aid the identification of such targets. The aims of this study were to determine; 1) the impact of a low-energy diet on plasma sphingolipid/ceramide profiles in people with T2D compared to healthy controls and, 2) if the change in sphingolipid/ceramide profile is associated with reverse cardiovascular remodelling. METHODS Post-hoc analysis of a randomised controlled trial (NCT02590822) including adults with T2D with no cardiovascular disease who completed a 12-week low-energy (∼810 kcal/day) meal-replacement plan (MRP) and matched healthy controls (HC). Echocardiography, cardiac MRI and a fasting blood for lipidomics were undertaken pre/post-intervention. Candidate biomarkers were identified from case-control comparison (fold change > 1.5 and statistical significance p < 0.05) and their response to the MRP reported. Association between change in biomarkers and change indices of cardiac remodelling were explored. RESULTS Twenty-four people with T2D (15 males, age 51.1 ± 5.7 years), and 25 HC (15 male, 48.3 ± 6.6 years) were included. Subjects with T2D had increased left ventricular (LV) mass:volume ratio (0.84 ± 0.13 vs. 0.70 ± 0.08, p < 0.001), increased systolic function but impaired diastolic function compared to HC. Twelve long-chain polyunsaturated sphingolipids, including four ceramides, were downregulated in subjects with T2D at baseline. Three sphingomyelin species and all ceramides were inversely associated with LV mass:volume. There was a significant increase in all species and shift towards HC following the MRP, however, none of these changes were associated with reverse cardiac remodelling. CONCLUSION The lack of association between change in sphingolipids/ceramides and reverse cardiac remodelling following the MRP casts doubt on a causative role of sphingolipids/ceramides in the progression of heart failure in T2D. TRIAL REGISTRATION NCT02590822.
Collapse
Affiliation(s)
- Emer M Brady
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
- Leicester Van Geest Multi-Omics Facility, University of Leicester, Leicester, UK
| | - Thong H Cao
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
- Leicester Van Geest Multi-Omics Facility, University of Leicester, Leicester, UK
| | - Alastair J Moss
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
- Leicester Van Geest Multi-Omics Facility, University of Leicester, Leicester, UK
| | - Lavanya Athithan
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
| | - Sarah L Ayton
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
| | - Emma Redman
- Diabetes Research Centre, NIHR Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, UK
| | - Stavroula Argyridou
- Diabetes Research Centre, NIHR Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, UK
| | - Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
| | - Colleen B Maxwell
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
- Leicester Van Geest Multi-Omics Facility, University of Leicester, Leicester, UK
| | - Donald J L Jones
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
- Leicester Van Geest Multi-Omics Facility, University of Leicester, Leicester, UK
| | - Leong Ng
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
- Leicester Van Geest Multi-Omics Facility, University of Leicester, Leicester, UK
| | - Thomas Yates
- Diabetes Research Centre, NIHR Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, UK
| | - Melanie J Davies
- Diabetes Research Centre, NIHR Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
- Leicester Van Geest Multi-Omics Facility, University of Leicester, Leicester, UK
| | - Gaurav S Gulsin
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK.
| |
Collapse
|
8
|
Greenwood SA, Young HML, Briggs J, Castle EM, Walklin C, Haggis L, Balkin C, Asgari E, Bhandari S, Burton JO, Billany RE, Bishop NC, Bramham K, Campbell J, Chilcot J, Cooper NJ, Deelchand V, Graham-Brown MPM, Hamilton A, Jesky M, Kalra PA, Koufaki P, McCafferty K, Nixon AC, Noble H, Saynor Z, Taal MW, Tollit J, Wheeler DC, Wilkinson TJ, Worboys H, Macdonald JH. Evaluating the effect of a digital health intervention to enhance physical activity in people with chronic kidney disease (Kidney BEAM): a multicentre, randomised controlled trial in the UK. Lancet Digit Health 2024; 6:e23-e32. [PMID: 37968170 DOI: 10.1016/s2589-7500(23)00204-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/04/2023] [Accepted: 09/27/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Remote digital health interventions to enhance physical activity provide a potential solution to improve the sedentary behaviour, physical inactivity, and poor health-related quality of life that are typical of chronic conditions, particularly for people with chronic kidney disease. However, there is a need for high-quality evidence to support implementation in clinical practice. The Kidney BEAM trial evaluated the clinical effect of a 12-week physical activity digital health intervention on health-related quality of life. METHODS In a single-blind, randomised controlled trial conducted at 11 centres in the UK, adult participants (aged ≥18 years) with chronic kidney disease were recruited and randomly assigned (1:1) to the Kidney BEAM physical activity digital health intervention or a waiting list control group. Randomisation was performed with a web-based system, in randomly permuted blocks of six. Outcome assessors were masked to treatment allocation. The primary outcome was the difference in the Kidney Disease Quality of Life Short Form version 1.3 Mental Component Summary (KDQoL-SF1.3 MCS) between baseline and 12 weeks. The trial was powered to detect a clinically meaningful difference of 3 arbitrary units (AU) in KDQoL-SF1.3 MCS. Outcomes were analysed by an intention-to-treat approach using an analysis of covariance model, with baseline measures and age as covariates. The trial was registered with ClinicalTrials.gov, NCT04872933. FINDINGS Between May 6, 2021, and Oct 30, 2022, 1102 individuals were assessed for eligibility, of whom 340 participants were enrolled and randomly assigned to the Kidney BEAM intervention group (n=173) or the waiting list control group (n=167). 268 participants completed the trial (112 in the Kidney BEAM group and 156 in the waiting list control group). All 340 randomly assigned participants were included in the intention-to treat population. At 12 weeks, there was a significant improvement in KDQoL-SF.13 MCS score in the Kidney BEAM group (from mean 44·6 AU [SD 10·8] at baseline to 47·0 AU [10·6] at 12 weeks) compared with the waiting list control group (from 46·1 AU [10·5] to 45·0 AU [10·1]; between-group difference of 3·1 AU [95% CI 1·8-4·4]; p<0·0001). INTERPRETATION The Kidney BEAM physical activity platform is an efficacious digital health intervention to improve mental health-related quality of life in patients with chronic kidney disease. These findings could facilitate the incorporation of remote digital health interventions into clinical practice and offer a potential intervention worthy of investigation in other chronic conditions. FUNDING Kidney Research UK.
Collapse
Affiliation(s)
- Sharlene A Greenwood
- Department of Renal Medicine, King's College Hospital NHS Trust, London, UK; Renal Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
| | - Hannah M L Young
- NIHR Leicester Biomedical Research Centre, Leicester, UK; Leicester Diabetes Centre, University of Leicester, Leicester, UK; Physiotherapy Department, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Juliet Briggs
- Department of Renal Medicine, King's College Hospital NHS Trust, London, UK
| | - Ellen M Castle
- School of Physiotherapy, Department of Health Sciences, Brunel University, London, UK
| | - Christy Walklin
- Department of Renal Medicine, King's College Hospital NHS Trust, London, UK
| | - Lynda Haggis
- Department of Renal Medicine, King's College Hospital NHS Trust, London, UK
| | - Caitlin Balkin
- Department of Renal Medicine, King's College Hospital NHS Trust, London, UK
| | - Elham Asgari
- Department of Renal Medicine, Guy's and St Thomas' NHS Trust, London, UK
| | - Sunil Bhandari
- Department of Renal Medicine, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - James O Burton
- NIHR Leicester Biomedical Research Centre, Leicester, UK; Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Roseanne E Billany
- NIHR Leicester Biomedical Research Centre, Leicester, UK; Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Nicolette C Bishop
- School of Sport Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Kate Bramham
- Women's Health, King's College London, London, UK
| | - Jackie Campbell
- Faculty of Health, Education and Society, University of Northampton, Northampton, UK
| | - Joseph Chilcot
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Nicola J Cooper
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | | | - Matthew P M Graham-Brown
- NIHR Leicester Biomedical Research Centre, Leicester, UK; Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | | | - Mark Jesky
- Department of Renal Medicine, Nottingham NHS Trust, Nottingham, UK
| | - Philip A Kalra
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Pelagia Koufaki
- Department of Renal Medicine, Queen Margaret University, Edinburgh, UK
| | | | - Andrew C Nixon
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK; Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Helen Noble
- School of Nursing and Midwifery, Queen's University, Belfast, UK
| | - Zoe Saynor
- School of Sport, Health and Exercise Science, University of Portsmouth, Portsmouth, UK
| | - Maarten W Taal
- Centre for Kidney Research and Innovation, School of Medicine, University of Nottingham, Nottingham, UK
| | - James Tollit
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - Thomas J Wilkinson
- NIHR Leicester Biomedical Research Centre, Leicester, UK; Leicester Diabetes Centre, University of Leicester, Leicester, UK
| | - Hannah Worboys
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Jamie H Macdonald
- Institute for Applied Human Physiology, Bangor University, Bangor, UK
| |
Collapse
|
9
|
Bohoran TA, Parke KS, Graham-Brown MPM, Meisuria M, Singh A, Wormleighton J, Adlam D, Gopalan D, Davies MJ, Williams B, Brown M, McCann GP, Giannakidis A. Resource efficient aortic distensibility calculation by end to end spatiotemporal learning of aortic lumen from multicentre multivendor multidisease CMR images. Sci Rep 2023; 13:21794. [PMID: 38066222 PMCID: PMC10709583 DOI: 10.1038/s41598-023-48986-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 12/02/2023] [Indexed: 12/18/2023] Open
Abstract
Aortic distensibility (AD) is important for the prognosis of multiple cardiovascular diseases. We propose a novel resource-efficient deep learning (DL) model, inspired by the bi-directional ConvLSTM U-Net with densely connected convolutions, to perform end-to-end hierarchical learning of the aorta from cine cardiovascular MRI towards streamlining AD quantification. Unlike current DL aortic segmentation approaches, our pipeline: (i) performs simultaneous spatio-temporal learning of the video input, (ii) combines the feature maps from the encoder and decoder using non-linear functions, and (iii) takes into account the high class imbalance. By using multi-centre multi-vendor data from a highly heterogeneous patient cohort, we demonstrate that the proposed method outperforms the state-of-the-art method in terms of accuracy and at the same time it consumes [Formula: see text] 3.9 times less fuel and generates [Formula: see text] 2.8 less carbon emissions. Our model could provide a valuable tool for exploring genome-wide associations of the AD with the cognitive performance in large-scale biomedical databases. By making energy usage and carbon emissions explicit, the presented work aligns with efforts to keep DL's energy requirements and carbon cost in check. The improved resource efficiency of our pipeline might open up the more systematic DL-powered evaluation of the MRI-derived aortic stiffness.
Collapse
Affiliation(s)
- Tuan Aqeel Bohoran
- School of Science and Technology, Nottingham Trent University, Nottingham, NG11 8NS, UK
| | - Kelly S Parke
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
| | - Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
| | - Mitul Meisuria
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
| | - Anvesha Singh
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
| | - Joanne Wormleighton
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
| | - David Adlam
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
| | - Deepa Gopalan
- Imperial College London & Cambridge University Hospitals, Cambridge, CB2 0QQ, UK
| | - Melanie J Davies
- Leicester Diabetes Centre, University of Leicester and the NIHR Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, LE5 4PW, UK
| | - Bryan Williams
- Institute of Cardiovascular Science, University College London (UCL), National Institute for Health Research (NIHR), UCL Hospitals Biomedical Research Centre, London, WC1E 6DD, UK
| | - Morris Brown
- Department of Clinical Pharmacology, William Harvey Research Institute, Queen Mary University of London, London, EC1M 6BQ, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
| | - Archontis Giannakidis
- School of Science and Technology, Nottingham Trent University, Nottingham, NG11 8NS, UK.
| |
Collapse
|
10
|
Hull KL, Bramham K, Brookes CL, Cluley V, Conefrey C, Cooper NJ, Eborall H, Fotheringham J, Graham-Brown MPM, Gray LJ, Mark PB, Mitra S, Murphy GJ, Quann N, Rooshenas L, Warren M, Burton JO. The NightLife study - the clinical and cost-effectiveness of thrice-weekly, extended, in-centre nocturnal haemodialysis versus daytime haemodialysis using a mixed methods approach: study protocol for a randomised controlled trial. Trials 2023; 24:522. [PMID: 37573352 PMCID: PMC10422763 DOI: 10.1186/s13063-023-07565-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 08/03/2023] [Indexed: 08/14/2023] Open
Abstract
BACKGROUND In-centre nocturnal haemodialysis (INHD) offers extended-hours haemodialysis, 6 to 8 h thrice-weekly overnight, with the support of dialysis specialist nurses. There is increasing observational data demonstrating potential benefits of INHD on health-related quality of life (HRQoL). There is a lack of randomised controlled trial (RCT) data to confirm these benefits and assess safety. METHODS The NightLife study is a pragmatic, two-arm, multicentre RCT comparing the impact of 6 months INHD to conventional haemodialysis (thrice-weekly daytime in-centre haemodialysis, 3.5-5 h per session). The primary outcome is the total score from the Kidney Disease Quality of Life tool at 6 months. Secondary outcomes include sleep and cognitive function, measures of safety, adherence to dialysis and impact on clinical parameters. There is an embedded Process Evaluation to assess implementation, health economic modelling and a QuinteT Recruitment Intervention to understand factors that influence recruitment and retention. Adults (≥ 18 years old) who have been established on haemodialysis for > 3 months are eligible to participate. DISCUSSION There are 68,000 adults in the UK that need kidney replacement therapy (KRT), with in-centre haemodialysis the treatment modality for over a third of cases. HRQoL is an independent predictor of hospitalisation and mortality in individuals on maintenance dialysis. Haemodialysis is associated with poor HRQoL in comparison to the general population. INHD has the potential to improve HRQoL. Vigorous RCT evidence of effectiveness is lacking. The NightLife study is an essential step in the understanding of dialysis therapies and will guide patient-centred decisions regarding KRT in the future. TRIAL REGISTRATION Trial registration number: ISRCTN87042063. Registered: 14/07/2020.
Collapse
Affiliation(s)
- Katherine L Hull
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK.
| | - Kate Bramham
- King's Kidney Care, King's College Hospital, London, UK
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | | | - Victoria Cluley
- School of Sociology and Social Policy, University of Nottingham, Nottingham, UK
| | - Carmel Conefrey
- Bristol Population Health Science Institute, University of Bristol Medical School, Bristol, UK
| | - Nicola J Cooper
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Helen Eborall
- College of Medicine and Veterinary Medicine, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - James Fotheringham
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
- Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Laura J Gray
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Sandip Mitra
- Manchester Institute of Nephrology and Transplantation, Manchester Academic Health Science Centre, Research and Innovation, Manchester University NHS Foundation Trust, Manchester, UK
| | - Gavin J Murphy
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
- Cardiovascular Research Centre, University of Leicester, Leicester, UK
| | - Niamh Quann
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Leila Rooshenas
- Bristol Population Health Science Institute, University of Bristol Medical School, Bristol, UK
| | | | - James O Burton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| |
Collapse
|
11
|
Walklin CG, Young HML, Asghari E, Bhandari S, Billany RE, Bishop N, Bramham K, Briggs J, Burton JO, Campbell J, Castle EM, Chilcot J, Cooper N, Deelchand V, Graham-Brown MPM, Hamilton A, Jesky M, Kalra PA, Koufaki P, McCafferty K, Nixon AC, Noble H, Saynor ZL, Sothinathan C, Taal MW, Tollitt J, Wheeler DC, Wilkinson TJ, Macdonald JH, Greenwood SA. The effect of a novel, digital physical activity and emotional well-being intervention on health-related quality of life in people with chronic kidney disease: trial design and baseline data from a multicentre prospective, wait-list randomised controlled trial (kidney BEAM). BMC Nephrol 2023; 24:122. [PMID: 37131125 PMCID: PMC10152439 DOI: 10.1186/s12882-023-03173-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 04/18/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Physical activity and emotional self-management has the potential to enhance health-related quality of life (HRQoL), but few people with chronic kidney disease (CKD) have access to resources and support. The Kidney BEAM trial aims to evaluate whether an evidence-based physical activity and emotional wellbeing self-management programme (Kidney BEAM) leads to improvements in HRQoL in people with CKD. METHODS This was a prospective, multicentre, randomised waitlist-controlled trial, with health economic analysis and nested qualitative studies. In total, three hundred and four adults with established CKD were recruited from 11 UK kidney units. Participants were randomly assigned to the intervention (Kidney BEAM) or a wait list control group (1:1). The primary outcome was the between-group difference in Kidney Disease Quality of Life (KDQoL) mental component summary score (MCS) at 12 weeks. Secondary outcomes included the KDQoL physical component summary score, kidney-specific scores, fatigue, life participation, depression and anxiety, physical function, clinical chemistry, healthcare utilisation and harms. All outcomes were measured at baseline and 12 weeks, with long-term HRQoL and adherence also collected at six months follow-up. A nested qualitative study explored experience and impact of using Kidney BEAM. RESULTS 340 participants were randomised to Kidney BEAM (n = 173) and waiting list (n = 167) groups. There were 96 (55%) and 89 (53%) males in the intervention and waiting list groups respectively, and the mean (SD) age was 53 (14) years in both groups. Ethnicity, body mass, CKD stage, and history of diabetes and hypertension were comparable across groups. The mean (SD) of the MCS was similar in both groups, 44.7 (10.8) and 45.9 (10.6) in the intervention and waiting list groups respectively. CONCLUSION Results from this trial will establish whether the Kidney BEAM self management programme is a cost-effective method of enhancing mental and physical wellbeing of people with CKD. TRIAL REGISTRATION NCT04872933. Registered 5th May 2021.
Collapse
Affiliation(s)
- C G Walklin
- Renal Therapies, King's College Hospital NHS Trust, London, UK
| | - Hannah M L Young
- Leicester Diabetes Centre, Leicester General Hospital, Leicester, UK.
| | - E Asghari
- Department of Nephrology, Guy's and St Thomas' NHS Trust, London, UK
| | - S Bhandari
- Department of Nephrology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - R E Billany
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - N Bishop
- School of Sport, Exercise and Health Sciences, University of Loughborough, Loughborough, UK
| | - K Bramham
- Department of Women's Health, King's College London, London, UK
| | - J Briggs
- Renal Therapies, King's College Hospital NHS Trust, London, UK
| | - J O Burton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - J Campbell
- Faculty of Health, Education and Society, University of Northampton, Northampton, UK
| | - E M Castle
- School of Physiotherapy, Department of Health Sciences, Brunel University, London, UK
| | - J Chilcot
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - N Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - V Deelchand
- Department of Nephrology, Royal Free Hospital, London, UK
| | | | - A Hamilton
- Department of Nephrology, Royal Exeter Hospital, Devon, UK
| | - M Jesky
- Department of Nephrology, Nottingham NHS Trust, Nottingham, UK
| | - P A Kalra
- Department of Nephrology, Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - P Koufaki
- Dietetics, Nutrition and Biological Sciences, Queen Margaret University, Edinburgh, UK
| | - K McCafferty
- Department of Nephrology, Barts Health NHS Trust, London, UK
| | - A C Nixon
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
| | - H Noble
- School of Nursing and Midwifery, Queen's University, Belfast, UK
| | - Z L Saynor
- School of Sport, Health and Exercise Science, University of Portsmouth, Portsmouth, UK
| | - C Sothinathan
- Department of Physiotherapy, Chelsea and Westminster NHS Trust, London, UK
| | - M W Taal
- Centre for Kidney Research and Innovation, University of Nottingham, Nottingham, UK
| | - J Tollitt
- Department of Renal Medicine, University College London, London, UK
| | - D C Wheeler
- National Institute of Health Research Leicester Biomedical Research Centre , Leicester, UK
| | - T J Wilkinson
- Institute for Applied Human Physiology, Bangor University, Bangor, Gwynedd, UK
| | - J H Macdonald
- Faculty of life sciences and medicine, King's College London, London, UK
| | - S A Greenwood
- Renal Therapies, King's College Hospital NHS Trust, London, UK
| |
Collapse
|
12
|
Pallikadavath S, Richards C, Bountziouka V, Sandilands AJ, Graham-Brown MPM, Robinson T, Singh A, McCann GP. The AFLETES Study: Atrial Fibrillation in Veteran Athletes and the Risk of Stroke. Clin J Sport Med 2023; 33:209-216. [PMID: 37042823 DOI: 10.1097/jsm.0000000000001115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 11/01/2022] [Indexed: 04/13/2023]
Abstract
OBJECTIVES Endurance athletes are at an increased risk of atrial fibrillation (AF) when compared with the general population. However, the risk of stroke in athletes with AF is unknown. DESIGN AND SETTING We aimed to assess this risk using an international online survey. PATIENTS Individuals that had competed in ≥1 competitive events and were ≥40 years old were included. INTERVENTIONS Self-reported demographic, medical history, and training history data were collected, and a CHA 2 DS 2 -VASc was calculated. MAIN OUTCOME MEASURES Binary logistic regression was used to assess variables associated with AF and stroke. RESULTS There were 1002 responses from participants in 41 countries across Africa, Asia, Australasia, Europe, and North and South America, and 942 were included in the final analysis. The average age was 52.4 ± 8.5 years, and 84% were male. The most common sports were cycling (n = 677, 72%), running (n = 558, 59%), and triathlon (n = 245, 26%). There were 190 (20%) individuals who reported AF and 26 individuals (3%) who reported stroke; of which, 14 (54%) had AF. Lifetime exercise dose [odds ratio (OR), 1.02, 95% confidence interval (95% CI),1.00-1.03, P = 0.02] and swimming (OR, 1.56, 95% CI, 1.02-2.39, P = 0.04) were associated with AF in multivariable analysis, independent of other risk factors. Atrial fibrillation was associated with stroke (OR, 4.18, 95% CI, 1.80-9.72, P < 0.01), even in individuals with a low (0/1) CHA 2 DS 2 -VASc score (OR, 4.20, 95% CI, 1.83-9.66, P < 0.01). CONCLUSIONS This survey provides early evidence that veteran endurance athletes who develop AF may be at an increased risk of developing stroke, even in those deemed to be at low risk by CHA 2 DS 2 -VASc score.
Collapse
Affiliation(s)
- Susil Pallikadavath
- Department of Cardiovascular Sciences, University of Leicester and the National Institute of Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | | | | | | | | | | | | | | |
Collapse
|
13
|
Bishop NC, Burton JO, Graham-Brown MPM, Stensel DJ, Viana JL, Watson EL. Exercise and chronic kidney disease: potential mechanisms underlying the physiological benefits. Nat Rev Nephrol 2023; 19:244-256. [PMID: 36650232 DOI: 10.1038/s41581-022-00675-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 01/19/2023]
Abstract
Increasing evidence indicates that exercise has beneficial effects on chronic inflammation, cardiorespiratory function, muscle and bone strength and metabolic markers in adults with chronic kidney disease (CKD), kidney failure or kidney transplants. However, the mechanisms that underlie these benefits have received little attention, and the available clinical evidence is mainly from small, short-duration (<12 weeks) exercise intervention studies. The available data, mainly from patients with CKD or on dialysis, suggest that exercise-mediated shifts towards a less inflammatory immune cell profile, enhanced activity of the NRF2 pathway and reduced monocyte infiltration into adipose tissue may underlie improvements in inflammatory biomarkers. Exercise-mediated increases in nitric oxide release and bioavailability, reduced angiotensin II accumulation in the heart, left ventricular remodelling and reductions in myocardial fibrosis may contribute to improvements in left ventricular hypertrophy. Exercise stimulates an anabolic response in skeletal muscle in CKD, but increases in mitochondrial mass and satellite cell activation seem to be impaired in this population. Exercise-mediated activation of the canonical wnt pathway may lead to bone formation and improvements in the levels of the bone-derived hormones klotho and fibroblast growth factor 23 (FGF23). Longer duration studies with larger sample sizes are needed to confirm these mechanisms in CKD, kidney failure and kidney transplant populations and provide evidence for targeted exercise interventions.
Collapse
Affiliation(s)
- Nicolette C Bishop
- School of Sport, Exercise and Health Sciences and National Centre for Sport and Exercise Medicine, Loughborough University, Loughborough, UK.
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester, UK.
| | - James O Burton
- School of Sport, Exercise and Health Sciences and National Centre for Sport and Exercise Medicine, Loughborough University, Loughborough, UK
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester, UK
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Matthew P M Graham-Brown
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester, UK
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - David J Stensel
- School of Sport, Exercise and Health Sciences and National Centre for Sport and Exercise Medicine, Loughborough University, Loughborough, UK
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester, UK
- Faculty of Sport Sciences, Waseda University, Tokorozawa, Japan
- Department of Sports Science and Physical Education, The Chinese University of Hong Kong, Hong Kong, China
| | - João L Viana
- Research Centre in Sports Sciences, Health Sciences and Human Development, University of Maia, Maia, Portugal
| | - Emma L Watson
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester, UK
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| |
Collapse
|
14
|
Graham-Brown MPM, Smith AC, Greenwood SA. Digital health interventions in chronic kidney disease: levelling the playing field? Clin Kidney J 2022; 16:763-767. [PMID: 37151422 PMCID: PMC10157767 DOI: 10.1093/ckj/sfac259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Indexed: 12/12/2022] Open
Abstract
Abstract
Digital health interventions (DHIs) have long been thought of as a convenient way to deliver aspects of healthcare and broaden access to services. For patients with chronic kidney disease, DHIs designed to improve health literacy, self-efficacy and health-related behaviours like physical activity, diet and adherence have been developed and are being tested, but their translation into clinical practice will challenging. Whilst DHIs potentially have broad reach, it is increasingly clear that patients from lower socioeconomic and educational backgrounds, minority ethnic groups, elderly patients and those who face digital poverty are the least likely to access and benefit from DHIs, when they are precisely the patients who stand to gain the most. This article discusses the potential for DHIs to level the playing field for patients with chronic kidney disease as well as the steps researchers, clinicians and developers should consider to ensure DHIs are developed, in collaboration with patients, to be inclusive and effective as well as strategies that should be considered during development to support translation into practice.
Collapse
Affiliation(s)
- Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester , Leicester , UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust , Leicester , UK
| | - Alice C Smith
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust , Leicester , UK
- Department of Health Sciences, University of Leicester , Leicester , UK
| | - Sharlene A Greenwood
- King's College Hospital NHS Foundation Trust , London , UK
- School of Renal Medicine , King's College London, London , UK
| |
Collapse
|
15
|
Ayton SL, Yeo JL, Gulsin GS, Brady EM, Arnold JR, Graham-Brown MPM, Singh A, Dey D, McCann GP, Moss AJ. Epicardial adipose tissue volume and density is associated with cardiac dysfunction in asymptomatic people with type 2 diabetes. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Type 2 diabetes (T2D) is associated with several perturbations of cardiac structure and function, which are precursors to the development of heart failure. Excess accumulation of epicardial adipose tissue (EAT) may contribute to cardiac dysfunction in individuals with T2D. Lipid-laden adipocytes have a lower computed tomography (CT) attenuation and can be readily identified using cardiac CT. Using a multimodality cardiac imaging approach, we aimed to assess the association of total and low attenuation EAT volume with early markers of cardiac dysfunction in people with T2D.
Methods
Prospective case-control study, in which participants with and without T2D and no known cardiovascular disease, underwent comprehensive cardiovascular phenotyping including multiparametric cardiac magnetic resonance imaging (MRI), echocardiography and non-contrast cardiac CT. EAT volume was measured from CT scans using a deep learning method and volumes indexed to body surface area. Total EAT was defined according to CT adipose tissue attenuation range of −30 to −190 Hounsfield Units (HU) and low attenuation EAT as −90 to −190 HU. Left ventricular (LV) volumes, function and strain measurements were derived from cardiac MRI images and diastolic function also assessed using echocardiography. Markers of early cardiac dysfunction in those with T2D were assessed for associations with EAT in T2D participants using multivariable linear regression analyses.
Results
Two hundred and fifty-four participants were included: demographic, anthropometric and imaging variables are displayed in Table 1. Subjects with T2D had increased LV concentric remodelling (higher LV mass/volume ratio), diastolic dysfunction (lower circumferential peak early diastolic strain rate (PEDSR) and average E/e') and reduced systolic function (global longitudinal strain, GLS) compared with controls. Total and low attenuation indexed EAT volumes were 1.6-fold and 2-fold higher, respectively, in participants with T2D compared to controls (Figure 1). After adjustment for age, gender, ethnicity, insulin resistance, systolic blood pressure and waist/hip ratio, total and low attenuation indexed EAT volume were independently associated with LV mass/volume ratio (total indexed EAT volume: β=0.002, p=0.02, low attenuation indexed EAT volume: β=0.004, p=0.01) and LV GLS (total indexed EAT volume: β=−0.02, p<0.01, low attenuation indexed EAT volume: β=−0.04, p=0.02) in subjects with T2D, but not indices of diastolic dysfunction.
Conclusion
Total and low attenuation EAT volumes are higher in individuals with T2D, and excess EAT accumulation is independently associated with early markers of cardiac dysfunction. Further studies into the underlying mechanisms of this interaction may facilitate the development of interventions targeted at EAT, which could mitigate against the development of heart failure in people with T2D.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): United Kingdom National Institute for Health Research
Collapse
Affiliation(s)
- S L Ayton
- University of Leicester and the NIHR Leicester Biomedical Research Centre , Leicester , United Kingdom
| | - J L Yeo
- University of Leicester and the NIHR Leicester Biomedical Research Centre , Leicester , United Kingdom
| | - G S Gulsin
- University of Leicester and the NIHR Leicester Biomedical Research Centre , Leicester , United Kingdom
| | - E M Brady
- University of Leicester and the NIHR Leicester Biomedical Research Centre , Leicester , United Kingdom
| | - J R Arnold
- University of Leicester and the NIHR Leicester Biomedical Research Centre , Leicester , United Kingdom
| | - M P M Graham-Brown
- University of Leicester and the NIHR Leicester Biomedical Research Centre , Leicester , United Kingdom
| | - A Singh
- University of Leicester and the NIHR Leicester Biomedical Research Centre , Leicester , United Kingdom
| | - D Dey
- Cedars-Sinai Medical Center, Biomedical Imaging Research Institute , Los Angeles , United States of America
| | - G P McCann
- University of Leicester and the NIHR Leicester Biomedical Research Centre , Leicester , United Kingdom
| | - A J Moss
- University of Leicester and the NIHR Leicester Biomedical Research Centre , Leicester , United Kingdom
| |
Collapse
|
16
|
Pallikadavath S, Richards C, Bountziouka V, Sandilands AJ, Graham-Brown MPM, Robinson T, Singh A, McCann GP. The AFLETES study: atrial fibrillation in veteran athLETEs and the risk of stroke. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Endurance athletes are at an increased risk of atrial fibrillation (AF) when compared to the general population. However, the risk of stroke in athletes who develop AF is not known.
Purpose
We aimed to assess the risk of stroke in endurance veteran athletes with AF when compared to those that remain in sinus rhythm.
Methods
A questionnaire was broadcasted through social media and sports clubs. Individuals that had competed in at least one competitive event and were ≥40 years old were included. Self-reported demographic, past medical history and training history data were collected and a CHA2DS2-VASc was calculated. Binary logistic regression was used to assess variables associated with AF and stroke.
Results
The survey received 1002 responses from 41 countries across Africa, Asia, Australasia, Europe, North and South America, and 942 were included in the final analysis. The average age was 52.4±8.5 years and 83.7% were male. The most common sports were cycling (n=677, 71.9%), running (n=558, 59.2%) and triathlon (n=245, 26%). There were 190 (20.2%) individuals who reported AF and 26 (2.8%) individuals who reported stroke, of which 14 (53.9%) had AF. Lifetime exercise dose (OR: 1.02, 95% CI: 1.00, 1.03, p=0.02) and swimming (OR: 1.56, 95% CI: 1.02, 2.39, p=0.04) were associated with AF in multivariable analysis. AF (OR: 4.18, 95% CI: 1.80, 9.72 p<0.01) was positively associated with stroke, even in individuals with a CHA2DS2-VASc of 0 or 1 (OR: 4.20, 95% CI: 1.83, 9.66, p<0.01) (Figure 1).
Conclusions
This survey provides early evidence that the risk of stroke in veteran endurance athletes who develop AF is not negligible, even in those deemed to be at low risk by CHA2DS2-VASc score. Longitudinal studies are needed to substantiate these findings to inform decisions around anticoagulation.
Funding Acknowledgement
Type of funding sources: None.
Collapse
Affiliation(s)
- S Pallikadavath
- NIHR Biomedical Research Unit in Cardiovascular Disease , Leicester , United Kingdom
| | - C Richards
- NIHR Biomedical Research Unit in Cardiovascular Disease , Leicester , United Kingdom
| | - V Bountziouka
- NIHR Biomedical Research Unit in Cardiovascular Disease , Leicester , United Kingdom
| | - A J Sandilands
- NIHR Biomedical Research Unit in Cardiovascular Disease , Leicester , United Kingdom
| | - M P M Graham-Brown
- NIHR Biomedical Research Unit in Cardiovascular Disease , Leicester , United Kingdom
| | - T Robinson
- NIHR Biomedical Research Unit in Cardiovascular Disease , Leicester , United Kingdom
| | - A Singh
- NIHR Biomedical Research Unit in Cardiovascular Disease , Leicester , United Kingdom
| | - G P McCann
- NIHR Biomedical Research Unit in Cardiovascular Disease , Leicester , United Kingdom
| |
Collapse
|
17
|
Alfuhied A, Ayton S, Gulsin GS, Parke KS, Wormleighton JV, Moss A, Graham-Brown MPM, Arnold JR, McCann GP, Singh A. Inter-field strength agreement of left atrial assessment at 1.5T and 3T. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The agreement of left atrial (LA) volumetric and strain parameters between 1.5 and 3-tesla cardiovascular magnetic resonance (CMR) is not known. We aimed to investigate inter-field strength agreement of LA measurements in healthy volunteers scanned at both field strengths on the same day.
Methods
22 healthy volunteers were prospectively recruited and randomized to undergo scanning at either 1.5T or 3T first, immediately crossing over to the other field strength and scanned by the same radiographer. Steady-state free precession cines were analyzed blinded using Medis Suite. LA volumes and LA emptying fraction (LAEF) were calculated using the biplane area length method. LA strain (LAS) was assessed on 4- and 2-chamber and average values were calculated for LA reservoir, conduit, and booster pump function. Data were compared with paired t-tests and agreement was assessed by Bland-Altman plots and intra-class correlation coefficients (ICC).
Results
The median age was 32.5 (IQR 27.5, 42.5) and 45% were male. Key results are shown in the table and figure. There were no significant differences in the LA volumetric or strain mean values between 1.5T and 3T, although Bland-Altman analysis demonstrated a slightly positive bias at 1.5T for LAVmax, LAEF and LAS parameters. The inter-field strength agreement was excellent for LA volumes, reservoir and conduit strain (ICC >0.85, p<0.001), whilst LAEF showed good agreement (ICC=0.77, p=0.001). LAS at booster pump showed poor agreement, with the lowest ICC. The limits of agreement on Bland-Altman analysis were comparable for LAEF and LAS at reservoir.
Conclusion
There was excellent inter-field strength agreement for LA volumes, reservoir and conduit strain, suggesting that measurements can be used interchangeably between field strengths. Booster pump LAS had poor agreement, which is likely due to the fact that this measurement is less reproducible than volumes and reservoir/conduit LAS.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): National Institute for Health Research (NIHR)
Collapse
Affiliation(s)
- A Alfuhied
- Cardiovascular Sciences, University of Leicester, National Institute for Health Research (NIHR) Leicester Biomedical Research , Leicester , United Kingdom
| | - S Ayton
- Cardiovascular Sciences, University of Leicester, National Institute for Health Research (NIHR) Leicester Biomedical Research , Leicester , United Kingdom
| | - G S Gulsin
- Cardiovascular Sciences, University of Leicester, National Institute for Health Research (NIHR) Leicester Biomedical Research , Leicester , United Kingdom
| | - K S Parke
- Cardiovascular Sciences, University of Leicester, National Institute for Health Research (NIHR) Leicester Biomedical Research , Leicester , United Kingdom
| | - J V Wormleighton
- Cardiovascular Sciences, University of Leicester, National Institute for Health Research (NIHR) Leicester Biomedical Research , Leicester , United Kingdom
| | - A Moss
- Cardiovascular Sciences, University of Leicester, National Institute for Health Research (NIHR) Leicester Biomedical Research , Leicester , United Kingdom
| | - M P M Graham-Brown
- Cardiovascular Sciences, University of Leicester, National Institute for Health Research (NIHR) Leicester Biomedical Research , Leicester , United Kingdom
| | - J R Arnold
- Cardiovascular Sciences, University of Leicester, National Institute for Health Research (NIHR) Leicester Biomedical Research , Leicester , United Kingdom
| | - G P McCann
- Cardiovascular Sciences, University of Leicester, National Institute for Health Research (NIHR) Leicester Biomedical Research , Leicester , United Kingdom
| | - A Singh
- Cardiovascular Sciences, University of Leicester, National Institute for Health Research (NIHR) Leicester Biomedical Research , Leicester , United Kingdom
| |
Collapse
|
18
|
Ayton SL, Alfuhied A, Gulsin GS, Parke KS, Wormleighton JV, Arnold JR, Moss AJ, Singh A, Graham-Brown MPM, McCann GP. Inter-field strength agreement of cardiovascular magnetic resonance cine-derived strain and strain rate measures: a randomised study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Left ventricular (LV) strain and strain rate measurements can be derived from routinely acquired cardiovascular magnetic resonance (CMR) cine images by feature tracking techniques. However, the inter-field strength agreement of strain measurements derived from these techniques is not known. We hypothesised that there would be excellent inter-field strength agreement (between 1.5 and 3 Tesla [T]) for the measurement of global strain and strain rate derived from cine imaging.
Methods
Prospective, randomised cross-over observational study. Healthy volunteers each underwent CMR scans at 1.5T and 3T within 30 minutes on the same day in a randomised order. Retrospectively ECG gated, short and long-axis balanced steady state free precession cine images were obtained using standardised acquisition parameters at both field strengths. Two software packages were used to derive LV global longitudinal, circumferential and long and short axis radial systolic strain, peak systolic, early diastolic and late diastolic strain rates. All strain values are expressed as positive numbers.
Results
Twenty-two subjects (mean age 36±12 years; 45% male) were studied. No differences in heart rate and blood pressure measurements during scanning were observed between field strengths. The abstract figure shows an example of strain analysis and Bland-Altman plots for global longitudinal and circumferential strain. Minimal bias was seen in all strain and strain rate measurements between field strengths using the first software package. Strain and strain rate values derived from long axis images (longitudinal and long axis radial) showed poor to fair agreement (intraclass correlation co-efficient (ICC) range 0.39–0.71), whereas measures derived from short axis images (circumferential and short axis radial) showed good to excellent agreement between field strengths (ICC range 0.78–0.91). Similar results were observed with the second software package, though the differences in agreement between long and short axis derived measures were less pronounced.
Conclusion
Longitudinal strain and strain rate measures derived from CMR feature tracking have poor inter-field strength agreement between 1.5T and 3T. By contrast, agreement of circumferential and short axis radial strain and strain rate measurements at 1.5T and 3T is good. These results need to be considered when assessing strain at different field strengths.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): United Kingdom National Institute for Health Research
Collapse
Affiliation(s)
- S L Ayton
- University of Leicester and the NIHR Leicester Biomedical Research Centre , Leicester , United Kingdom
| | - A Alfuhied
- University of Leicester and the NIHR Leicester Biomedical Research Centre , Leicester , United Kingdom
| | - G S Gulsin
- University of Leicester and the NIHR Leicester Biomedical Research Centre , Leicester , United Kingdom
| | - K S Parke
- University of Leicester and the NIHR Leicester Biomedical Research Centre , Leicester , United Kingdom
| | - J V Wormleighton
- University of Leicester and the NIHR Leicester Biomedical Research Centre , Leicester , United Kingdom
| | - J R Arnold
- University of Leicester and the NIHR Leicester Biomedical Research Centre , Leicester , United Kingdom
| | - A J Moss
- University of Leicester and the NIHR Leicester Biomedical Research Centre , Leicester , United Kingdom
| | - A Singh
- University of Leicester and the NIHR Leicester Biomedical Research Centre , Leicester , United Kingdom
| | - M P M Graham-Brown
- University of Leicester and the NIHR Leicester Biomedical Research Centre , Leicester , United Kingdom
| | - G P McCann
- University of Leicester and the NIHR Leicester Biomedical Research Centre , Leicester , United Kingdom
| |
Collapse
|
19
|
Yeo JL, Gulsin GS, Brady EM, Dattani A, Bilak JM, Marsh AM, Sian M, Athithan L, Parke KS, Wormleighton J, Graham-Brown MPM, Singh A, Arnold JR, Lawson C, Davies MJ, Xue H, Kellman P, McCann GP. Association of ambulatory blood pressure with coronary microvascular and cardiac dysfunction in asymptomatic type 2 diabetes. Cardiovasc Diabetol 2022; 21:85. [PMID: 35643571 PMCID: PMC9148453 DOI: 10.1186/s12933-022-01528-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 05/20/2022] [Indexed: 02/07/2023] Open
Abstract
Background Type 2 diabetes (T2D) and hypertension commonly coexist and are associated with subclinical myocardial structural and functional changes. We sought to determine the association between blood pressure (BP) and left ventricular (LV) remodeling, systolic/diastolic function, and coronary microvascular function, among individuals with T2D without prevalent cardiovascular disease. Methods Participants with T2D and age-, sex-, and ethnicity-matched controls underwent comprehensive cardiovascular phenotyping including fasting bloods, transthoracic echocardiography, cardiovascular magnetic resonance imaging with quantitative adenosine stress/rest perfusion, and office and 24-h ambulatory BP monitoring. Multivariable linear regression was performed to determine independent associations between BP and imaging markers of remodeling and function in T2D. Results Individuals with T2D (n = 205, mean age 63 ± 7 years) and controls (n = 40, mean age 61 ± 8 years) were recruited. Mean 24-h systolic BP, but not office BP, was significantly greater among those with T2D compared to controls (128.8 ± 11.7 vs 123.0 ± 13.1 mmHg, p = 0.006). Those with T2D had concentric LV remodeling (mass/volume 0.91 ± 0.15 vs 0.82 ± 0.11 g/mL, p < 0.001), decreased myocardial perfusion reserve (2.82 ± 0.83 vs 3.18 ± 0.82, p = 0.020), systolic dysfunction (global longitudinal strain 16.0 ± 2.3 vs 17.2 ± 2.1%, p = 0.004) and diastolic dysfunction (E/e’ 9.30 ± 2.43 vs 8.47 ± 1.53, p = 0.044) compared to controls. In multivariable regression models adjusted for 14 clinical variables, mean 24-h systolic BP was independently associated with concentric LV remodeling (β = 0.165, p = 0.031), diastolic dysfunction (β = 0.273, p < 0.001) and myocardial perfusion reserve (β = − 0.218, p = 0.016). Mean 24-h diastolic BP was associated with LV concentric remodeling (β = 0.201, p = 0.016). Conclusion 24-h ambulatory systolic BP, but not office BP, is independently associated with cardiac remodeling, coronary microvascular dysfunction, and diastolic dysfunction among asymptomatic individuals with T2D. (Clinical trial registration. URL: https://clinicaltrials.gov/ct2/show/NCT03132129 Unique identifier: NCT03132129). Supplementary Information The online version contains supplementary material available at 10.1186/s12933-022-01528-2.
Collapse
|
20
|
Billany RE, Smith AC, Hutchinson GM, Graham-Brown MPM, Nixon DGD, Bishop NC. Feasibility and acceptability of high-intensity interval training and moderate-intensity continuous training in kidney transplant recipients: the PACE-KD study. Pilot Feasibility Stud 2022; 8:106. [PMID: 35597974 PMCID: PMC9123685 DOI: 10.1186/s40814-022-01067-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/06/2022] [Indexed: 11/29/2022] Open
Abstract
Background Kidney transplant recipients (KTRs) exhibit unique elevated inflammation, impaired immune function, and increased cardiovascular risk. Although exercise reduces cardiovascular risk, there is limited research on this population, particularly surrounding novel high-intensity interval training (HIIT). The purpose of this pilot study was to determine the feasibility and acceptability of HIIT in KTRs. Methods Twenty KTRs (male 14; eGFR 58±19 mL/min/1.73 m2; age 49±11 years) were randomised and completed one of three trials: HIIT A (4-, 2-, and 1-min intervals; 80–90% watts at V̇O2peak), HIITB (4×4 min intervals; 80–90% V̇O2peak) or MICT (~40 min; 50–60% V̇O2peak) for 24 supervised sessions on a stationary bike (approx. 3x/week over 8 weeks) and followed up for 3 months. Feasibility was assessed by recruitment, retention, and intervention acceptability and adherence. Results Twenty participants completed the intervention, and 8 of whom achieved the required intensity based on power output (HIIT A, 0/6 [0%]; HIITB, 3/8 [38%]; MICT, 5/6 [83%]). Participants completed 92% of the 24 sessions with 105 cancelled and rescheduled sessions and an average of 10 weeks to complete the intervention. Pre-intervention versus post-intervention V̇O2peak (mL/kg-1/min-1) was 24.28±4.91 versus 27.06±4.82 in HIITA, 24.65±7.67 versus 27.48±8.23 in HIIT B, and 29.33±9.04 versus 33.05±9.90 in MICT. No adverse events were reported. Conclusions This is the first study to report the feasibility of HIIT in KTRs. Although participants struggled to achieve the required intensity (power), this study highlights the potential that exercise has to reduce cardiovascular risk in KTRs. HIIT and MICT performed on a cycle, with some modification, could be considered safe and feasible in KTRs. Larger scale trials are required to assess the efficacy of HIIT in KTRs and in particular identify the most appropriate intensities, recovery periods, and session duration. Some flexibility in delivery, such as incorporating home-based sessions, may need to be considered to improve recruitment and retention. Trial registration ISRCTN, ISRCTN17122775. Registered on 30 January 2017. Supplementary Information The online version contains supplementary material available at 10.1186/s40814-022-01067-3.
Collapse
Affiliation(s)
- Roseanne E Billany
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Alice C Smith
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK.,Department of Health Sciences, University of Leicester, Leicester, UK
| | | | - Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Daniel G D Nixon
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK.,Department of Health Sciences, University of Leicester, Leicester, UK
| | - Nicolette C Bishop
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, LE11 3TU, UK.
| |
Collapse
|
21
|
March DS, Wilkinson TJ, Burnell T, Billany RE, Jackson K, Baker LA, Thomas A, Robinson KA, Watson EL, Graham-Brown MPM, Jones AW, Burton JO. The Effect of Non-Pharmacological and Pharmacological Interventions on Measures Associated with Sarcopenia in End-Stage Kidney Disease: A Systematic Review and Meta-Analysis. Nutrients 2022; 14:nu14091817. [PMID: 35565785 PMCID: PMC9101978 DOI: 10.3390/nu14091817] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/11/2022] [Accepted: 04/14/2022] [Indexed: 02/07/2023] Open
Abstract
This systematic review and meta-analysis provides a synthesis of the available evidence for the effects of interventions on outcome measures associated with sarcopenia in end-stage kidney disease (ESKD). Thirteen databases were searched, supplemented with internet and hand searching. Randomised controlled trials of non-pharmacological or pharmacological interventions in adults with ESKD were eligible. Trials were restricted to those which had reported measures of sarcopenia. Primary outcome measures were hand grip strength and sit-to-stand tests. Sixty-four trials were eligible (with nineteen being included in meta-analyses). Synthesised data indicated that intradialytic exercise increased hand grip strength (standardised mean difference, 0.58; 0.24 to 0.91; p = 0.0007; I2 = 40%), and sit-to-stand (STS) 60 score (mean difference, 3.74 repetitions; 2.35 to 5.14; p < 0.001; I2 = 0%). Intradialytic exercise alone, and protein supplementation alone, resulted in no statistically significant change in STS5 (−0.78 s; −1.86 to 0.30; p = 0.16; I2 = 0%), and STS30 (MD, 0.97 repetitions; −0.16 to 2.10; p = 0.09; I2 = 0%) performance, respectively. For secondary outcomes, L-carnitine and nandrolone-decanoate resulted in significant increases in muscle quantity in the dialysis population. Intradialytic exercise modifies measures of sarcopenia in the haemodialysis population; however, the majority of trials were low in quality. There is limited evidence for efficacious interventions in the peritoneal dialysis and transplant recipient populations.
Collapse
Affiliation(s)
- Daniel S. March
- York Trials Unit, Department of Health Sciences, University of York, York YO10 5DD, UK
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (R.E.B.); (K.A.R.); (E.L.W.); (M.P.M.G.-B.); (J.O.B.)
- Correspondence:
| | - Thomas J. Wilkinson
- NIHR Applied Research Collaboration, Leicester Diabetes Centre, University of Leicester, Leicester LE5 4PW, UK;
| | - Thomas Burnell
- Leicester Medical School, University of Leicester, Leicester LE1 7HA, UK; (T.B.); (K.J.)
| | - Roseanne E. Billany
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (R.E.B.); (K.A.R.); (E.L.W.); (M.P.M.G.-B.); (J.O.B.)
| | - Katherine Jackson
- Leicester Medical School, University of Leicester, Leicester LE1 7HA, UK; (T.B.); (K.J.)
| | - Luke A. Baker
- Department of Respiratory Sciences, College of Life Sciences, University of Leicester, Leicester LE1 7RH, UK;
- NIHR Leicester Biomedical Research Centre, University Hospital of Leicester NHS Trust, University of Leicester, Leicester LE5 4PW, UK
| | - Amal Thomas
- University Hospital of Leicester NHS Trust, Leicester LE1 5WW, UK;
| | - Katherine A. Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (R.E.B.); (K.A.R.); (E.L.W.); (M.P.M.G.-B.); (J.O.B.)
| | - Emma L. Watson
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (R.E.B.); (K.A.R.); (E.L.W.); (M.P.M.G.-B.); (J.O.B.)
- NIHR Leicester Biomedical Research Centre, University Hospital of Leicester NHS Trust, University of Leicester, Leicester LE5 4PW, UK
| | - Matthew P. M. Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (R.E.B.); (K.A.R.); (E.L.W.); (M.P.M.G.-B.); (J.O.B.)
- NIHR Leicester Biomedical Research Centre, University Hospital of Leicester NHS Trust, University of Leicester, Leicester LE5 4PW, UK
- University Hospital of Leicester NHS Trust, Leicester LE1 5WW, UK;
| | - Arwel W. Jones
- Central Clinical School, Monash University, Melbourne 3004, Australia;
| | - James O. Burton
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (R.E.B.); (K.A.R.); (E.L.W.); (M.P.M.G.-B.); (J.O.B.)
- NIHR Leicester Biomedical Research Centre, University Hospital of Leicester NHS Trust, University of Leicester, Leicester LE5 4PW, UK
- University Hospital of Leicester NHS Trust, Leicester LE1 5WW, UK;
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough LE11 3TU, UK
| |
Collapse
|
22
|
Baker LA, O'Sullivan TF, Robinson KA, Graham-Brown MPM, Major RW, Ashford RU, Smith AC, Philp A, Watson EL. Primary skeletal muscle cells from chronic kidney disease patients retain hallmarks of cachexia in vitro. J Cachexia Sarcopenia Muscle 2022; 13:1238-1249. [PMID: 35029054 PMCID: PMC8978027 DOI: 10.1002/jcsm.12802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/23/2021] [Accepted: 08/23/2021] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Skeletal muscle wasting and dysfunction are common characteristics noted in people who suffer from chronic kidney disease (CKD). The mechanisms by which this occurs are complex, and although progress has been made, the key underpinning mechanisms are not yet fully elucidated. With work to date primarily conducted in nephrectomy-based animal models, translational capacity to our patient population has been challenging. This could be overcome if rationale developing work could be conducted in human based models with greater translational capacity. This could be achieved using cells derived from patient biopsies, if they retain phenotypic traits noted in vivo. METHODS Here, we performed a systematic characterization of CKD derived muscle cells (CKD; n = 10; age: 54.40 ± 15.53 years; eGFR: 22.25 ± 13.22 ml/min/1.73 m2 ) in comparison with matched controls (CON; n = 10; age: 58.66 ± 14.74 years; eGFR: 85.81 ± 8.09 ml/min/1.73 m2 ). Harvested human derived muscle cells (HDMCs) were taken through proliferative and differentiation phases and investigated in the context of myogenic progression, inflammation, protein synthesis, and protein breakdown. Follow up investigations exposed HDMC myotubes from each donor type to 0, 0.4, and 100 nM of IGF-1 in order to investigate any differences in anabolic resistance. RESULTS Harvested human derived muscle cells isolated from CKD patients displayed higher rates of protein degradation (P = 0.044) alongside elevated expression of both TRIM63 (2.28-fold higher, P = 0.054) and fbox32 (6.4-fold higher, P < 0.001) in comparison with CONs. No differences were noted in rates of protein synthesis under basal conditions (P > 0.05); however, CKD derived cells displayed a significant degree of anabolic resistance in response to IGF-1 stimulation (both doses) in comparison with matched CONs (0.4 nm: P < 0.001; 100 nM: P < 0.001). CONCLUSIONS In summary, we report for the first time that HDMCs isolated from people suffering from CKD display key hallmarks of the well documented in vivo phenotype. Not only do these findings provide further mechanistic insight into CKD specific cachexia, but they also demonstrate this is a reliable and suitable model in which to perform targeted experiments to begin to develop novel therapeutic strategies targeting the CKD associated decline in skeletal muscle mass and function.
Collapse
Affiliation(s)
- Luke A Baker
- Department of Health Sciences, University of Leicester, Leicester, UK
| | | | | | - Matthew P M Graham-Brown
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK.,Department of Cardiovascular Science, NIHR Leicester Cardiovascular Biomedical Research Unit, Leicester, UK
| | - Rupert W Major
- Department of Health Sciences, University of Leicester, Leicester, UK.,John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Robert U Ashford
- Leicester Orthopaedics, University Hospitals of Leicester, Leicester, UK.,Department of Cancer Studies, University of Leicester, Leicester, UK
| | - Alice C Smith
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Andrew Philp
- Mitochondrial Metabolism and Ageing Laboratory, Garvan Institute of Medical Research, Sydney, NSW, Australia.,St Vincent's Clinical School, UNSW Medicine, UNSW, Sydney, NSW, Australia
| | - Emma L Watson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| |
Collapse
|
23
|
Baker LA, March DS, Wilkinson TJ, Billany RE, Bishop NC, Castle EM, Chilcot J, Davies MD, Graham-Brown MPM, Greenwood SA, Junglee NA, Kanavaki AM, Lightfoot CJ, Macdonald JH, Rossetti GMK, Smith AC, Burton JO. Clinical practice guideline exercise and lifestyle in chronic kidney disease. BMC Nephrol 2022; 23:75. [PMID: 35193515 PMCID: PMC8862368 DOI: 10.1186/s12882-021-02618-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 11/22/2021] [Indexed: 12/13/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | - Mark D. Davies
- Betsi Cadwaladr University Health Board and Bangor University, Bangor, UK
| | | | | | | | | | | | - Jamie H. Macdonald
- School of Sport, Health and Exercise Sciences, Bangor University, Bangor, UK
| | | | | | - James O. Burton
- University of Leicester and Leicester Hospitals NHS Trust, Leicester, UK
| |
Collapse
|
24
|
Billany RE, Smith AC, Stevinson C, Clarke AL, Graham-Brown MPM, Bishop NC. Perceived barriers and facilitators to exercise in kidney transplant recipients: A qualitative study. Health Expect 2022; 25:764-774. [PMID: 35014114 PMCID: PMC8957725 DOI: 10.1111/hex.13423] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 11/16/2021] [Accepted: 12/11/2021] [Indexed: 01/07/2023] Open
Abstract
Background Exercise has the potential to attenuate the high levels of cardiovascular morbidity and mortality present in kidney transplant recipients (KTRs). Despite this, activity levels in KTRs remain low. The aim of this qualitative study was to explore the barriers and facilitators of exercise in KTRs. Methods Thirteen KTRs (eight males; mean ± SD; age 53 ± 13 years; estimated glomerular filtration rate 53 ± 21 ml/min/1.73 m2) were recruited and completed semistructured one‐to‐one interviews at University Hospitals of Leicester NHS Trust. All KTRs were eligible if their kidney transplant was completed >12 weeks before interview and their consultant considered them to have no major contraindications to exercise. All interviews were audio recorded, transcribed verbatim and subject to framework analysis to identify and report themes. Results Themes were organized into personal, behavioural and environmental factors based on social cognitive theory. Facilitators of exercise were largely internal: enjoyment, exercise for general health and health of the transplanted kidney and desire to maintain normality. Social interaction, support and guidance of healthcare professionals and goal setting were perceived as motivational. Harming the kidney, a lack of guidance, self‐motivation and accessibility were barriers to exercise. Conclusion These results provide detailed insight into the development of interventions designed to increase physical activity in KTRs. They provide strong evidence that specific exercise guidelines are required for this population and that the healthcare system could have a key role in supporting KTRs to become more physically active. Interventions need to be multifaceted to appeal to the differing levels of support desired by KTRs. Patient or Public Contribution KTRs were involved in the development of the interview topic guide to ensure all relevant topics were explored.
Collapse
Affiliation(s)
- Roseanne E Billany
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Alice C Smith
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK.,Department of Health Sciences, University of Leicester, Leicester, UK
| | - Clare Stevinson
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Amy L Clarke
- Centre for Behavioural Medicine, UCL School of Pharmacy, University College London, London, UK
| | - Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Nicolette C Bishop
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| |
Collapse
|
25
|
Gulsin GS, Graham-Brown MPM, Squire IB, Davies MJ, McCann GP. Benefits of sodium glucose cotransporter 2 inhibitors across the spectrum of cardiovascular diseases. Heart 2022; 108:16-21. [PMID: 33972360 DOI: 10.1136/heartjnl-2021-319185] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/22/2021] [Accepted: 03/30/2021] [Indexed: 01/10/2023] Open
Abstract
Sodium glucose cotransporter 2 inhibitors (SGLT2i) have emerged as a class of medications with positive cardiovascular (CV) effects across a spectrum of patients with and without type 2 diabetes (T2D). In heart failure with reduced ejection fraction, there is clear evidence that SGLT2i reduce hospitalisations and mortality regardless of the presence of diabetes, and they are now recognised as the fourth pillar of pharmacological management. Recent trial data also indicate promising effects in heart failure with preserved ejection fraction. In patients with T2D and atherosclerotic CV diseases, multiple CV outcomes trials have shown reductions in major adverse CV events. Meta-analysis of these trials also shows lower rates of incident and recurrent atrial fibrillation with SGLT2i. Concerns regarding utilisation in patients with chronic kidney disease have been allayed in trials showing SGLT2i in fact have renoprotective effects. Questions still remain regarding the safety of SGLT2i in the acute heart failure setting and immediately post myocardial infarction, as well as in patients with more advanced stages of chronic kidney disease. Furthermore, studies are underway evaluating SGLT2i in patients with heart valve disease, where positive effects on left ventricular remodelling may, for example, improve functional mitral regurgitation. In this review, we summarise the available evidence of recent CV outcomes trials of SGLT2i, focusing particularly on the application of these agents across various CV diseases. We detail evidence to support increased utilisation of these drugs, which in many cases will reduce mortality and improve quality of life in patients routinely encountered by the CV specialist physician.
Collapse
Affiliation(s)
- Gaurav S Gulsin
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Glenfield Hospital, Groby Road, Leicester, UK
| | | | - Iain B Squire
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Glenfield Hospital, Groby Road, Leicester, UK
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester and the Leicester NIHR Biomedical Research Centre, Leicester General Hospital, Gwendolen Road, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Glenfield Hospital, Groby Road, Leicester, UK
| |
Collapse
|
26
|
Patel R, Pallikadavath S, Graham-Brown MPM, Singh A. Shared decision making in athletes with cardiovascular disease: what we can learn from a masters athlete. BMJ Case Rep 2021; 14:e245822. [PMID: 34887289 PMCID: PMC8663107 DOI: 10.1136/bcr-2021-245822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2021] [Indexed: 11/04/2022] Open
Abstract
A 75-year-old male cyclist began suffering from palpitations on exertion. Symptoms terminated spontaneously with cessation of physical activity. The episodes caused significant distress with an impact on physical performance and quality of life. An echocardiogram showed a dilated left atrium, and an exercise ECG demonstrated that episodes of atrial fibrillation developed when his ventricular rate was above 140 beats per minute. Rate control could not be offered due to a history of sinus bradycardia nor rhythm control due to low likelihood of success. Anticoagulant therapy was commenced but discontinued at patient request as he considered risks to outweigh benefits given his desire to continue cycling. Management of athletes with atrial fibrillation is based on guidelines for the general population; however, treatment goals for athletes may differ. Shared decision making is essential to allow patients to make informed decisions about their care, accepting that individuals view treatment risks and benefits differently.
Collapse
Affiliation(s)
- Roshan Patel
- Leicester Medical School, College of Life Sciences, University of Leicester, Leicester, UK
| | - Susil Pallikadavath
- College of Life Sciences, University of Leicester, Leicester, UK
- Departmet of Cardiovascular Sciences, University of leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Matthew P M Graham-Brown
- Departmet of Cardiovascular Sciences, University of leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | - Anvesha Singh
- Departmet of Cardiovascular Sciences, University of leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| |
Collapse
|
27
|
Highton PJ, March DS, Churchward DR, Grantham CE, Young HML, Graham-Brown MPM, Estruel S, Martin N, Brunskill NJ, Smith AC, Burton JO, Bishop NC. Intradialytic cycling does not exacerbate microparticles or circulating markers of systemic inflammation in haemodialysis patients. Eur J Appl Physiol 2021; 122:599-609. [PMID: 34854982 PMCID: PMC8854296 DOI: 10.1007/s00421-021-04846-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 11/09/2021] [Indexed: 11/24/2022]
Abstract
Purpose Patients receiving haemodialysis (HD) display elevated circulating microparticle (MP) concentration, tissue factor (TF) expression and markers of systemic inflammation, though regular intradialytic cycling (IDC) may have a therapeutic effect. This study investigated the impact of regular, moderate-intensity IDC on circulating MPs and inflammatory markers in unit-based HD patients. Methods Patients were cluster-randomised to intervention (n = 20, age: 51.4 ± 18.1 years, body mass: 77.6 ± 18.3 kg, mean ± SD) or no-exercise control (n = 20, 56.8 ± 14.0 years, 80.5 ± 26.5 kg). Intervention participants completed 30 min of moderate intensity (rating of perceived exertion [RPE] of 12–14) IDC, thrice weekly for 6 months. Pre-dialysis venous blood samples were obtained at 0, 3 and 6 months. Circulating MP phenotypes, cytokines, chemokine and MP TF expression were quantified using flow cytometry and cytometric bead array assays. Results Despite high exercise compliance (82%), no IDC-dependent effects were observed for any MP, cytokine or chemokine measure (p ≥ 0.051, ηρ2 ≤ 0.399) other than TNF-α (p = 0.001, ηρ2 = 0.186), though no significance was revealed upon post hoc analysis. Conclusion Six months of regular, moderate-intensity IDC had no effect on MPs, cytokines or chemokines. This suggests that the exercise did not exacerbate thrombotic or inflammatory status, though further functional assays are required to confirm this. Trial registration ISRCTN1129707, prospectively registered on 05/03/2015.
Collapse
Affiliation(s)
- Patrick J Highton
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK.,NIHR Applied Research Collaboration East Midlands, Leicester Diabetes Centre of Research, University of Leicester, Leicester, UK
| | - Daniel S March
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester, Leicester, UK
| | - Darren R Churchward
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | | | - Hannah M L Young
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester, Leicester, UK.,Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester, Leicester, UK
| | - Seila Estruel
- Department of Physiological Sciences, University of Barcelona, Barcelona, Spain
| | - Naomi Martin
- Leicester School of Allied Health Sciences, Faculty of Health and Life Sciences, De Montfort University, Leicester, UK
| | - Nigel J Brunskill
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester, Leicester, UK
| | - Alice C Smith
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester, Leicester, UK.,Department of Health Sciences, University of Leicester, Leicester, UK
| | - James O Burton
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK.,Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester, Leicester, UK
| | - Nicolette C Bishop
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK.
| |
Collapse
|
28
|
Hull KL, Quann N, Glover S, Wimbury C, Churchward DR, Pickering WP, Preston R, Baines R, Graham-Brown MPM, Burton JO. Evaluating the clinical experience of a regional in-center nocturnal hemodialysis program: The patient and staff perspective. Hemodial Int 2021; 25:447-456. [PMID: 34133061 DOI: 10.1111/hdi.12953] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/10/2021] [Accepted: 05/23/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION End-stage kidney disease causes significant morbidity, mortality, and reduced quality of life. Despite improvements in conventional hemodialysis, these problems persist. In-center nocturnal hemodialysis (INHD) has been shown to be beneficial in observational studies. This report outlines a 4-year renal network experience of INHD from the patient and frontline staff perspective. METHODS Staff and patients' experiences of INHD were evaluated through two work streams. Work stream one: 12 patients who chose to stop INHD and 24 patients who chose to continue with INHD completed an anonymous survey. Work stream two: one-to-one interviews with 20 patients receiving INHD and seven staff working INHD shifts were conducted. Clinical incident reporting for conventional hemodialysis and INHD from April 2014 to December 2018 was reviewed. FINDINGS Work stream one: Five themes were identified; facilities, time, health and well-being, sleep, and transport. A patient "starter pack" was developed and improvements to the dialysis unit were completed. Work stream two: Patient interviews demonstrated starter packs to aid sleep were well received; sleep itself was not a single reason to discontinue INHD. Staff indicated that their greatest concern was staffing levels; although staff-to-patient ratio remains unchanged, total numbers on INHD shifts were fewer, causing concern around less colleague availability for support during an emergency. SAFETY 363 clinical incidents were reported across all dialysis shifts; for conventional hemodialysis, a larger proportion were due to medical interventions, infection control, and transport; for INHD, most incidents centered around communication with patients and relatives, delays in patient transfer, and issues with medical equipment or facilities. DISCUSSION Patients continue with INHD due to increased social time and perceived health benefits. Patient starter packs and adjustments to the dialysis unit may enhance sleep. This experience has optimized the design of the NightLife study; a randomized controlled trial evaluated the effect of INHD on quality of life.
Collapse
Affiliation(s)
- Katherine L Hull
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | - Niamh Quann
- Leicester Clinical Trials Unit, College of Life Sciences, University of Leicester, Leicester, UK
| | - Suzanne Glover
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | - Coral Wimbury
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | - Darren R Churchward
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | | | - Rob Preston
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | - Richard Baines
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | - Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | - James O Burton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, Leicester General Hospital, Leicester, UK
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| |
Collapse
|
29
|
Dickson-Lowe R, Buitendag JJP, Graham-Brown MPM, Oosthuizen GVE. Falanga: The clinical correlates of surgical outcomes as a result of foot whipping in a resource poor setting. Injury 2021; 52:3139-3142. [PMID: 33894990 DOI: 10.1016/j.injury.2021.02.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/02/2021] [Accepted: 02/15/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Falanga is a punishment that involves hitting the bare soles of a person's feet. The consequences of this punishment may be limb and life-threatening. Post-traumatic acute kidney injury (AKI) secondary to rhabdomyolysis is a well-documented complication. Patients often require prompt surgical intervention and renal replacement therapy (RRT). The clinical and biochemical presentation of these patients and subsequent outcomes are poorly understood. AIMS This prospective observational study describes the clinical presentation and effects of foot whipping on patient outcomes. METHODOLOGY Prospective data were collected over a one-year period for 135 patients presenting following blunt force assault admitted to a single centre. Presenting clinical characteristics and patient outcomes were recorded and correlations between presenting clinical characteristics and surgical and clinical outcomes were assessed. RESULTS Of 138 patients presenting following blunt force assault 96% were male with a mean age of 28.8 ± 8.01. Thirty-six out of the 138 patients presenting following blunt force assault had received foot-whipping only (falanga group, FG). Ten of these 36 patients in the FG group required surgical intervention, with one requiring a below knee amputation, compared with only two patients who required surgical intervention in the group who experienced blunt force trauma not restricted to foot whipping (Sjambok group). Average length of stay was 4 days (range 2-38) in FG group compared with 5 (range 1-21) in SG group, with no mortalities in either group. For patients in the FG, Hb was higher at presentation compared to patients in the SG group (135.2 33.7 vs 124.2 21.3, p = 0.03) and correlated positively with the need for surgical intervention (r = 0.6, p < 0.01). In this same group, the presenting characteristics of CK (4251.3 3087.4, p = 0.1 vs 7422.6 12347.7, p = 0.1) and urine output (0.95 0.4 vs 0.7 0.4) positively correlated with RRT [CK r = 0.6, p < 0.01, UO r = 0.46, p < 0.01]. CONCLUSION Patients who present following falanga frequently require surgical intervention and the related healthcare utilisation and morbidity is high. Clinical indicators of a greater systemic injury at presentation may correlate with an increased likelihood of requiring surgical intervention or RRT.
Collapse
Affiliation(s)
- R Dickson-Lowe
- Department of General & Colorectal Surgery, Medway Maritime Hospital, Medway NHS Foundation Trust, United Kingdom
| | - J J P Buitendag
- Department of Surgery, Tygerberg Hospital, University of Stellenbosch, Cape Town, Western Cape, South Africa.
| | - M P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester and Cardiovascular Theme, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom; John Walls Renal Unit, University Hospitals of Leicester, United Kingdom
| | - G V E Oosthuizen
- Ngwelezana Hospital, Department of Surgery, University of KwaZulu Natal, Province of KwaZulu-Natal, South Africa
| |
Collapse
|
30
|
March DS, Lai KB, Neal T, Graham-Brown MPM, Highton PJ, Churchward DR, Young HML, Dungey M, Stensel DJ, Smith AC, Bishop NC, Szeto CC, Burton JO. Circulating endotoxin and inflammation: associations with fitness, physical activity and the effect of a six-month programme of cycling exercise during haemodialysis. Nephrol Dial Transplant 2021; 37:366-374. [PMID: 33983449 DOI: 10.1093/ndt/gfab178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Intradialytic cycling (IDC) may provide cardiovascular benefit to individuals receiving haemodialysis, but the exact mechanism behind these improvements remains unclear. The primary aim of this study was to investigate the effect of a six-month programme of IDC on circulating endotoxin (secondary analysis from the CYCLE-HD trial). Secondary aims were to investigate changes in circulating cytokines (IL-6, IL-10, TNF-α, CRP and IL6/IL-10), and their associations with physical activity, fitness and cardiovascular outcomes. METHODS Participants were randomised to either a six-month programme of IDC (thrice weekly, moderate intensity cycling at RPE 12-14) in addition to usual care (n = 46), or usual care only (control group; n = 46). Outcome measures were obtained at baseline and then again at six months. RESULTS There was no significant (P=0.137) difference in circulating endotoxin between groups at 6-months (IDC group: 0.34±0.08 EU/mL; control group: 0.37±0.07 EU/mL). There were no significant between group difference in any circulating cytokine following the 6-month programme of IDC. Higher levels of physical activity and fitness were associated with lower levels of endotoxin, IL-6, CRP, and IL-6/IL-10. CONCLUSIONS Our data show no change in circulating endotoxin or cytokines following a 6-month programme of IDC. However, higher levels of physical activity outside of haemodialysis were associated with lower levels of inflammation.
Collapse
Affiliation(s)
- Daniel S March
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.,NIHR Leicester Biomedical Research Centre, Leicester, United Kingdom.,University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Ka-Bik Lai
- Department of Medicine & Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Tracy Neal
- Affinity Biomarker Labs, Translation & Innovation Hub, Imperial College White City Campus, London, United Kingdom
| | - Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.,NIHR Leicester Biomedical Research Centre, Leicester, United Kingdom.,University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Patrick J Highton
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
| | - Darren R Churchward
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.,NIHR Leicester Biomedical Research Centre, Leicester, United Kingdom.,University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Hannah M L Young
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom.,Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
| | - Maurice Dungey
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.,NIHR Leicester Biomedical Research Centre, Leicester, United Kingdom.,University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - David J Stensel
- NIHR Leicester Biomedical Research Centre, Leicester, United Kingdom.,School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
| | - Alice C Smith
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Nicolette C Bishop
- NIHR Leicester Biomedical Research Centre, Leicester, United Kingdom.,School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
| | - Cheuk Chun Szeto
- Department of Medicine & Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - James O Burton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.,NIHR Leicester Biomedical Research Centre, Leicester, United Kingdom.,University Hospitals of Leicester NHS Trust, Leicester, United Kingdom.,School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
| |
Collapse
|
31
|
Graham-Brown MPM, Gulsin GS, Poli F, Parke K, Burton JO, McCann GP. Differences in native T1 and native T2 mapping between patients on hemodialysis and control subjects. Eur J Radiol 2021; 140:109748. [PMID: 33962255 DOI: 10.1016/j.ejrad.2021.109748] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 04/21/2021] [Accepted: 04/28/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Myocardial native T1 is a potential measure of myocardial fibrosis, but concerns remain over the potential influence of myocardial edema to increased native T1 signal in subjects prone to fluid overload. This study describes differences in native T2 (typically raised in states of myocardial edema) and native T1 times in patients on hemodialysis by comparing native T1 and native T2 times between subjects on hemodialysis to an asymptomatic control group. Reproducibility of these sequences was tested. METHODS Subjects were recruited prospectively and underwent 3 T-cardiac MRI with acquisition of native T1 and native T2 maps. Between group differences in native T1 and T2 maps were assessed using one-way ANOVAs. 30 subjects underwent test-retest scans within a week of their original scan to define sequence reproducibility. RESULTS 261 subjects completed the study (hemodialysis n = 124, control n = 137). Native T1 times were significantly increased in subjects on hemodialysis compared to control subjects (1259 ms ± 51 vs 1212 ms ± 37, p < 0.01). There was no difference in native T2 times between subjects on hemodialysis and control subjects (39.5 ms ± 2.5 vs 39.5 ms ± 2.3, p = 0.9). These differences were unchanged after adjustment for relevant baseline differences (age, sex and hemoglobin). Inter-study reproducibility for native T1 and T2 mapping was excellent (coefficient of variability 0.9 % and 2.6 % respectively). CONCLUSIONS The increased native T1 signal demonstrated in subjects on hemodialysis occurs independently of differences in native T2 and the two parameters are not orthogonal. Elevated native T1 in patients on hemodialysis may be driven by water related to myocardial fibrosis rather than edema from volume overload.
Collapse
Affiliation(s)
- Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester and Cardiovascular Theme, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom; John Walls Renal Unit, University Hospitals of Leicester, UK.
| | - Gaurav S Gulsin
- Department of Cardiovascular Sciences, University of Leicester and Cardiovascular Theme, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Federica Poli
- Department of Cardiovascular Sciences, University of Leicester and Cardiovascular Theme, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Kelly Parke
- Department of Cardiovascular Sciences, University of Leicester and Cardiovascular Theme, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - James O Burton
- Department of Cardiovascular Sciences, University of Leicester and Cardiovascular Theme, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom; John Walls Renal Unit, University Hospitals of Leicester, UK; National Centre for Sport and Exercise Medicine, Loughborough University, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and Cardiovascular Theme, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| |
Collapse
|
32
|
Graham-Brown MPM, Herrington WG, Burton JO. Spinning the legs and blood: should intradialytic exercise be routinely offered during maintenance haemodialysis? Clin Kidney J 2021; 14:1297-1300. [PMID: 34221366 PMCID: PMC8247751 DOI: 10.1093/ckj/sfab018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Indexed: 11/13/2022] Open
Abstract
Patients with end-stage kidney disease on haemodialysis (HD) have an elevated risk of cardiovascular disease (CVD). These patients also experience high levels of physical deconditioning and programmes of rehabilitation have been tested in a variety of forms with variable success. It has been suggested that programmes of exercise rehabilitation have a role to play in improving the physical condition of patients on HD and in addressing the traditional and non-traditional risk factors that drive CVD for this population. Intradialytic exercise has often been suggested as a convenient way of delivering rehabilitation for patients on HD, as it makes use of otherwise dead time, but there are legitimate concerns about this group of at-risk patients undertaking exercise at a time when their myocardium is already vulnerable to the insults of demand ischaemia from the processes of dialysis and ultrafiltration. A study in this issue of Clinical Kidney Journal provides reassuring data, showing that cycling during dialysis potentially reduces evidence of demand ischaemia (episodes of myocardial stunning). Together with the safety and quality of life data, we expect from the multicentre PrEscription of Intra-Dialytic Exercise to Improve quAlity of Life in Patients With Chronic Kidney Disease study (the protocol for which is published concurrently), rehabilitation programmes that include intradialytic exercise are perhaps closer than ever for patients on HD.
Collapse
Affiliation(s)
- Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - William G Herrington
- Nuffield Department of Population Health, Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK
- Nuffield Department of Population Health, Medical Research Council Population Health Research Unit at the University of Oxford, Oxford, UK
- Oxford Kidney Unit, Churchill Hospital, Oxford, UK
| | - James O Burton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| |
Collapse
|
33
|
Graham-Brown MPM, March DS, Young R, Highton PJ, Young HML, Churchward DR, Dungey M, Stensel DJ, Bishop NC, Brunskill NJ, Smith AC, McCann GP, McConnachie A, Burton JO. A randomized controlled trial to investigate the effects of intra-dialytic cycling on left ventricular mass. Kidney Int 2021; 99:1478-1486. [PMID: 34023029 DOI: 10.1016/j.kint.2021.02.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 02/02/2021] [Accepted: 02/10/2021] [Indexed: 12/22/2022]
Abstract
Cardiovascular disease is the leading cause of death for patients receiving hemodialysis. Since exercise mitigates many risk factors which drive cardiovascular disease for these patients, we assessed effects of a program of intra-dialytic cycling on left ventricular mass and other prognostically relevant measures of cardiovascular disease as evaluated by cardiac MRI (the CYCLE-HD trial). This was a prospective, open-label, single-blinded cluster-randomized controlled trial powered to detect a 15g difference in left ventricular mass measured between patients undergoing a six-month program of intra-dialytic cycling (exercise group) and patients continuing usual care (control group). Pre-specified secondary outcomes included measures of myocardial fibrosis, aortic stiffness, physical functioning, quality of life and ventricular arrhythmias. Outcomes were analyzed as intention-to-treat according to a pre-specified statistical analysis plan. Initially, 130 individuals were recruited and completed baseline assessments (65 each group). Ultimately, 101 patients completed the trial protocol (50 control group and 51 exercise group). The six-month program of intra-dialytic cycling resulted in a significant reduction in left ventricular mass between groups (-11.1g; 95% confidence interval -15.79, -6.43), which remained significant on sensitivity analysis (missing data imputed) (-9.92g; 14.68, -5.16). There were significant reductions in both native T1 mapping and aortic pulse wave velocity between groups favoring the intervention. There was no increase in either ventricular ectopic beats or complex ventricular arrhythmias as a result of exercise with no significant effect on physical function or quality of life. Thus, a six-month program of intradialytic cycling reduces left ventricular mass and is safe, deliverable and well tolerated.
Collapse
Affiliation(s)
- Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; National Institute of Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK; National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health, Loughborough University, Loughborough, UK
| | - Daniel S March
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; National Institute of Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Robin Young
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Patrick J Highton
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health, Loughborough University, Loughborough, UK
| | - Hannah M L Young
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Darren R Churchward
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Maurice Dungey
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health, Loughborough University, Loughborough, UK
| | - David J Stensel
- National Institute of Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK; National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health, Loughborough University, Loughborough, UK
| | - Nicolette C Bishop
- National Institute of Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK; National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health, Loughborough University, Loughborough, UK
| | - Nigel J Brunskill
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; National Institute of Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Alice C Smith
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; National Institute of Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - James O Burton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; National Institute of Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK; National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health, Loughborough University, Loughborough, UK.
| |
Collapse
|
34
|
March DS, Hurt AW, Grantham CE, Churchward DR, Young HML, Highton PJ, Dungey M, Bishop NC, Smith AC, Graham-Brown MPM, Cooper NJ, Burton JO. A Cost-Effective Analysis of the CYCLE-HD Randomized Controlled Trial. Kidney Int Rep 2021; 6:1548-1557. [PMID: 34169195 PMCID: PMC8207470 DOI: 10.1016/j.ekir.2021.02.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 01/27/2021] [Accepted: 02/22/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction No formal cost-effectiveness analysis has been performed for programs of cycling exercise during dialysis (intradialytic cycling [IDC]). The objective of this analysis is to determine the effect of a 6-month program of IDC on health care costs. Methods This is a retrospective formal cost-effectiveness analysis of adult participants with end-stage kidney disease undertaking in-center maintenance hemodialysis enrolled in the CYCLE-HD trial. Data on hospital utilization, primary care consultations, and prescribed medications were extracted from medical records for the 6 months before, during, and after a 6-month program of thrice-weekly IDC. The cost-effectiveness analysis was conducted from a health care service perspective and included the cost of implementing the IDC intervention. The base-case analyses included a 6-month “within trial” analysis and a 12-month “within and posttrial” analysis considering health care utilization and quality of life (QoL) outcomes. Results Data from the base-case within trial analysis, based on 109 participants (n = 56 control subjects and n = 53 IDC subjects) showed a reduction in health care utilization costs between groups, favoring the IDC group, and a 73% chance of IDC being cost-effective compared with control subjects at a willingness to pay of £20,000 and £30,000 per quality-adjusted life year (QALY) gained. When QoL data points were extrapolated forward to 12 months, the probability of IDC being cost-effective was 93% and 94% at £20,000 and £30,000 per QALY gained. Sensitivity analysis broadly confirms these findings. Conclusion A 6-month program of IDC is cost-effective and the implementation of these programs nationally should be a priority.
Collapse
Affiliation(s)
- Daniel S March
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.,National Institute of Health Research Leicester Biomedical Research Center, Leicester, United Kingdom.,University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Adam W Hurt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Charlotte E Grantham
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.,University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Darren R Churchward
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.,National Institute of Health Research Leicester Biomedical Research Center, Leicester, United Kingdom.,University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Hannah M L Young
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom.,Department of Health Sciences, University of Leicester, United Kingdom
| | - Patrick J Highton
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
| | - Maurice Dungey
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.,University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Nicolette C Bishop
- National Institute of Health Research Leicester Biomedical Research Center, Leicester, United Kingdom.,School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
| | - Alice C Smith
- Department of Health Sciences, University of Leicester, United Kingdom
| | - Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.,National Institute of Health Research Leicester Biomedical Research Center, Leicester, United Kingdom.,University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, United Kingdom
| | - James O Burton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.,National Institute of Health Research Leicester Biomedical Research Center, Leicester, United Kingdom.,University Hospitals of Leicester NHS Trust, Leicester, United Kingdom.,School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
| |
Collapse
|
35
|
Adenwalla SF, Billany RE, March DS, Gulsin GS, Young HML, Highton P, Churchward DC, Young R, Careless A, Tomlinson CL, McCann GP, Burton JO, Graham-Brown MPM. The cardiovascular determinants of physical function in patients with end-stage kidney disease on haemodialysis. Int J Cardiovasc Imaging 2021; 37:1405-1414. [PMID: 33258084 PMCID: PMC8026413 DOI: 10.1007/s10554-020-02112-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 11/20/2020] [Indexed: 12/11/2022]
Abstract
Patients with end-stage kidney disease (ESKD) are often sedentary and decreased functional capacity associates with mortality. The relationship between cardiovascular disease (CVD) and physical function has not been fully explored. Understanding the relationships between prognostically relevant measures of CVD and physical function may offer insight into how exercise interventions might target specific elements of CVD. 130 patients on haemodialysis (mean age 57 ± 15 years, 73% male, dialysis vintage 1.3 years (0.5, 3.4), recruited to the CYCLE-HD trial (ISRCTN11299707), underwent cardiovascular phenotyping with cardiac MRI (left ventricular (LV) structure and function, pulse wave velocity (PWV) and native T1 mapping) and cardiac biomarker assessment. Participants completed the incremental shuttle walk test (ISWT) and sit-to-stand 60 (STS60) as field-tests of physical function. Linear regression models identified CV determinants of physical function measures, adjusted for age, gender, BMI, diabetes, ethnicity and systolic blood pressure. Troponin I, PWV and global native T1 were univariate determinants of ISWT and STS60 performance. NT pro-BNP was a univariate determinant of ISWT performance. In multivariate models, NT pro-BNP and global native T1 were independent determinants of ISWT and STS60 performance. LV ejection fraction was an independent determinant of ISWT distance. However, age and diabetes had the strongest relationships with physical function. In conclusion, NT pro-BNP, global native T1 and LV ejection fraction were independent CV determinants of physical function. However, age and diabetes had the greatest independent influence. Targeting diabetic care may ameliorate deconditioning in these patients and a multimorbidity approach should be considered when developing exercise interventions.
Collapse
Affiliation(s)
- Sherna F. Adenwalla
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, UK
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Roseanne E. Billany
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, UK
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Daniel S. March
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, UK
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Gaurav S. Gulsin
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Hannah M. L. Young
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
- Research and Innovation Department, University Hospitals Leicester NHS Trust, Leicester, UK
| | - Patrick Highton
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, UK
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Darren C. Churchward
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Robin Young
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Alysha Careless
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Clare L. Tomlinson
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Gerry P. McCann
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - James O. Burton
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, UK
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Matthew P. M. Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, UK
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| |
Collapse
|
36
|
Young HML, March DS, Highton PJ, Graham-Brown MPM, Churchward DC, Grantham C, Goodliffe S, Jones W, Cheung MM, Greenwood SA, Eborall HC, Conroy S, Singh SJ, Smith AC, Burton JO. Exercise for people living with frailty and receiving haemodialysis: a mixed-methods randomised controlled feasibility study. BMJ Open 2020; 10:e041227. [PMID: 33148767 PMCID: PMC7640592 DOI: 10.1136/bmjopen-2020-041227] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Frailty is highly prevalent in haemodialysis (HD) patients, leading to poor outcomes. This study aimed to determine whether a randomised controlled trial (RCT) of intradialytic exercise is feasible for frail HD patients, and explore how the intervention may be tailored to their needs. DESIGN Mixed-methods feasibility. SETTING AND PARTICIPANTS Prevalent adult HD patients of the CYCLE-HD trial with a Clinical Frailty Scale Score of 4-7 (vulnerable to severely frail) were eligible for the feasibility study. INTERVENTIONS Participants in the exercise group undertook 6 months of three times per week, progressive, moderate intensity intradialytic cycling (IDC). OUTCOMES Primary outcomes were related to feasibility. Secondary outcomes were falls incidence measured from baseline to 1 year following intervention completion, and exercise capacity, physical function, physical activity and patient-reported outcomes measured at baseline and 6 months. Acceptability of trial procedures and the intervention were explored via diaries and interviews with n=25 frail HD patients who both participated in (n=13, 52%), and declined (n=12, 48%), the trial. RESULTS 124 (30%) patients were eligible, and of these 64 (52%) consented with 51 (80%) subsequently completing a baseline assessment. n=24 (71% male; 59±13 years) dialysed during shifts randomly assigned to exercise and n=27 (81% male; 65±11 years) shifts assigned to usual care. n=6 (12%) were lost to follow-up. The exercise group completed 74% of sessions. 27%-89% of secondary outcome data were missing. Frail HD patients outlined several ways to enhance trial procedures. Maintaining ability to undertake activities of daily living and social participation were outcomes of primary importance. Participants desired a varied exercise programme. CONCLUSIONS A definitive RCT is feasible, however a comprehensive exercise programme may be more efficacious than IDC in this population. TRIAL REGISTRATION NUMBERS ISRCTN11299707; ISRCTN12840463.
Collapse
Affiliation(s)
- Hannah M L Young
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
- Department of Research and Innovation, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Daniel S March
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Patrick J Highton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- National Centre for Sport and Exercise Medicine, Loughborough University, Loughborough, UK
| | - Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- National Centre for Sport and Exercise Medicine, Loughborough University, Loughborough, UK
| | - Darren C Churchward
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Charlotte Grantham
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | | | - William Jones
- Emergency Department, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Mei-Mei Cheung
- Renal, Respiratory and Cardiovascular Clinical Management Group, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sharlene A Greenwood
- Department of Physiotherapy and Renal Medicine, King's College Hospital, London, UK
- Department of Renal Medicine, King's College London, London, UK
| | - Helen C Eborall
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Simon Conroy
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Sally J Singh
- Centre for Exercise and Rehabilitation Science, Leicester Biomedical Research Unit, Leicester, UK
- Department of Respiratory Medicine, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Alice C Smith
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - James O Burton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- National Centre for Sport and Exercise Medicine, Loughborough University, Loughborough, UK
| |
Collapse
|
37
|
Athithan L, Chowdhary A, Swarbrick D, Gulsin GS, Singh A, Jex N, Jain M, Khan JN, Graham-Brown MPM, Wormleighton JV, Parke KS, Davies MJ, Karamitsos T, Clarke K, Neubauer S, Levelt E, McCann GP. Male sex adversely affects the phenotypic expression of diabetic heart disease. Ther Adv Endocrinol Metab 2020; 11:2042018820927179. [PMID: 32523675 PMCID: PMC7257847 DOI: 10.1177/2042018820927179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 04/21/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Type 2 diabetes (T2D) is associated with an increased risk of heart failure (HF) and cardiovascular mortality. A large-scale meta-analysis on HF found that diabetes was more frequent in women than men, and diabetes appeared to have attenuated the otherwise protective effect of female sex on progression of cardiomyopathy. The exact underlying mechanisms for this remain unclear. Here, we aimed to determine the effect of sex on the phenotypic expression of diabetic heart disease in patients with T2D. METHODS A total of 62 male [mean age 44 ± 8 years, body mass index (BMI) 33 ± 5 kg/m2, mean HBA1c of 7.8 ± 1.8%] and 67 female (44 ± 10 years, BMI 35 ± 6 kg/m2, HBA1c 7.6 ± 1.2%) T2D patients on oral glucose-lowering treatment, and 16 male (48 ± 17 years, BMI 25 ± 3 kg/m2) and 14 female (50 ± 10 years, BMI 25 ± 4 kg/m2) controls were recruited. Left ventricular (LV) volumes, mass, function and deformation, and left atrial (LA) volumes and function were assessed using cardiac magnetic resonance imaging (CMR). RESULTS Participants in all groups were of similar age, and there were no significant differences in blood pressure (BP), diabetes duration or metabolic profile between the two diabetes groups. Concentric remodeling was present in both sexes (p < 0.0001), with greater degree of concentric hypertrophy in males (12%, p = 0.0015). Biplane LA ejection fraction (LAEF) (p = 0.038), peak systolic circumferential strain (p < 0.0001) and diastolic strain rates (p = 0.001) were significantly reduced in men compared with women with T2D. There were no significant differences in biplane LAEF, peak systolic circumferential strain and diastolic strain rates in women with T2D compared with female controls. Whereas in women with T2D, glycaemic control was linked to LV contractile function, there was no such relationship in men with T2D. CONCLUSION Male sex adversely affects the phenotypic expression of diabetic heart disease. The striking differences in the cardiac phenotype between male and female patients with T2D promote awareness of gender-specific risk factors in search of treatment and prevention of diabetes-associated HF. CONDENSED ABSTRACT We aimed to determine the effect of sex on the phenotypic expression of diabetic heart disease in patients with T2D. While our findings support the notion that in T2D, male sex adversely affects the phenotypic expression of diabetic heart disease, this is in apparent conflict with the previous large-scale study showing diabetes attenuates the otherwise protective effect of female sex on progression of cardiomyopathy. Further longitudinal studies looking at gender differences in clinical outcomes in T2D patients are needed. These sex-related differences promote awareness of sex-specific risk factors in search of treatment and prevention of diabetes-associated HF.
Collapse
Affiliation(s)
- Lavanya Athithan
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Leicester, UK
| | - Amrit Chowdhary
- Multidisciplinary Cardiovascular Research Centre and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, West Yorkshire, UK
| | - Daniel Swarbrick
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Leicester, UK
| | - Gaurav S. Gulsin
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Leicester, UK
| | - Anvesha Singh
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Leicester, UK
| | - Nicholas Jex
- Multidisciplinary Cardiovascular Research Centre and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, West Yorkshire, UK
| | - Manali Jain
- Multidisciplinary Cardiovascular Research Centre and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, West Yorkshire, UK
| | - Jamal N. Khan
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Leicester, UK
| | - Matthew P. M. Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Leicester, UK
| | - Joanne V. Wormleighton
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Leicester, UK
| | - Kelly S. Parke
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Leicester, UK
| | | | - Theodoros Karamitsos
- Radcliffe Department of Medicine, University of Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Kieran Clarke
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, Oxfordshire, UK
| | - Stefan Neubauer
- Radcliffe Department of Medicine, University of Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | | | - Gerry P. McCann
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Leicester, UK
| |
Collapse
|
38
|
Robinson KA, Baker LA, Graham-Brown MPM, Watson EL. Skeletal muscle wasting in chronic kidney disease: the emerging role of microRNAs. Nephrol Dial Transplant 2019; 35:1469-1478. [DOI: 10.1093/ndt/gfz193] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 08/27/2019] [Indexed: 12/17/2022] Open
Abstract
Abstract
Skeletal muscle wasting is a common complication of chronic kidney disease (CKD), characterized by the loss of muscle mass, strength and function, which significantly increases the risk of morbidity and mortality in this population. Numerous complications associated with declining renal function and lifestyle activate catabolic pathways and impair muscle regeneration, resulting in substantial protein wasting. Evidence suggests that increasing skeletal muscle mass improves outcomes in CKD, making this a clinically important research focus. Despite extensive research, the pathogenesis of skeletal muscle wasting is not completely understood. It is widely recognized that microRNAs (miRNAs), a family of short non-coding RNAs, are pivotal in the regulation of skeletal muscle homoeostasis, with significant roles in regulating muscle growth, regeneration and metabolism. The abnormal expression of miRNAs in skeletal muscle during disease has been well described in cellular and animal models of muscle atrophy, and in recent years, the involvement of miRNAs in the regulation of muscle atrophy in CKD has been demonstrated. As this exciting field evolves, there is emerging evidence for the involvement of miRNAs in a beneficial crosstalk system between skeletal muscle and other organs that may potentially limit the progression of CKD. In this article, we describe the pathophysiological mechanisms of muscle wasting and explore the contribution of miRNAs to the development of muscle wasting in CKD. We also discuss advances in our understanding of miRNAs in muscle–organ crosstalk and summarize miRNA-based therapeutics currently in clinical trials.
Collapse
Affiliation(s)
- Kate A Robinson
- Department of Infection Immunity and Inflammation, College of Life Sciences, University of Leicester, Leicester, UK
| | - Luke A Baker
- Department of Health Sciences, College of Life Sciences, George Davies Centre, University of Leicester, Leicester, UK
| | - Matthew P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital Leicester, Leicester, UK
| | - Emma L Watson
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital Leicester, Leicester, UK
| |
Collapse
|
39
|
Gulsin GS, Graham-Brown MPM, Davies MJ, McCann GP. Emerging glucose-lowering therapies: a guide for cardiologists. Heart 2019; 106:18-23. [PMID: 31551292 DOI: 10.1136/heartjnl-2019-315758] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/19/2019] [Accepted: 08/28/2019] [Indexed: 01/07/2023] Open
Abstract
In recent large-scale cardiovascular outcome trials, two new classes of glucose-lowering medications-sodium glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RAs)-demonstrated cardiovascular benefits in adults with type 2 diabetes mellitus (T2DM). These findings have prompted growing optimism among clinicians regarding the potential for these agents to reduce the burden of cardiovascular disease in people with T2DM. GLP-1RAs and SGLT2i are now advocated as second-line agents in European and US guidelines for management of both hyperglycaemia and for primary prevention of cardiovascular disease in people with T2DM. Given the high prevalence of T2DM in patients with cardiovascular disease, cardiologists will increasingly encounter these agents in routine clinical practice. In this review, we summarise evidence from cardiovascular outcome trials of GLP-1RAs and SGLT2i, give practical advice on prescribing and detail safety considerations associated with their use. We also highlight areas where further work is needed, giving details on active clinical trials. The review aims to familiarise cardiologists with these emerging treatments, which will be increasingly encountered in clinical practice, given the expanding representation of T2DM in patients with cardiovascular disease. Whether these drugs will be initiated by cardiologists remains to be determined.
Collapse
Affiliation(s)
- Gaurav S Gulsin
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | | | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| |
Collapse
|
40
|
Young HML, March DS, Graham-Brown MPM, Jones AW, Curtis F, Grantham CS, Churchward DR, Highton P, Smith AC, Singh SJ, Bridle C, Burton JO. Effects of intradialytic cycling exercise on exercise capacity, quality of life, physical function and cardiovascular measures in adult haemodialysis patients: a systematic review and meta-analysis. Nephrol Dial Transplant 2019; 33:1436-1445. [PMID: 29608708 DOI: 10.1093/ndt/gfy045] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 02/05/2018] [Indexed: 11/13/2022] Open
Abstract
Background Intradialytic cycling (IDC), delivered during haemodialysis (HD), has the potential to improve many health issues. This systematic review and meta-analysis examine the evidence on the effects of IDC on exercise capacity, quality of life (QoL), physical function and cardiovascular health. Methods Twenty-four databases were searched alongside Internet and hand searching, and consultation with experts. Eligibility criteria were cluster randomized, randomized and quasi-randomized controlled trials (RCTs) of IDC versus usual care in prevalent adult HD patients. Primary outcome measures were exercise capacity (VO2 peak and field tests) and QoL. Secondary measures were cardiac and physical function. Results Thirteen RCTs were eligible. Eight provided data for use in meta-analyses, which indicated no significant change in VO2 peak (mean difference, MD 1.19 mL/kg/min, 95% confidence interval -1.15 to 3.52, P = 0.3), physical (mean change, MC 1.97, -8.27 to 12.22, P = 0.7) or mental component (MC 3.37, -7.94 to 14.68, P = 0.6) summary scores of the Medical Outcomes Short Form 36, pulse wave velocity (MD -0.57 m/s, -1.55 to 0.41, P = 0.4), systolic (MD -2.28 mmHg, -14.46 to 9.90, P = 0.7) or diastolic blood pressure (MD 2.25 mmHg, -3.01 to 7.50, P = 0.4) following IDC. IDC, however, leads to an improvement in performance on the 6-min walk test (MD 87.84 m, 39.60-136.09, P = 0.0004). All included studies were considered to have high risk of bias. Conclusions There is insufficient evidence demonstrating whether cycling exercise during HD improves patient outcomes. High-quality, adequately powered RCTs of IDC are required.
Collapse
Affiliation(s)
- Hannah M L Young
- Department of Infection, Immunity & Inflammation; and John Walls Renal Unit, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Daniel S March
- Department of Infection, Immunity & Inflammation; and John Walls Renal Unit, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Matthew P M Graham-Brown
- Department of Infection, Immunity & Inflammation; and John Walls Renal Unit, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK.,National Centre for Sport and Exercise Medicine, Loughborough University, Loughborough, UK
| | - Arwel W Jones
- Lincoln Institute for Health, University of Lincoln, Lincoln, UK
| | - Ffion Curtis
- Lincoln Institute for Health, University of Lincoln, Lincoln, UK
| | - Charlotte S Grantham
- Department of Infection, Immunity & Inflammation; and John Walls Renal Unit, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Darren R Churchward
- Department of Infection, Immunity & Inflammation; and John Walls Renal Unit, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Patrick Highton
- Department of Infection, Immunity & Inflammation; and John Walls Renal Unit, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK.,National Centre for Sport and Exercise Medicine, Loughborough University, Loughborough, UK
| | - Alice C Smith
- Department of Infection, Immunity & Inflammation; and John Walls Renal Unit, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sally J Singh
- Centre for Exercise & Rehabilitation Science, Leicester Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | - Chris Bridle
- Lincoln Institute for Health, University of Lincoln, Lincoln, UK
| | - James O Burton
- Department of Infection, Immunity & Inflammation; and John Walls Renal Unit, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK.,National Centre for Sport and Exercise Medicine, Loughborough University, Loughborough, UK
| |
Collapse
|
41
|
Hull KL, Churchward DR, Graham-Brown MPM, Glover S, Jesus-Silva J, Baines R, Burton JO. SP679EXPLORING THE EXPERIENCES AND CONCERNS OF STAFF AND PATIENTS ON AN IN-CENTRE NOCTURNAL HAEMODIALYSIS PROGRAMME. Nephrol Dial Transplant 2019. [DOI: 10.1093/ndt/gfz103.sp679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | | | - Suzanne Glover
- University Hospitals of Leicester, Leicester, United Kingdom
| | | | - Richard Baines
- University Hospitals of Leicester, Leicester, United Kingdom
| | | |
Collapse
|
42
|
Athithan L, Kanagala P, Singh A, Gulsin GS, Graham-Brown MPM, Mcadam J, Marsh A, Parke K, Wormleighton J, Arnold JR, Squire IB, Ng LL, Mccann GP. P598Correlation between arterial stiffness using oscillometry and cardiovascular magnetic resonance in a population with heart failure with preserved ejection fraction (HFpEF). Eur Heart J Cardiovasc Imaging 2019. [DOI: 10.1093/ehjci/jez116.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- L Athithan
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - P Kanagala
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - A Singh
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - G S Gulsin
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - M P M Graham-Brown
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - J Mcadam
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - A Marsh
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - K Parke
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - J Wormleighton
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - J R Arnold
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - I B Squire
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - L L Ng
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - G P Mccann
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| |
Collapse
|
43
|
Athithan L, Kanagala PK, Singh A, Gulsin GS, Graham-Brown MPM, Marsh A, Mcadam J, Parke K, Wormleighton J, Arnold JR, Squire IB, Ng LL, Mccann GP. 348Association of arterial stiffness with left ventricular remodelling in heart failure with preserved ejection fraction. Eur Heart J Cardiovasc Imaging 2019. [DOI: 10.1093/ehjci/jez103.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- L Athithan
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - P K Kanagala
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - A Singh
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - G S Gulsin
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - M P M Graham-Brown
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - A Marsh
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - J Mcadam
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - K Parke
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - J Wormleighton
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - J R Arnold
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - I B Squire
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - L L Ng
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| | - G P Mccann
- University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Centre, Department of Cardiovascular Sciences, Leicester, United Kingdom of Great Britain & Northern Ireland
| |
Collapse
|
44
|
Gulsin GS, Kanagala P, Chan DCS, Cheng ASH, Athithan L, Graham-Brown MPM, Singh A, Yang J, Li Z, Khunti K, Davies MJ, Arnold JR, Squire IB, Ng LL, McCann GP. Differential left ventricular and left atrial remodelling in heart failure with preserved ejection fraction patients with and without diabetes. Ther Adv Endocrinol Metab 2019; 10:2042018819861593. [PMID: 31308926 PMCID: PMC6613057 DOI: 10.1177/2042018819861593] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 05/20/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Attempts to characterize cardiac structure in heart failure with preserved ejection fraction (HFpEF) in people with type 2 diabetes (T2D) have yielded inconsistent findings. We aimed to determine whether patients with HFpEF and T2D have a distinct pattern of cardiac remodelling compared with those without diabetes and whether remodelling was related to circulating markers of inflammation and fibrosis and clinical outcomes. METHODS We recruited 140 patients with HFpEF (75 with T2D and 65 without). Participants underwent comprehensive cardiovascular phenotyping, including echocardiography, cardiac magnetic resonance imaging and plasma biomarker profiling. RESULTS Patients with T2D were younger (age 70 ± 9 versus 75 ± 9y, p = 0.002), with evidence of more left ventricular (LV) concentric remodelling (LV mass/volume ratio 0.72 ± 0.15 versus 0.62 ± 0.16, p = 0.024) and smaller indexed left atrial (LA) volumes (maximal LA volume index 48 ± 20 versus 59 ± 29 ml/m2, p = 0.004) than those without diabetes. Plasma biomarkers of inflammation and extracellular matrix remodelling were elevated in those with T2D. Overall, there were 45 hospitalizations for HF and 22 deaths over a median follow-up period of 47 months [interquartile range (IQR) 38-54]. There was no difference in the primary composite endpoint of hospitalization for HF and mortality between groups. On multivariable Cox regression analysis, age, prior HF hospitalization, history of pulmonary disease and LV mass/volume were independent predictors of the primary endpoint. CONCLUSIONS Patients with HFpEF and T2D have increased concentric LV remodelling, smaller LA volumes and evidence of increased systemic inflammation compared with those without diabetes. This suggests the underlying pathophysiology for the development of HFpEF is different in patients with and without T2D. CLINICALTRIALSGOV IDENTIFIER NCT03050593.
Collapse
Affiliation(s)
| | | | - Daniel C. S. Chan
- Department of Cardiovascular Sciences, University of Leicester and the Leicester National Institute for Health Research (NIHR) Biomedical Research Centre, Leicester, UK
| | | | - Lavanya Athithan
- Department of Cardiovascular Sciences, University of Leicester and the Leicester National Institute for Health Research (NIHR) Biomedical Research Centre, Leicester, UK
| | | | - Anvesha Singh
- Department of Cardiovascular Sciences, University of Leicester and the Leicester National Institute for Health Research (NIHR) Biomedical Research Centre, Leicester, UK
| | - Jing Yang
- Bristol-Myers Squibb, Princeton, NJ, USA
| | - Zhuyin Li
- Bristol-Myers Squibb, Princeton, NJ, USA
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester and the Leicester NIHR Biomedical Research Centre, Leicester, UK
| | - Melanie J. Davies
- Diabetes Research Centre, University of Leicester and the Leicester NIHR Biomedical Research Centre, Leicester, UK
| | - Jayanth R. Arnold
- Department of Cardiovascular Sciences, University of Leicester and the Leicester National Institute for Health Research (NIHR) Biomedical Research Centre, Leicester, UK
| | - Iain B. Squire
- Department of Cardiovascular Sciences, University of Leicester and the Leicester National Institute for Health Research (NIHR) Biomedical Research Centre, Leicester, UK
| | - Leong L. Ng
- Department of Cardiovascular Sciences, University of Leicester and the Leicester National Institute for Health Research (NIHR) Biomedical Research Centre, Leicester, UK
| | | |
Collapse
|
45
|
Graham-Brown MPM, Adenwalla SF, Lai FY, Hunt WH, Parke K, Gulsin G, Burton JO, McCann GP. The reproducibility of cardiac magnetic resonance imaging measures of aortic stiffness and their relationship to cardiac structure in prevalent haemodialysis patients. Clin Kidney J 2018; 11:864-873. [PMID: 30524722 PMCID: PMC6275449 DOI: 10.1093/ckj/sfy042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 04/27/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Aortic stiffness is one of the earliest signs of cardiovascular disease (CVD) in patients with chronic kidney disease and an independent predictor of mortality. It is thought to drive left ventricular (LV) remodelling, an established biomarker for mortality. The relationship between direct and indirect measures of aortic stiffness and LV remodelling is not defined in dialysis patients, nor are the reproducibility of methods used to assess aortic stiffness using cardiac magnetic resonance (CMR) imaging. METHODS Using 3T CMR, we report the results of (i) the interstudy, interobserver and intra-observer reproducibility of ascending aortic distensibility (AAD), descending aortic distensibility (DAD) and aortic pulse wave velocity (aPWV) in 10 haemodialysis (HD) patients and (ii) the relationship between AAD, DAD and aPWV and LV mass index (LVMi) and LV remodelling in 70 HD patients. RESULTS Inter- and intra-observer variability of AAD, DAD and aPWV were excellent [intraclass correlation (ICC) > 0.9 for all]. Interstudy reproducibility of AAD was excellent {ICC 0.94 [95% confidence interval (CI) 0.78-0.99]}, but poor for DAD and aPWV [ICC 0.51 (-0.13-0.85) and 0.51 (-0.31-0.89)]. AAD, DAD and aPWV associated with LVMi on univariate analysis (β = -0.244, P = 0.04; β =-0.315, P < 0.001 and β = 0.242, P = 0.04, respectively). Only systolic blood pressure, serum phosphate and a history of CVD remained independent determinants of LVMi on multivariable linear regression. CONCLUSIONS AAD is the most reproducible CMR-derived measure of aortic stiffness in HD patients. CMR-derived measures of aortic stiffness were not independent determinants of LVMi in HD patients. Whether one should target blood pressure over aortic stiffness to mitigate cardiovascular risk still needs determination.
Collapse
Affiliation(s)
- Matthew P M Graham-Brown
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK
- Department of Infection Immunity and Inflammation, School of Medicine and Biological Sciences, University of Leicester, Leicester, UK
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Leicestershire, UK
- Correspondence and offprint requests to: Matthew P.M. Graham-Brown; E-mail:
| | - Sherna F Adenwalla
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Florence Y Lai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - William H Hunt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Kelly Parke
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Gaurav Gulsin
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - James O Burton
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK
- Department of Infection Immunity and Inflammation, School of Medicine and Biological Sciences, University of Leicester, Leicester, UK
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| |
Collapse
|
46
|
Levelt E, Swarbrick D, Gulsin GS, Athithan L, Singh A, Khan JN, Graham-Brown MPM, Davies MJ, Karamitsos T, Clarke K, Neubauer S, McCann GP. P3690Male gender adversely affects the phenotypic expression of diabetic heart disease. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p3690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- E Levelt
- University of Leeds, Leeds, United Kingdom
| | - D Swarbrick
- University of Leicester, Leicester, United Kingdom
| | - G S Gulsin
- University of Leicester, Leicester, United Kingdom
| | - L Athithan
- University of Leicester, Leicester, United Kingdom
| | - A Singh
- University of Leicester, Leicester, United Kingdom
| | - J N Khan
- University of Leicester, Leicester, United Kingdom
| | | | - M J Davies
- University of Leicester, Leicester, United Kingdom
| | - T Karamitsos
- Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - K Clarke
- University of Oxford, Oxford, United Kingdom
| | - S Neubauer
- University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom
| | - G P McCann
- University of Leicester, Leicester, United Kingdom
| |
Collapse
|
47
|
Gulsin GS, Swarbrick DJ, Hunt WH, Levelt E, Graham-Brown MPM, Parke KS, Wormleighton JV, Lai FY, Yates T, Wilmot EG, Webb DR, Davies MJ, McCann GP. Relation of Aortic Stiffness to Left Ventricular Remodeling in Younger Adults With Type 2 Diabetes. Diabetes 2018; 67:1395-1400. [PMID: 29661781 DOI: 10.2337/db18-0112] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 04/09/2018] [Indexed: 11/13/2022]
Abstract
Individuals with type 2 diabetes have a three- to fivefold increased risk of developing heart failure. Diabetic cardiomyopathy is typified by left ventricular (LV) concentric remodeling, which is a recognized predictor of adverse cardiovascular events. Although the mechanisms underlying LV remodeling in type 2 diabetes are unclear, progressive aortic stiffening may be a key determinant. The aim of this study was to assess the relationship between aortic stiffness and LV geometry in younger adults with type 2 diabetes, using multiparametric cardiovascular MRI. We prospectively recruited 80 adults (aged 18-65 years) with type 2 diabetes and no cardiovascular disease and 20 age- and sex-matched healthy control subjects. All subjects underwent comprehensive bio-anthropometric assessment and cardiac MRI, including measurement of aortic stiffness by aortic distensibility (AD). Type 2 diabetes was associated with increased LV mass, concentric LV remodeling, and lower AD compared with control subjects. On multivariable linear regression, AD was independently associated with concentric LV remodeling in type 2 diabetes. Aortic stiffness may therefore be a potential therapeutic target to prevent the development of heart failure in type 2 diabetes.
Collapse
Affiliation(s)
- Gaurav S Gulsin
- Department of Cardiovascular Sciences, University of Leicester and Leicester National Institute for Health Research Biomedical Research Centre, Glenfield Hospital, Leicester, U.K
| | - Daniel J Swarbrick
- Department of Cardiovascular Sciences, University of Leicester and Leicester National Institute for Health Research Biomedical Research Centre, Glenfield Hospital, Leicester, U.K
| | - William H Hunt
- Department of Cardiovascular Sciences, University of Leicester and Leicester National Institute for Health Research Biomedical Research Centre, Glenfield Hospital, Leicester, U.K
| | - Eylem Levelt
- Department of Cardiovascular Sciences, University of Leicester and Leicester National Institute for Health Research Biomedical Research Centre, Glenfield Hospital, Leicester, U.K
| | | | - Kelly S Parke
- Department of Cardiovascular Sciences, University of Leicester and Leicester National Institute for Health Research Biomedical Research Centre, Glenfield Hospital, Leicester, U.K
| | - Joanne V Wormleighton
- Department of Cardiovascular Sciences, University of Leicester and Leicester National Institute for Health Research Biomedical Research Centre, Glenfield Hospital, Leicester, U.K
| | - Florence Y Lai
- Department of Cardiovascular Sciences, University of Leicester and Leicester National Institute for Health Research Biomedical Research Centre, Glenfield Hospital, Leicester, U.K
| | - Thomas Yates
- National Centre of Sport and Exercise Medicine, University of Loughborough, Loughborough, U.K
| | - Emma G Wilmot
- Department of Endocrinology and Diabetes, Royal Derby Hospital, Derby, U.K
| | - David R Webb
- Diabetes Research Centre, University of Leicester and Leicester National Institute for Health Research Biomedical Research Centre, Leicester General Hospital, Leicester, U.K
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester and Leicester National Institute for Health Research Biomedical Research Centre, Leicester General Hospital, Leicester, U.K
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and Leicester National Institute for Health Research Biomedical Research Centre, Glenfield Hospital, Leicester, U.K.
| |
Collapse
|
48
|
Wickenden K, Graham-Brown MPM, Veitch D, Dormer J, Bamford M, Graham-Brown RAC, Warwick G, Wagner S, Burton JO. Sézary Syndrome Presenting With Renal Involvement. Am J Kidney Dis 2018; 72:890-894. [PMID: 29941220 DOI: 10.1053/j.ajkd.2018.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 04/14/2018] [Indexed: 11/11/2022]
Abstract
Sézary syndrome is a rare aggressive leukemic variant of primary cutaneous T-cell lymphoma, typically presenting with erythroderma, lymphadenopathy, and an atypical clonal T-cell population. Though it often involves the spleen and liver, we report a case of Sézary syndrome with renal involvement that was treated successfully. Visceral involvement confers a poor prognosis requiring systemic treatment. The patient we describe was a 66-year-old man who was referred from Dermatology services for deteriorating kidney function. Polymerase chain reaction of genomic DNA from skin and kidney biopsies confirmed a clonal T-cell population matching a population isolated in peripheral blood. The patient was treated initially with alemtuzumab, which led to a significant improvement in kidney function, and he has subsequently received a successful allogeneic stem cell transplant. This case represents a rare cause of decreased kidney function and highlights the role of biopsy in patients with suspected Sézary syndrome.
Collapse
Affiliation(s)
- Katie Wickenden
- Department of Haematology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Matthew P M Graham-Brown
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, United Kingdom.
| | - David Veitch
- Department of Dermatology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - John Dormer
- Department of Histopathology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Mark Bamford
- Department of Dermatology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Robin A C Graham-Brown
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, United Kingdom
| | - Graham Warwick
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Simon Wagner
- Department of Haematology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - James O Burton
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, United Kingdom
| |
Collapse
|
49
|
Graham-Brown MPM, Vasilica C, Oates T, Light B, Clausner C, Antonacoloulos A, Chen LYJ, Ormandy P, Barratt J. Study protocol: responding to the needs of patients with IgA nephropathy, a social media approach. Clin Kidney J 2017; 11:474-478. [PMID: 30094011 PMCID: PMC6070102 DOI: 10.1093/ckj/sfx131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 10/04/2017] [Indexed: 11/14/2022] Open
Abstract
Background IgA nephropathy is the most common cause of glomerulonephritis in the Western world and predominantly affects young adults. Demographically these patients are the biggest users of social media. With increasing numbers of patients turning to social media to seek information and support in dealing with their disease, analysis of social media streams is an attractive modern strategy for understanding and responding to unmet patient need. Methods To identify unmet patient need in this population, a framework analysis will be undertaken of prospectively acquired social media posts from patients with IgA nephropathy, acquired from a range of different social media platforms. In collaboration with patients and members of the clinical multidisciplinary team, resources will be created to bridge gaps in patient knowledge and education identified through social media analysis and returned to patients via social media channels and bespoke websites. Analysis of the impact of these resources will be undertaken with further social media analysis, surveys and focus groups. Conclusions Patients with chronic diseases are increasingly using social networking channels to connect with others with similar diseases and to search for information to help them understand their condition. This project is a 21st century digital solution to understanding patient need and developing resources in partnership with patients, and has wide applicability as a future model for understanding patient needs in a variety of conditions.
Collapse
Affiliation(s)
- Matthew P M Graham-Brown
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK.,National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK.,Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
| | | | - Tom Oates
- UCL Centre for Nephrology, London, UK
| | - Ben Light
- School of Nursing and Midwifery, University of Salford, Salford, UK
| | | | | | | | - Paula Ormandy
- School of Nursing and Midwifery, University of Salford, Salford, UK
| | - Jonathan Barratt
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK.,Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
| |
Collapse
|
50
|
Graham-Brown MPM, March DS, Churchward DR, Stensel DJ, Singh A, Arnold R, Burton JO, McCann GP. Novel cardiac nuclear magnetic resonance method for noninvasive assessment of myocardial fibrosis in hemodialysis patients. Kidney Int 2017; 90:835-44. [PMID: 27633869 DOI: 10.1016/j.kint.2016.07.014] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 07/05/2016] [Accepted: 07/07/2016] [Indexed: 01/11/2023]
Abstract
Left ventricular hypertrophy and myocardial fibrosis frequently occur in patients with end-stage renal disease receiving hemodialysis therapy and are associated with poor prognosis. Native T1 mapping is a novel cardiac magnetic resonance imaging technique that measures native myocardial T1 relaxation, a surrogate of myocardial fibrosis. Here we compared global and segmental native myocardial T1 time and global longitudinal, circumferential and segmental strain, and cardiac function of 35 hemodialysis patients and 22 control individuals. The median native global T1 time was significantly higher in the hemodialysis than the control group (1270 vs. 1085 ms), with the septal regions of hemodialysis patients having significantly higher median T1 times than nonseptal regions (1293 vs. 1252 ms). The mean peak global circumferential strain and global longitudinal strain were both significantly reduced in hemodialysis patients compared with controls (-18.3 vs. -21.7 and -16.1 vs. -20.4, respectively). Systolic strain was also significantly reduced in the septum compared with the nonseptal myocardium in hemodialysis patients (-16.2 vs. -21.9) but not in control subjects. Global circumferential strain and longitudinal strain significantly correlated with global native T1 values (r = 0.41 and 0.55, respectively), and the septal native T1 significantly correlated with the septal systolic strain (r = 0.46). Thus, myocardial fibrosis may be assessed noninvasively with native T1 mapping; the interventricular septum appears to be particularly prone to the development of fibrosis in hemodialysis patients.
Collapse
Affiliation(s)
- Matthew P M Graham-Brown
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, United Kingdom; Department of Infection Immunity and Inflammation, School of Medicine and Biological Sciences, University of Leicester, Leicester, United Kingdom; National Centre for Sport and Exercise Medicine, School of Sport, Exercise, and Health Sciences, Loughborough University, Loughborough, United Kingdom.
| | - Daniel S March
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, United Kingdom; Department of Infection Immunity and Inflammation, School of Medicine and Biological Sciences, University of Leicester, Leicester, United Kingdom
| | - Darren R Churchward
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, United Kingdom; Department of Infection Immunity and Inflammation, School of Medicine and Biological Sciences, University of Leicester, Leicester, United Kingdom
| | - David J Stensel
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise, and Health Sciences, Loughborough University, Loughborough, United Kingdom
| | - Anvesha Singh
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital Leicester, Leicester, United Kingdom
| | - Ranjit Arnold
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital Leicester, Leicester, United Kingdom
| | - James O Burton
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, United Kingdom; Department of Infection Immunity and Inflammation, School of Medicine and Biological Sciences, University of Leicester, Leicester, United Kingdom; Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital Leicester, Leicester, United Kingdom
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital Leicester, Leicester, United Kingdom
| |
Collapse
|