Anemia and renal insufficiency are independent risk factors for death among patients with congestive heart failure admitted to community hospitals: a population-based study

Effective strategies to improve the management of heart failure

The purpose of this article is to provide resources for primary care physicians to manage heart failure as a chronic disease. We review evidence-based interventions that can be adopted in primary care practices to improve adherence to available guidelines for medication use, promotion of self-care behaviors, transitions of care in acute decompensated heart failure, and end of life care. This information will be valuable to primary care providers who care for patients with heart failure in all care settings but is focused on the management of heart failure in the outpatient setting.

Beyond the cardiorenal anaemia syndrome: recognizing the role of iron deficiency

Growing awareness that heart failure, renal impairment, and anaemia are frequent co-morbidities which can exacerbate one another in a vicious circle of clinical deterioration has led to the concept of the cardiorenal anaemia syndrome (CRAS). The role of iron deficiency within this complex interplay has been less well examined. Scrutiny of data from the recent FAIR-HF trial raises a new hypothesis: is it time for ‘CRAS’ to be supplemented with new acronyms such as CRIDS (cardiorenal–iron deficiency syndrome) or even CRAIDS (cardiorenal–anaemia–iron deficiency syndrome)? Iron deficiency occurs frequently in heart failure patients with or without anaemia. It not only impairs oxygen transport through reduced erythropoiesis, but adversely affects oxidative metabolism, cellular energetics, and immune mechanisms, and the synthesis and degradation of complex molecules such as DNA. One large observational study in patients with heart failure found iron deficiency to be an independent predictor of death or urgent heart transplantation (hazard ratio 1.58, 95% confidence interval 1.14–2.17, P = 0.005). In the FAIR-HF trial, i.v. iron therapy was associated with significant improvements in physical functioning in iron-deficient patients with heart failure, even in non-anaemic patients in whom haemoglobin levels did not change following i.v. iron administration. Key questions regarding the use of i.v. iron supplementation in the setting of heart failure merit exploration and could readily be answered by appropriately designed clinical trials. It is to be hoped that these important clinical trials are conducted, to permit a more subtle characterization of the patient's pathological condition and interventional requirements.

Targeting the hepcidin-ferroportin axis to develop new treatment strategies for anemia of chronic disease and anemia of inflammation

Anemia of chronic disease (ACD) or anemia of inflammation is prevalent in patients with chronic infection, autoimmune disease, cancer, and chronic kidney disease. ACD is associated with poor prognosis and lower quality of life. Management of ACD using intravenous iron and erythropoiesis stimulating agents are ineffective for some patients and are not without adverse effects, driving the need for new alternative therapies. Recent advances in our understanding of the molecular mechanisms of iron regulation reveal that increased hepcidin, the iron regulatory hormone, is a key factor in the development of ACD. In this review, we will summarize the role of hepcidin in iron homeostasis, its contribution to the pathophysiology of ACD, and novel strategies that modulate hepcidin and its target ferroportin for the treatment of ACD.

Renal dysfunction in patients with heart failure with preserved versus reduced ejection fraction: impact of the new Chronic Kidney Disease-Epidemiology Collaboration Group formula

BACKGROUND

Prior studies in heart failure (HF) have used the Modification of Diet in Renal Disease (MDRD) equation to calculate estimated glomerular filtration rate (eGFR). The Chronic Kidney Disease-Epidemiology Collaboration Group (CKD-EPI) equation provides a more-accurate eGFR than the MDRD when compared against the radionuclide gold standard. The prevalence and prognostic import of renal dysfunction in HF if the CKD-EPI equation is used rather than the MDRD is uncertain.

METHODS AND RESULTS

We used individual patient data from 25 prospective studies to stratify patients with HF by eGFR using the CKD-EPI and the MDRD equations and examined survival across eGFR strata. In 20 754 patients (15 962 with HF with reduced ejection fraction [HF-REF] and 4792 with HF with preserved ejection fraction [HF-PEF]; mean age, 68 years; deaths per 1000 patient-years, 151; 95% CI, 146-155), 10 589 (51%) and 11 422 (55%) had an eGFR <60 mL/min using the MDRD and CKD-EPI equations, respectively. Use of the CKD-EPI equation resulted in 3760 (18%) patients being reclassified into different eGFR risk strata; 3089 (82%) were placed in a lower eGFR category and exhibited higher all-cause mortality rates (net reclassification improvement with CKD-EPI, 3.7%; 95% CI, 1.5%-5.9%). Reduced eGFR was a stronger predictor of all-cause mortality in HF-REF than in HF-PEF.

CONCLUSIONS

Use of the CKD-EPI rather than the MDRD equation to calculate eGFR leads to higher estimates of renal dysfunction in HF and a more-accurate categorization of mortality risk. Renal function is more closely related to outcomes in HF-REF than in HF-PEF.

Is worsening renal function an ominous prognostic sign in patients with acute heart failure? The role of congestion and its interaction with renal function

BACKGROUND

Worsening renal function (WRF), traditionally defined as an increase in serum creatinine levels ≥0.3 mg/dL, is a frequent finding in patients with acute heart failure (AHF) and has been associated with poorer outcomes in some but not all studies. We hypothesized that these discrepancies may be caused by the interaction between WRF and congestion in AHF patients.

METHODS AND RESULTS

We measured serum creatinine levels on a daily basis during the hospitalization and assessed the persistence of signs of congestion at discharge in 599 consecutive patients admitted at our institute for AHF. They had a postdischarge mortality and mortality or AHF readmission rates of 13% and 43%, respectively, after 1 year. Patients were subdivided into 4 groups according to the development or not of WRF and the persistence of ≥1 sign of congestion at discharge. Patients with WRF and no congestion had similar outcomes compared with those with no WRF and no congestion, whereas the risk of death or of death or AHF readmission was increased in the patients with persistent congestion alone and in those with both WRF and congestion (hazard ratio, 5.35; 95% confidence interval, 3.0-9.55 at univariable analysis; hazard ratio, 2.44; 95% confidence interval, 1.24-4.18 at multivariable analysis for mortality; hazard ratio, 2.14; 95% confidence interval, 1.39-3.3 at univariable analysis; and hazard ratio, 1.39; 95% confidence interval, 0.88-2.2 at multivariable analysis for mortality and rehospitalizations).

CONCLUSIONS

WRF alone, when detected using serial serum creatinine measurements, is not an independent determinant of outcomes in patients with AHF. It has an additive prognostic value when it occurs in patients with persistent signs of congestion.

Decreased glomerular filtration rate is associated with mortality and cardiovascular events in patients with hypertension: a prospective study

Background

Few studies reported the associations between decreased glomerular filtration rate (GFR) and mortality, coronary heart disease (CHD), and stroke in hypertensive patients. We aim to assess the associations between GFR and mortality, CHD, and stroke in hypertensive patients and to evaluate whether low GFR can improve the prediction of these outcomes in addition to conventional cardiovascular risk factors.

Methods and Findings

This is an observational prospective study and 3,711 eligible hypertensive patients aged ≥5 years from rural areas of China were used for the present analysis. The associations between eGFR and outcomes, followed by a median of 4.9 years, were evaluated using Cox proportional hazards models adjusting for other potential confounders. Low eGFR was independently associated with risk of all-cause mortality, cardiovascular mortality, and incident stroke [multivariable adjusted hazard ratios (95% confidence intervals) for eGFR <60 ml/min/1.73 m² relative to eGFR ≥90 ml/min/1.73 m² were 1.824 (1.047–3.365), 2.371 (1.109–5.068), and 2.493 (1.193–5.212), respectively]. We found no independent association between eGFR and the risk of CHD. For 4-year all-cause and cardiovascular mortality, integrated discrimination improvement (IDI) was positive when eGFR were added to traditional risk factors (1.51%, P = 0.016, and 1.99%, P = 0.017, respectively). For stroke and CHD events, net reclassification improvements (NRI) were 5.9% (P = 0.012) and 1.8% (P = 0.083) for eGFR, respectively.

Conclusions

We have established an inversely independent association between eGFR and all-cause mortality, cardiovascular mortality, and stroke in hypertensive patients in rural areas of China. Further, addition of eGFR significantly improved the prediction of 4-year mortality and stroke over and above that of conventional risk factors. We recommend that eGFR be incorporated into prognostic assessment for patients with hypertension in rural areas of China.

Limitations

We did not have sufficient information on atrial fibrillation to control for the potential covariate. These associations should be further confirmed in future.

Meta-analysis of efficacy and safety of intravenous ferric carboxymaltose (Ferinject) from clinical trial reports and published trial data

BACKGROUND

Recommendations given for intravenous iron treatment are typically not supported by a high level of evidence. This meta-analysis addressed this by summarising the available date from clinical trials of ferric carboxymaltose using clinical trial reports and published reports.

METHODS

Clinical trial reports were supplemented by electronic literature searches comparing ferric carboxymaltose with active comparators or placebo. Various outcomes were sought for efficacy (attainment of normal haemoglobin (Hb), increase of Hb by a defined amount, for example), together with measures of harm, including serious adverse events and deaths.

RESULTS

Fourteen studies were identified with 2,348 randomised patients exposed to ferric carboxymaltose, 832 to oral iron, 762 to placebo, and 384 to intravenous iron sucrose. Additional data were available from cohort studies. Intravenous ferric carboxymaltose was given up to the calculated iron deficit (up to 1,000 mg in one week) for iron deficiency anaemia secondary to chronic kidney disease, blood loss in obstetric and gynaecological conditions, gastrointestinal disease, and other conditions like heart failure. The most common comparator was oral iron, and trials lasted 1 to 24 weeks. Intravenous ferric carboxymaltose improved mean Hb, serum ferritin, and transferrin saturation levels; the mean end-of-trial increase over oral iron was, for Hb 4.8 (95% confidence interval 3.3 to 6.3) g/L, for ferritin 163 (153 to 173) μg/L, and for transferrin saturation 5.3% (3.7 to 6.8%). Ferric carboxymaltose was significantly better than comparator in achievement of target Hb increase (number needed to treat (NNT) 6.8; 5.3 to 9.7) and target Hb NNT (5.9; 4.7 to 8.1). Serious adverse events and deaths were similar in incidence in ferric carboxymaltose and comparators; rates of constipation, diarrhoea, and nausea or vomiting were lower than with oral iron.

CONCLUSIONS

This review examined the available trials of intravenous ferric carboxymaltose using details from published papers and unpublished clinical trial reports. It increases the evidence available to support recommendations given for intravenous iron treatment, but there are limited trial data comparing different intravenous iron preparations.

Comparison of rates and risk factors for development of anaemia and erythropoiesis-stimulating agent utilization after radical or partial nephrectomy

OBJECTIVE

To examine the incidence of and risk factors for the development of anaemia and erythropoiesis-stimulation agent (ESA) treatment in patients undergoing radical nephrectomy (RN) and partial nephrectomy (PN) because anaemia is a significant cause of morbidity in chronic kidney disease.

PATIENTS AND METHODS

The study comprised a retrospective review of 905 patients (610 RN/295 PN; mean age, 57.5 years; mean follow-up, 6.4 years) who underwent surgery for renal tumours at two institutions from July 1987 to June 2007. Demographics, disease characteristics and pre- and postoperative (i.e. renal function, metabolic parameters, anaemia and ESA treatment) were recorded. Data were analyzed within subgroups based on treatment (RN vs PN). Multivariate analysis was conducted to determine the risk factors for developing anaemia after surgery.

RESULTS

Tumour size (cm) was significantly larger for RN (RN 7.0 vs PN 3.7; P < 0.001). No significant differences were noted with respect to demographics and preoperative anaemia (RN 16.4% vs PN 18.6%; P = 0.454) and ESA-treatment (RN 0.7% vs PN 1.4%; P = 0.499). After surgery, significantly less de novo anaemia (PN 4.1% vs RN 17.5%; P < 0.001) and ESA utilization (PN 2.7% vs RN 13.4%; P < 0.001) occurred in the PN cohort. Multivariate analysis showed that age ≥60 years (odds ratio, OR, 1.62; P = 0.008), African American ethnicity (OR, 2.30; P < 0.001), smoking (OR, 1.60; P = 0.013), glomerular filtration rate (GFR) <60 mL/min/1.73 m(2) (OR, 4.09; P < 0.001), ≥1+ proteinuria (OR, 2.19; P < 0.03), metabolic acidosis (OR, 4.08; P = 0.007) and RN (OR, 2.58; P < 0.001) were significantly associated with de novo anaemia.

CONCLUSIONS

Patients who underwent RN had a significantly higher prevalence of anaemia and ESA-treatment compared to a well-matched cohort that underwent PN. In addition to RN, age ≥60 years, African American ethnicity, history of smoking, GFR < 60 mL/min/1.73 m(2), proteinuria and metabolic acidosis were associated with developing anaemia.

Epidemiology of cardiorenal syndrome

The interdependence of cardiac and renal dysfunction has emerged as a focus of intense interest in heart failure management due to the substantial associated morbidity and mortality. Captured in the clinical entity known as cardiorenal syndrome, recent definitions afford discussion of the acute and longitudinal evaluation and management of these patients. This article discusses potential pathophysiologic mechanisms of cardiorenal syndrome, epidemiology, inpatient and long-term care (including investigational therapies and mechanical fluid removal), and end-of-life and palliative care.

Characteristics, outcomes and predictors of long-term mortality for patients hospitalized for acute heart failure: a report from the korean heart failure registry

Background and Objectives

Acute heart failure (AHF) is associated with a poor prognosis and it requires repeated hospitalizations. However, there are few studies on the characteristics, treatment and prognostic factors of AHF. The aims of this study were to describe the clinical characteristics, management and outcomes of the patients hospitalized for AHF in Korea.

Subjects and Methods

We analyzed the clinical data of 3,200 hospitalization episodes that were recorded between June 2004 and April 2009 from the Korean Heart Failure (KorHF) Registry database. The mean age was 67.6±14.3 years and 50% of the patients were female.

Results

Twenty-nine point six percent (29.6%) of the patients had a history of previous HF and 52.3% of the patients had ischemic heart disease. Left ventricular ejection fraction (LVEF) was reported for 89% of the patients. The mean LVEF was 38.5±15.7% and 26.1% of the patients had preserved systolic function (LVEF ≥50%), which was more prevalent in the females (34.0% vs. 18.4%, respectively, p<0.001). At discharge, 58.6% of the patients received beta-blockers (BB), 53.7% received either angiotensin converting enzyme-inhibitors or angiotensin receptor blockers (ACEi/ARB), and 58.4% received both BB and ACEi/ARB. The 1-, 2-, 3- and 4-year mortality rates were 15%, 21%, 26% and 30%, respectively. Multivariate analysis revealed that advanced age {hazard ratio: 1.023 (95% confidence interval: 1.004-1.042); p=0.020}, a previous history of heart failure {1.735 (1.150-2.618); p=0.009}, anemia {1.973 (1.271-3.063); p=0.002}, hyponatremia {1.861 (1.184-2.926); p=0.007}, a high level of serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) {3.152 (1.450-6.849); p=0.004} and the use of BB at discharge {0.599 (0.360-0.997); p=0.490} were significantly associated with total death.

Conclusion

We present here the characteristics and prognosis of an unselected population of AHF patients in Korea. The long-term mortality rate was comparable to that reported in other countries. The independent clinical risk factors included age, a previous history of heart failure, anemia, hyponatremia, a high NT-proBNP level and taking BB at discharge.

Outcomes associated with anemia in patients with heart failure

Over the past decade, a growing body of literature has led to a greater understanding of the relationship between anemia and the outcomes in patients with heart failure. This article reviews the current literature on the association between anemia and a broad range of clinical outcomes, including mortality, hospitalization, health status, and cost.

Anemia and iron deficiency in heart failure: mechanisms and therapeutic approaches

Anemia and iron deficiency are common in patients with heart failure (HF), and are associated with worse symptoms and adverse outcomes in this population. Although the two can occur together, anemia in HF is often not caused by iron deficiency, and iron deficiency can be present without causing anemia. Erythropoiesis-stimulating agents have been investigated extensively in the past few years and might be of benefit in patients with HF and anemia. However, concerns have arisen regarding the safety of erythropoiesis-stimulating agents in patients with chronic kidney disease and so the results of a large mortality trial are eagerly awaited to provide information on safety in patients with HF. Iron supplementation or replacement is a much older treatment option for patients with HF and anemia, but questions about the safety of intravenous iron, and absorption problems with oral formulations have prevented its widespread use to date. In the past few years, however, new data on the importance of iron deficiency in HF have become available, and a number of studies with intravenous iron have shown promising results. Therefore, this treatment approach is likely to become an attractive option for patients with HF and iron deficiency, both with and without anemia.

[Characteristics, outcome and predictors of one year mortality rate in patients with acute heart failure]

BACKGROUND/AIM

Acute heart failure (AHF) is one of the most common diseases in emergency medicine, associated with poor prognosis and high in-hospital and long-term mortality. The aim of this study was to investigate characteristics, outcomes and one year mortality of patients with AHF in the local population.

METHODS

This prospective study consisted of 64 consecutive unselected patients treated in the Coronary Care Unit of the Emergency Centre (Clinical Center of Serbia, Belgrade) and were followed for one year after the discharge.

RESULTS

Mean age of the patients was 63.6 +/- 12.6 years and 59.4% were males. Acute congestion (43.8%) and pulmonary edema (39.1%) were the most common presentations of AHF. Mean left ventricular ejection fraction (LVEF) was 39.7% +/- 9.25%, while 44.4% of the patients had LVEF > or = 50%. At discharge, 55.9% of the patients received therapy with P-blockers, 94.9% diuretics, out of which 47.7% spironolactone, 94.9% patients were given ACE-inhibitors or angiotensin receptor blockers (ARB). The 12-month all-cause mortality was 26.5%. Independent predictors of one year mortality were previous hospitalization due to heart disease, reduced LVEF, reduced fraction of shortening (FS) and a higher tricuspid velocity.

CONCLUSION

One year mortality of our patients with AHF was high, similar to the known European studies. Independent predictors of one year mortality were previous hospitalization due to heart disease, reduced LVEF and LVFS and a higher tricuspid velocity.

An update on the controversies in anemia management in chronic kidney disease: lessons learned and lost

Background. Erythropoietin deficiency and anemia occur in Chronic Kidney Disease (CKD) and may be treated with Erythropoietin Stimulating Agents (ESAs). The optimal hemoglobin, in non-End Stage Renal Disease CKD, is controversial. Methods. We review three recent randomized trials in anemia in CKD: CHOIR, CREATE, and TREAT. Results. CHOIR (N = 1432) was terminated early with more frequent death and cardiovascular outcomes in the higher Hb group (HR 1.34: 95% C.I. 1.03-1.74, P = .03). CREATE (N = 603) showed no difference in primary cardiovascular endpoints. Stroke was more common in the higher Hb group (HR 1.92; 95% C.I. 1.38-2.68; P < .001) in TREAT (N = 4038). Conclusions. There is no benefit to an Hb outside the 10-12 g/dL range in this population. To avoid transfusions and improve Quality of Life, ESAs should be used cautiously, especially in patients with Diabetes, CKD, risk factors for stroke, and ESA resistance.

Serum midkine is related to NYHA class and cystatin C in heart transplant recipients

Heart transplantation is now the established method of therapy for end-stage heart failure, with significantly improved outcomes over recent years. However, an increasingly prevalent complication in this population is that chronic kidney disease appears to be generally associated with subclinical inflammation. Midkine is a heparin-binding growth factor with various functions ranging from cell growth and survival to angiogenesis, repair, and inflammation. Recently, serum midkine has been reported to be a novel marker of cardiac events in heart failure patients. The aim of this study was to assess midkine concentration in 134 heart transplant recipients in relation to kidney function and New York Heart Association (NYHA) class. Heart transplant recipients had significantly higher serum creatinine, urea, cholesterol, triglycerides, fasting glucose, white blood cell count, and serum midkine, and lower estimated glomerular filtration rate than the control group. Serum midkine levels rose together with advancing NYHA class. Serum midkine was related to kidney function, NT-proBNP, transferrin, and prednisone dose. Cystatin C and NT-proBNP class turn out to be predictors of midkine in heart transplant recipients. Midkine levels are dependent on heart and kidney function, and might also represent a surrogate marker of subclinical inflammation.

Advancements in anemias related to chronic conditions

Anemia of chronic disease (ACD), the most frequent anemia among hospitalized patients, occurs in chronic inflammatory disorders, such as chronic infections, cancer and autoimmune diseases. Different causes contribute to ACD including diversion of iron traffic, diminished erythropoiesis, blunted response to erythropoietin, erythrophagocytosis, hematologic malignancies and solid tumors. A particular case of ACD is represented by anemia of chronic kidney disease (CKD). ACD is characterized by hyposideremia and altered iron transport. Cytokines are implicated in the ACD by reducing erythropoiesis and increasing iron sequestration in the reticuloendothelial system. The regulation of iron absorption across the epithelium of the proximal small intestine is essential for maintaining body iron concentrations within a physiologically defined range. Hepcidin controls cellular iron efflux by binding to the iron export protein ferroportin, causing ferroportin to be phosphorylated and degraded in lysosomes. Finally, hepcidin inhibits iron release from the reticulo-endothelial system. Increased expression of hepcidin leads to decreased iron absorption and iron deficient anemia. Hepcidin, therefore, is a negative regulator of iron transport in plasma. Causes of anemia in patients with CKD are multifactorial, but the most well-known cause is inadequate erythropoietin production. In these patients, anemia increases the risk of either cardiovascular disease or renal failure.

Characteristics and outcomes among heart failure patients with anemia and renal insufficiency with and without blood transfusions (public discharge data from California 2000-2006)

Renal insufficiency and anemia are increasingly recognized as predictors of adverse events in heart failure. The impact of blood transfusion on mortality in patients with heart failure has not been previously characterized. We examined temporal changes in admissions and in-hospital mortality using public discharge data from California (2000 to 2006) and then evaluated the impact of renal insufficiency, anemia, and transfusion on in-hospital mortality in univariate and multivariate analyses. In total 596,456 unique patient admissions for heart failure were recorded. Renal insufficiency and anemia were common co-morbidities (27.4% and 27.1%, respectively) and 6.2% of patients received a transfusion of red blood cells. Renal insufficiency and anemia were associated with increased mortality (unadjusted odds ratio [OR] 2.45, 95% confidence interval [CI] 2.39 to 2.52, and 1.27, 95% CI 1.24 to 1.30, respectively). After adjustment, renal insufficiency (OR 2.54, 95% CI 2.46 to 2.62) and anemia (OR 1.12 95% CI 1.07 to 1.17) remained significant; however, transfusion emerged as the strongest single predictor (OR 3.81, 95% CI 3.51 to 4.13) of mortality. In conclusion, these data suggest that anemia and renal insufficiency are independently associated with mortality in an unselected heart failure population. This is the first study to demonstrate that transfusion magnifies this effect and is associated with a particularly poor prognosis.

Efficacy and safety of continuous hemodiafiltration for acute decompensated heart failure

The mortality of heart failure patients with renal insufficiency is high, and these patients tend to develop diuretic resistance. Under these conditions, continuous hemodiafiltration (CHDF) is a possible alternative volume reduction therapy to diuretics. However, its efficacy and safety are not clear. Between April 2005 and March 2008, 248 patients with acute decompensated heart failure were admitted to the CCU of Kyoto City Hospital. Of those patients, 31 (20 volume overloaded heart failure, 11 cardiogenic shock) received CHDF therapy, and their weight loss, acute hemodynamic changes, and clinical outcome were assessed to evaluate the efficacy and safety of CHDF therapy. CHDF was performed for 6.5 +/- 6.5 days. There was no significant change in acute hemodynamics after CHDF initiation. In the volume overloaded heart failure (VH) group, significant weight loss was observed at 24 hours and 48 hours after CHDF initiation (P < 0.001). In-hospital mortality of the VH group and cardiogenic shock (CS) group were 10.0% and 54.5%, respectively. CHDF for acute decompensated heart failure (ADHF) is a safe, effective, and reliable volume reduction therapy for volume overloaded heart failure. Further investigation is required to assess the effectiveness of CHDF for cardiogenic shock.

Estimate of maintenance EPO to darbepoetin alfa dose conversion ratio in a hospital-based dialysis patient population

BACKGROUND

Epoetin alfa (EPO) and darbepoetin alfa are erythropoiesis-stimulating agents (ESAs) used to treat anemia in patients with chronic kidney disease. EPO and darbepoetin alfa have a non-proportional dose conversion relationship across the dosing spectrum. However, reports comparing the dose relationship between the two ESAs do not adjust for the non-proportional dose relationship or for population differences. Because drug cost is directly related to dosage, appropriate methods to assess the dose relationship between the two ESAs are important to understand the economic implications of converting patient populations from one ESA treatment to another.

OBJECTIVE

To describe dose conversion methods that take into account the non-proportional dose relationship between EPO and darbepoetin alfa, and calculate the dose conversion ratio (DCR) between the two ESAs in a hospital-based dialysis patient population.

METHODS

This was a retrospective observational study where longitudinal data from medical charts were collected for chronic hemodialysis patients being treated at hospital-based dialysis centers. Mean maintenance DCRs were calculated at the population level for hemodialysis patients converted from EPO to darbepoetin alfa treatment and subsequently maintained on darbepoetin alfa. Two methods were used to determine the DCRs: a regression-based method using ordinary least squares regression, and ratio-based method using an arithmetic mean.

RESULTS

The estimated population mean maintenance DCR for the population in this analysis was 320:1 (Units EPO:µg darbepoetin alfa) using the regression-based method, and 350:1 using the ratio-based method. Sensitivity analysis yielded DCRs ranging from 311 to 333:1.

CONCLUSIONS

The two methods in estimating the DCR presented here provide payers with an empirical way of comparing ESA utilization for pharmacoeconomic evaluation. DCR results may vary according to patient characteristics; however, mean DCRs of greater than 300:1 were obtained in this analysis. Exclusion of other patient-related factors that may influence ESA dose is a possible limitation of the study.

Anemia and chronic kidney disease are potential risk factors for mortality in stroke patients: a historic cohort study

Background

Chronic kidney disease (CKD) is associated to a higher stroke risk. Anemia is a common consequence of CKD, and is also a possible risk factor for cerebrovascular diseases. The purpose of this study was to examine if anemia and CKD are independent risk factors for mortality after stroke.

Methods

This historic cohort study was based on a stroke registry and included patients treated for a first clinical stroke in the stroke unit of one academic hospital over a three-year period. Mortality predictors comprised demographic characteristics, CKD, glomerular filtration rate (GFR), anemia and other stroke risk factors. GFR was estimated by means of the simplified Modification of Diet in Renal Disease formula. Renal function was assessed according to the Kidney Disease Outcomes Quality Initiative (K/DOQI)-CKD classification in five groups. A value of hemoglobin < 120 g/L in women and < 130 g/L in men on admission defined anemia. Kaplan-Meier survival curves and Cox models were used to describe and analyze one-year survival.

Results

Among 890 adult stroke patients, the mean (Standard Deviation) calculated GFR was 64.3 (17.8) ml/min/1.73 m² and 17% had anemia. Eighty-two (10%) patients died during the first year after discharge. Among those, 50 (61%) had K/DOQI CKD stages 3 to 5 and 32 (39%) stages 1 or 2 (p < 0.001). Anemia was associated with an increased risk of death one year after discharge (p < 0.001). After adjustment for other factors, a higher hemoglobin level was independently associated with decreased mortality one year after discharge [hazard ratio (95% CI) 0.98 (0.97-1.00)].

Conclusions

Both CKD and anemia are frequent among stroke patients and are potential risk factors for decreased one-year survival. The inclusion of patients with a first-ever clinical stroke only and the determination of anemia based on one single measure, on admission, constitute limitations to the external validity. We should investigate if an early detection and management of both CKD and anemia could improve survival in stroke patients.

Changes in erythropoiesis-stimulating agent (ESA) dosing and haemoglobin levels in US non-dialysis chronic kidney disease patients between 2005 and 2009

BACKGROUND

Recent clinical trials in cancer patients treated with erythropoiesis-stimulating agents (ESAs) and in CKD patients treated to haemoglobin (Hb) targets above the labeled range of 10-12 g/dL with ESAs raised safety concerns regarding ESA therapy. Subsequently, product labeling was revised including addition of a black-box warning and removal of many quality of life claims not supported by current standards, and there were changes in reimbursement and anaemia guidelines. The extent to which these events influenced ESA dosing and Hb levels in patients with chronic kidney disease not on dialysis (CKD-NOD) is not known.

METHODS

We used data collected in a series of cross-sectional surveys between March 2005 and July 2009. Patients with CKD-NOD were selected from a random sample of free-standing US nephrology clinics. Information on demographics, insurance information, laboratory data and ESA use was abstracted from medical records by site investigators. We evaluated ESA treatment (use and dosing) and Hb levels over time and used multivariate linear regression to assess changes in ESA doses and Hb levels over time adjusting for case-mix differences.

RESULTS

Between 2005 and 2009, 15 836 CKD-NOD patients were sampled. During this period, ESA use declined from 60 to 46%, and the mean dose declined from 176 to 136 mcg/month; the largest decline in use and in dose occurred beginning in 2007. Simultaneously, the mean (standard deviation) Hb level in ESA-treated patients declined from 11.5 (1.4) to 10.6 (1.2) g/dL, though the decline was most pronounced starting in 2007. As the mean Hb declined, the percent of treated patients with an Hb > 12 g/dL dropped from 27 to 12%, and the mean dose in this sub-population declined from 173 to 111 mcg/month.

CONCLUSION

The emergence of safety concerns and the subsequent changes in product labeling, reimbursement and clinical practice guidelines all appear to have influenced physician dosing practices resulting in less frequent use of ESAs, lower ESA doses and lower achieved Hb levels in CKD-NOD patients.

Anemia Evaluation and Management in Nursing Home Residents

Anemia is often an unrecognized and/or undertreated diagnosis in older adults. Failure to diagnose anemia leads to delayed treatment and thus delayed relief of symptoms. Given the potentially significant impact of anemia on cardiovascular disease and physical performance among older nursing home (NH) residents, it is important to evaluate current clinical practice related to anemia.The purpose of this secondary data analysis was to evaluate the frequency of laboratory evaluation and medication treatment for anemia among older NH residents. Results indicated that more than half of NH residents were anemic at baseline, and of those, less than 20% had additional testing done to further evaluate for an underlying cause of their anemia and only 45.3% received any pharmacologic treatment. Future research is needed to clarify the potential benefits of timely diagnosis and appropriate treatment for anemic older adults in long-term-care settings and establish evidence-based guidelines to direct care in this area.

[Are de novo acute heart failure and acutely worsened chronic heart failure two subgroups of the same syndrome?]

INTRODUCTION

Acute heart failure (AHF) is one of the most common diseases in emergency medicine, associated with poor prognosis and high in-hospital and long-term mortality.

OBJECTIVE

To investigate clinical presentation of patients with de novo AHF and acute worsening of chronic heart failure (CHF) and to identify differences in blood levels of biomarkers and echocardiography findings.

METHODS

This prospective study comprised 64 consecutive patients being grouped according to the onset of the disease into patients with the de novo AHF (45.3%), and patients with acute worsening of CHF (54.7%).

RESULTS

Acute congestion (60%) was the most common manifestation of de novo AHF, whereas pulmonary oedema (43.1%) was the most common manifestation of acutely decompensated CHF. Patients with acutely decompensated CHF had significantly higher blood values of creatinine (147.10 vs 113.16 micromol/l; p < 0.05), urea (12.63 vs. 7.82 mmol/l; p < 0.05), BNP (1440.11 vs. 712.24 pg/ml; p < 001) and NTproBNP (9097.00 vs. 2827.70 pg/ml; p < 0.01) on admission, and lower values of M-mode left ventricular ejection fraction (LVEF) during hospitalization (49.44% vs. 42.94%; p < 0.05). The follow-up after one year revealed still significantly higher BNP (365.49 vs. 164.02 pg/ml; p < 0.05) and lower average values of both LVEF in patients with acutely worsened CHF (46.62% vs. 54.41% and 39.52% vs. 47.88%; p < 0.05).

CONCLUSION

Considering differences in clinical severity on admission, echocardiography and natriuretic peptide values during hospitalization and after one year follow-up, de novo AHF and acutely worsened CHF are two different subgroups of the same syndrome.

Epidemiology of cardiorenal syndrome

The interdependence of cardiac and renal dysfunction has emerged as a focus of intense interest in heart failure management due to the substantial associated morbidity and mortality. Captured in the clinical entity known as cardiorenal syndrome, recent definitions afford discussion of the acute and longitudinal evaluation and management of these patients. This article discusses potential pathophysiologic mechanisms of cardiorenal syndrome, epidemiology, inpatient and long-term care (including investigational therapies and mechanical fluid removal), and end-of-life and palliative care.

Managing anemia in patients with chronic heart failure: what do we know?

Anemia is common in patients with chronic heart failure (HF) with an incidence ranging from 4% to 55% depending on the studied population. Several studies have highlighted that the prevalence of anemia increases with worsening heart failure as reflected by New York Heart Association classification. Additionally, several epidemiological studies have highlighted its role as a prognostic marker, linking it to worse outcomes including; malnutrition, increased hospitalizations, refractory heart failure and death. The pathophysiology of anemia is multifactorial and related to various factors including; hemodilution, iron losses from anti-platelet drugs, activation of the inflammatory cascade, urinary losses of erythropoietin and associated renal insufficiency. There are a host of epidemiological studies examining HF outcomes and anemia, but only a few randomized trials addressing this issue. The purpose of this article is to review the literature that examines the interrelationship of anemia and congestive HF, analyzing its etiology, impact on outcomes and also the role of associated kidney disease as well as cardiorenal syndrome both as a marker of morbidity and mortality.

Anemia and its impact on function in nursing home residents: what do we know?

PURPOSE

To provide the advanced practice nurse (APN) information on the prevalence and causes of anemia in elderly nursing home (NH) residents, in order to affect diagnostic and management strategies that may help improve physical function and mobility outcomes.

DATA SOURCES

Literature review of current peer-reviewed research articles.

CONCLUSIONS

In the United States, the prevalence of anemia increases with advancing age, and are reported to be much higher among older NH residents than among community-dwelling older adults. Causes of anemia among the elderly are often multifactorial. Older individuals with anemia, including mild anemia and even low normal level, have demonstrated lower muscle strength, physical function, mobility, and increased morbidity and mortality outcomes.

IMPLICATIONS FOR PRACTICE

Given the potentially significant relationship between anemia and physical performance outcomes among NH residents, gaining a better understanding will help guide future evidence-based care by allowing the APN an opportunity to tailor both medical and restorative care interventions. Because anemia is a potentially modifiable condition, intervention may preserve, limit, or reverse functional impairment and/or disablement, and allow for maximal functional independence.

Integrated Care of Anemia in Chronic Kidney Disease Patients: Concepts in Intravenous Iron Management: Part One

Chronic kidney disease (CKD) has become a worldwide public health issue with increasing prevalence in the United States. As kidney function declines, anemia or other complications may arise, and hemodialysis (HD) or kidney transplantation may be needed. Early intervention and treatment of CKD complications will improve clinical outcomes and may delay or prevent disease sequelae. Primary or adjuvant iron replacement in CKD patients with anemia is recommended. The National Kidney Foundation guidelines state that patients receiving erythropoiesis-stimulating agent (ESA) therapy and HD will require intravenous (IV) iron for optimal iron stores and ESA efficacy. This article, the first of a two-part series, details the optimization of IV iron therapy in CKD patients, clinical trial evaluation of IV versus oral iron in the non–HD-dependent CKD patient, and a comparison of the four available IV iron agents. The percent changes in ESA utilization in conjunction with iron therapy and the associated cost savings are also addressed. The second article in this series goes on to describe elements of the medication use process for care of CKD patients with anemia.

Mortality after hospitalization for heart failure in blacks compared to whites

Heart failure (HF) disproportionately affects black compared to white Americans, and overall mortality from HF is greater among blacks. Paradoxically, mortality rates after a hospitalization for HF are lower in black than in white patients. These racial differences might reflect hospital, physician, and patient factors and could have implications for comparative hospital profiles. We identified published studies reporting the posthospitalization mortality for black and white patients with a discharge diagnosis of HF and conducted random-effects meta-analyses with the outcome of all-cause mortality. We included 29 cohorts of hospitalized black and white patients with HF. The unadjusted mean mortality rate after HF hospitalization for black and white patients, respectively, was 6% and 9% for in-hospital, 6% and 10% for 30-day, 10% and 15% for 60- to 180-day, 28% and 34% for 1-year, and 41% and 47% for >1-year follow-up, respectively. The unadjusted combined odds ratios for mortality in black versus white patients ranged from 0.48 for in-hospital (95% confidence interval [CI] 0.45 to 0.51) to 0.77 after >1 year follow-up (95% CI 0.75 to 0.79). In meta-analyses using adjusted data, the combined odds ratio was 0.68 for short-term mortality (95% CI 0.63 to 0.74), and the combined hazard ratio was 0.84 for long-term mortality (95% CI 0.77 to 0.91). In conclusion, mortality after hospitalization for HF was 32% lower during short-term follow-up and 16% lower during long-term follow-up for black than for white patients. The mortality differences imply unmeasured differences by race in clinical severity of illness at hospital admission and might lead to biased hospital mortality profiles.

Clinical practice: heart failure in children. Part I: clinical evaluation, diagnostic testing, and initial medical management

Current evidence suggests that almost half of all children with cardiomyopathy and symptomatic heart failure will die or require a cardiac transplant within 5 years of diagnosis. The recognition, diagnostic assessment, and treatment of heart failure in children are therefore challenging undertakings, to say the least. It involves an assessment of cardiac appearance and function, adaptation of the child as a whole, and a diagnostic approach that evaluates many possible root causes. This review is intended to assist the practicing pediatrician and cardiologist by providing a framework for this diagnostic assessment and to give an overview of the treatment options available for children with heart failure. In this first part, we will focus on clinical evaluation, diagnostic testing, and initial medical management. In the second part of this series, the maintenance treatment and treatment options applicable when medical treatment is insufficient will be addressed.

Prospective evaluation of the association between hemoglobin concentration and quality of life in patients with heart failure

BACKGROUND

Reduced hemoglobin has been associated with adverse outcomes in heart failure, but the relationship of hemoglobin to health-related quality of life in outpatients with this syndrome has not been well studied.

METHODS

We used data from the prospective, observational Study of Anemia in a Heart Failure Population Registry, which randomly selected outpatients with heart failure from specialty or community cardiology clinics. Hemoglobin was determined by finger stick at baseline and during medically indicated follow-up visits. Health-related quality of life was assessed using the Kansas City Cardiomyopathy Questionnaire and the Minnesota Living with Heart Failure Questionnaire at 3-month intervals for 12 months.

RESULTS

Adjusted regression analysis demonstrated a significant, direct, linear relationship between hemoglobin and health-related quality of life from baseline through 12 months follow-up on all Kansas City Cardiomyopathy Questionnaire domains (all P < .001) and the Summary and Physical domains of the Minnesota Living with Heart Failure Questionnaire (all P < .05). Adjusted categorical analysis of the change in Kansas City Cardiomyopathy Questionnaire Clinical scores associated with change in hemoglobin from baseline to 6 months also showed a significant relationship between increasing hemoglobin and improved health status (5.9 +/- 1.8 units for a hemoglobin increase of >or=1 g/dL, 0.7 +/- 1.2 units for change in hemoglobin <1 g/dL, and -2.6 +/- 1.4 units for a >or=1 g/dL decrease in hemoglobin, P < .001).

CONCLUSIONS

These prospective, observational results indicate that reduced hemoglobin is associated with poorer quality of life in patients with heart failure. Additional studies will be required to establish if this is a cause-and-effect relationship.