Cardiogenic shock and acute kidney injury: the rule rather than the exception

Acute kidney injury and in-hospital outcomes after transcatheter aortic valve replacement in patients without chronic kidney disease: insights from the national inpatient sample

BACKGROUND

Acute kidney injury (AKI) complicates transcatheter aortic valve replacement (TAVR), leading to higher mortality. The incidence and effects of AKI on clinical outcomes in patients undergoing TAVR without chronic kidney disease (CKD) are unclear. We aimed to determine the association between AKI and in-hospital outcomes in patients with TAVR using propensity score matching (PSM).

METHODS

Using International Classification of Diseases-10th Revision codes, we queried the National Inpatient Sample for TAVR performed between 2016 and 2021. Patients were divided into two groups according to perioperative AKI development. Patients with CKD or on permanent hemodialysis at baseline were excluded. We conducted 1:1 PSM to assemble a cohort of patients with similar baseline characteristics. Multivariate logistic regression was used to assess the association between AKI and in-hospital outcomes. Sensitivity analysis was conducted to evaluate the robustness of our inferences.

RESULTS

Of 47,372 unweighted patient admissions for TAVR, 1617 (3.41%) had a concomitant diagnosis of AKI. The incidence of AKI decreased from 4.82 to 3.18% from 2016 to 2021 (P-trend < 0.01). Before PSM, patients with AKI had a significantly higher rate of in-hospital mortality compared with those without AKI (6.12% vs. 0.48%, respectively; odds ratio [OR] 8.59, 95% confidence interval [CI] 6.32-11.68). Using the PSM algorithm, 1579 well-matched patients were included in each group. After PSM, an association was observed between patients with TAVR and concomitant AKI and a higher risk of in-hospital mortality (6.21% vs. 1.08%, respectively; OR 5.96; 95% CI 3.54-10.04). In subgroup analyses stratified according to age (≤ 80 and > 80 years), sex (male/female), and hypertension status, consistent associations were observed between AKI and the risk of in-hospital mortality. AKI patients were at higher risk for acute myocardial infarction (OR 1.78, 95% CI 1.35-2.34), major bleeding (OR 1.62, 95% CI 1.13-2.33), blood transfusion (OR 1.65, 95% CI 1.28-2.11), and cardiogenic shock (OR 3.73, 95% CI 2.77-5.01). No significant betweengroup differences were observed in stroke (P = 0.12).

CONCLUSION

AKI was a strong predictor of in-hospital mortality in patients undergoing TAVR without CKD and was associated with higher post-procedure complication rates.

Cardiogenic Shock: Focus on Non-Cardiac Biomarkers

PURPOSE OF REVIEW

To examine the evolving multifaceted nature of cardiogenic shock (CS) in the context of non-cardiac biomarkers that may improve CS management and risk stratification.

RECENT FINDINGS

There are increasing data highlighting the role of lactate, glucose, and other markers of inflammation and end-organ dysfunction in CS. These biomarkers provide a more comprehensive understanding of the concurrent hemo-metabolic and cellular disturbances observed in CS and offer insights beyond standard structural and functional cardiac assessments. Non-cardiac biomarkers both refine the diagnostic accuracy and improve the prognostic assessments in CS. Further studies revolving around novel biomarkers are warranted to support more targeted and effective therapeutic and management interventions in these high-risk patients.

Prognostic Factors Associated with Mortality in Cardiogenic Shock - A Systematic Review and Meta-Analysis

BACKGROUND

Cardiogenic shock remains highly associated with early mortality, with mortality often exceeding 50%. We sought to determine the association between prognostic factors and in-hospital and 30-day mortality in cardiogenic shock.

METHODS

We performed a systematic review and meta-analysis of prognostic factors in cardiogenic shock, searching MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for records up to June 5, 2023. English-language studies that investigated prognostic factors and in-hospital and/or 30-day mortality in cardiogenic shock were included. Studies were excluded if they evaluated the pediatric population, were postmortem studies, or included fewer than 100 patients. The primary aim was to identify modifiable and non-modifiable prognostic factors associated with in-hospital and 30-day mortality in cardiogenic shock.

RESULTS

We identified 160 studies, including 2,459,703 patients with a median in-hospital mortality of 41.4% (interquartile range, 33.6% to 49.2%). The majority were retrospective cohort studies. Patient factors potentially associated with an increase in early mortality included an age greater than or equal to 75 years of age, peripheral arterial disease, chronic kidney disease, and female sex. Procedural and presentation factors potentially associated with increased mortality included out-of-hospital cardiac arrest, left main culprit artery, left ventricular ejection fraction less than 30%, dialysis, and need for mechanical circulatory support. Revascularization in the form of coronary artery bypass graft and percutaneous coronary intervention were potentially associated with reduced in-hospital mortality.

CONCLUSIONS

This analysis quantifies the association between patient, presentation, and treatment-related factors and early mortality in cardiogenic shock. Increased certainty in the association of these prognostic factors with cardiogenic shock outcomes can aid in clinical risk assessment, development of risk tools, and analysis of clinical trials.

Acute kidney injury during extracorporeal life support in cardiogenic shock: Does flow matter?

BACKGROUND

This study examines the role of extracorporeal life support flow in the development of acute kidney injury in cardiogenic shock.

METHODS

We performed a retrospective analysis of 465 patients placed on extracorporeal life support at our institution between January 2015 and December 2020 for cardiogenic shock. Flow index was calculated by dividing mean flow by body surface. Stages of acute kidney injury were determined according to Kidney Disease: Improving Global Outcomes (KDIGO) organization guidelines.

RESULTS

There were 179 (38.5%) patients who developed acute kidney injury, 63.1% of which were classified as Stage 3--the only subgroup associated with 1-year mortality (hazard ratio = 2.03, p < .001). Risk of kidney injury increased up to a flow index of 1.6 L/min/m2, and kidney injury was more common among patients with flow index greater than 1.6 L/min/m2 (p = .034). Those with kidney injury had higher baseline lactate levels (4.4 vs 3.1, p = .04), and Stage 3 was associated wit higher baseline creatinine (p < .001).

CONCLUSIONS

In our cohort, kidney injury was common and Stage 3 kidney injury was associated with worse outcomes compared to other stages. Low flow was not associated with increased risk of kidney injury. Elevated baseline lactate and creatinine among patients with acute kidney injury suggest underlying illness severity, rather than flow, may influence kidney injury risk.

Strategies for the Management of Cardiorenal Syndrome in the Acute Hospital Setting

Cardiorenal syndrome (CRS) is a life-threatening disorder that involves a complex interplay between the two organs. Managing this multifaceted syndrome is challenging in the hospital and requires a multidisciplinary approach to tackle the many manifestations and complications. There is no universally accepted algorithm to treat patients, and therapeutic options vary from one patient to another. The mainstays of therapy involve the stabilization of hemodynamics, decongestion using diuretics or renal replacement therapy, improvement of cardiac output with inotropes, and goal-directed medical treatment with renin–angiotensin–aldosterone system inhibitors, beta-blockers, and other medications. Mechanical circulatory support is another viable option in the armamentarium of agents that improve symptoms in select patients.

The medical treatment of cardiogenic shock

Cardiogenic shock is characterized by tissue hypoperfusion due to the inadequate cardiac output to maintain the tissue oxygen demand. Despite some advances in cardiogenic shock management, extremely high mortality is still associated with this clinical syndrome. Its management is based on the immediate stabilization of hemodynamic parameters through medical care and the use of mechanical circulatory supports in specialized centers. This review aims to understand the cardiogenic shock current medical treatment, consisting mainly of inotropic drugs, vasopressors and coronary revascularization. In addition, we highlight the relevance of applying measures to other organ levels based on the optimization of mechanical ventilation and the appropriate initiation of renal replacement therapy.

Prevention and Rehabilitation After Heart Transplantation: A Clinical Consensus Statement of the European Association of Preventive Cardiology, Heart Failure Association of the ESC, and the European Cardio Thoracic Transplant Association, a Section of ESOT

Little is known either about either physical activity patterns, or other lifestyle-related prevention measures in heart transplantation (HTx) recipients. The history of HTx started more than 50 years ago but there are still no guidelines or position papers highlighting the features of prevention and rehabilitation after HTx. The aims of this scientific statement are (i) to explain the importance of prevention and rehabilitation after HTx, and (ii) to promote the factors (modifiable/non-modifiable) that should be addressed after HTx to improve patients' physical capacity, quality of life and survival. All HTx team members have their role to play in the care of these patients and multidisciplinary prevention and rehabilitation programmes designed for transplant recipients. HTx recipients are clearly not healthy disease-free subjects yet they also significantly differ from heart failure patients or those who are supported with mechanical circulatory support. Therefore, prevention and rehabilitation after HTx both need to be specifically tailored to this patient population and be multidisciplinary in nature. Prevention and rehabilitation programmes should be initiated early after HTx and continued during the entire post-transplant journey. This clinical consensus statement focuses on the importance and the characteristics of prevention and rehabilitation designed for HTx recipients.

Exploring Acute Kidney Injury Following Aortic Dissection: A Comprehensive Review of Machine Learning Models for Predicting Risk, Management Strategies, Complications, and Racial and Gender Disparities

Both types of aortic dissection (AD), Stanford type A and type B, can result in complications such as acute kidney injury (AKI) and aortic rupture. Renal complications in AD arise from compromised renal perfusion affecting the renal arteries. Understanding the intricate connection between AD and AKI is crucial for navigating the complexities of tailored treatment and formulating specific management plans. Concerning machine learning models, in patients with type A aortic dissection, factors such as decreased platelet count on admission, increased D-dimer level, longer cardiopulmonary bypass duration, elevated white blood cell levels, the need for blood transfusion, longer aortic clamp time, extended surgery duration, advanced age, and an elevated body mass index were positively associated with the development of AKI. For the risk of AKI after type B aortic dissection, elevated Nt-pro brain natriuretic peptide, prolonged activated partial thromboplastin time, elevated admission systolic blood pressure, and a higher contrast agent requirement during operative repair were found to predict the risk. Male gender was associated with a higher risk of AKI, and nonwhite race was linked to a higher risk of AKI, a greater likelihood of requiring more urgent procedures, and lower levels of insurance coverage. The treatment of AKI following AD requires a multifaceted approach. Identifying and addressing the underlying cause, such as low blood pressure, renal artery involvement, or medication-induced injury, is crucial for effective management and preventing further kidney damage. Maintaining proper fluid balance is essential for improving renal perfusion, but careful monitoring is necessary to avoid complications. The evolving landscape of research, particularly in biomarkers and AI programs, reveals a promising role in predicting the risk for and managing AKI post-AD.

Unraveling Chronic Cardiovascular and Kidney Disorder through the Butterfly Effect

Chronic Cardiovascular and Kidney Disorder (CCKD) represents a growing challenge in healthcare, characterized by the complex interplay between heart and kidney diseases. This manuscript delves into the "butterfly effect" in CCKD, a phenomenon in which acute injuries in one organ lead to progressive dysfunction in the other. Through extensive review, we explore the pathophysiology underlying this effect, emphasizing the roles of acute kidney injury (AKI) and heart failure (HF) in exacerbating each other. We highlight emerging therapies, such as renin-angiotensin-aldosterone system (RAAS) inhibitors, SGLT2 inhibitors, and GLP1 agonists, that show promise in mitigating the progression of CCKD. Additionally, we discuss novel therapeutic targets, including Galectin-3 inhibition and IL33/ST2 pathway modulation, and their potential in altering the course of CCKD. Our comprehensive analysis underscores the importance of recognizing and treating the intertwined nature of cardiac and renal dysfunctions, paving the way for more effective management strategies for this multifaceted syndrome.

Identification of distinct clinical phenotypes of cardiogenic shock using machine learning consensus clustering approach

BACKGROUND

Cardiogenic shock (CS) is a complex state with many underlying causes and associated outcomes. It is still difficult to differentiate between various CS phenotypes. We investigated if the CS phenotypes with distinctive clinical profiles and prognoses might be found using the machine learning (ML) consensus clustering approach.

METHODS

The current study included patients who were diagnosed with CS at the time of admission from the electronic ICU (eICU) Collaborative Research Database. Among 21,925 patients with CS, an unsupervised ML consensus clustering analysis was conducted. The optimal number of clusters was identified by means of the consensus matrix (CM) heat map, cumulative distribution function (CDF), cluster-consensus plots, and the proportion of ambiguously clustered pairs (PAC) analysis. We calculated the standardized mean difference (SMD) of each variable and used the cutoff of ± 0.3 to identify each cluster's key features. We examined the relationship between the phenotypes and several clinical endpoints utilizing logistic regression (LR) analysis.

RESULTS

The consensus cluster analysis identified two clusters (Cluster 1: n = 9,848; Cluster 2: n = 12,077). The key features of patients in Cluster 1, compared with Cluster 2, included: lower blood pressure, lower eGFR (estimated glomerular filtration rate), higher BUN (blood urea nitrogen), higher creatinine, lower albumin, higher potassium, lower bicarbonate, lower red blood cell (RBC), higher red blood cell distribution width (RDW), higher SOFA score, higher APS III score, and higher APACHE IV score on admission. The results of LR analysis showed that the Cluster 2 was associated with lower in-hospital mortality (odds ratio [OR]: 0.374; 95% confidence interval [CI]: 0.347-0.402; P < 0.001), ICU mortality (OR: 0.349; 95% CI: 0.318-0.382; P < 0.001), and the incidence of acute kidney injury (AKI) after admission (OR: 0.478; 95% CI: 0.452-0.505; P < 0.001).

CONCLUSIONS

ML consensus clustering analysis synthesized the pattern of clinical and laboratory data to reveal distinct CS phenotypes with different clinical outcomes.

Clinical Outcomes for Acute Kidney Injury in Acute Myocardial Infarction Patients after Intra-Aortic Balloon Pump Implantation: A Single-Center Observational Study

Background

Acute kidney injury (AKI) is common after cardiac interventional procedures. The prevalence and clinical outcome of AKI in patients with acute myocardial infarction (AMI) after undergoing intra-aortic balloon pump (IABP) implantation remains unknown. The aim of this study was to investigate the incidence, risk factors, and prognosis of AKI in specific patient populations.

Methods

We retrospectively reviewed 319 patients with AMI between January 2017 and December 2021 and who had successfully received IABP implantation. The diagnostic and staging criteria used for AKI were based on guidelines from "Kidney Disease Improving Global Outcomes". The composite endpoint included all-cause mortality, recurrent myocardial infarction, rehospitalization for heart failure, and target vessel revascularization.

Results

A total of 139 patients (43.6%) developed AKI after receiving IABP implantation. These patients showed a higher incidence of major adverse cardiovascular events (hazard ratio [HR]: 1.55, 95% confidence interval [CI]: 1.06-2.26, p = 0.022) and an increased risk of all-cause mortality (HR: 1.62, 95% CI: 1.07-2.44, p = 0.019). Multivariable regression models found that antibiotic use (odds ratio [OR]: 2.07, 95% CI: 1.14-3.74, p = 0.016), duration of IABP use (OR: 1.24, 95% CI: 1.11-1.39, p < 0.001) and initial serum creatinine (SCr) (OR: 1.01, 95% CI: 1.0-1.01, p = 0.01) were independent risk factors for AKI, whereas emergency percutaneous coronary intervention was a protective factor (OR: 0.35, 95% CI: 0.18-0.69, p = 0.003).

Conclusions

AMI patients who received IABP implantation are at high risk of AKI. Close monitoring of these patients is critical, including the assessment of renal function before and after IABP implantation. Additional preventive measures are needed to reduce the risk of AKI in these patients.

Autologous Extracellular Vesicles Attenuate Cardiac Injury in Experimental Atherosclerotic Renovascular Disease More Effectively Than Their Parent Mesenchymal Stem/Stromal Cells

Atherosclerotic renovascular disease (RVD) leads to hypertension, chronic kidney disease (CKD), and heart disease. Intrarenal delivery of mesenchymal stem cells (MSCs) and MSC-derived extracellular vesicles (EVs) attenuate renal injury and suppress release of inflammatory cytokines in porcine RVD. We hypothesized that this strategy would also be useful for cardioprotection. Pigs with renovascular hypertension and metabolic syndrome were studied 4 weeks after treatment with a single intrarenal infusion of autologous MSCs, EVs, or vehicle. Cardiac structure and function were assessed in vivo, and myocardial remodeling and expression of the pro-fibrotic factor growth factor receptor-bound protein-2 (Grb2) were measured ex-vivo. Inflammatory cytokine levels were measured in the systemic circulation and myocardial tissue. Blood pressure was elevated in all RVD groups, but serum creatinine increased in RVD and decreased in both RVD + MSCs and RVD + EVs. RVD-induced diastolic dysfunction (lower E/A ratio) was normalized in both MSCs- and EVs- treated pigs. Intrarenal delivery of MSCs and EVs also attenuated RVD-induced myocardial fibrosis, collagen deposition, and Grb2 expression, yet EVs restored capillary density and inflammation more effectively than MSCs. These observations suggest that autologous EVs attenuate cardiac injury in experimental RVD more effectively than their parent MSCs.

New Insight in Cardiorenal Syndrome: From Biomarkers to Therapy

Cardiorenal syndrome consists in the coexistence of acute or chronic dysfunction of heart and kidneys resulting in a cascade of feedback mechanisms and causing damage to both organs associated with high morbidity and mortality. In the last few years, different biomarkers have been investigated with the aim to achieve an early and accurate diagnosis of cardiorenal syndrome, to provide a prognostic role and to guide the development of targeted pharmacological and non-pharmacological therapies. In such a context, sodium-glucose cotransporter 2 (SGLT2) inhibitors, recommended as the first-line choice in the management of heart failure, might represent a promising strategy in the management of cardiorenal syndrome due to their efficacy in reducing both cardiac and renal outcomes. In this review, we will discuss the current knowledge on the pathophysiology of cardiorenal syndrome in adults, as well as the utility of biomarkers in cardiac and kidney dysfunction and potential insights into novel therapeutics.

Pathophysiology-Based Management of Acute Heart Failure

Even though acute heart failure (AHF) is one of the most common admission diagnoses globally, its pathogenesis is poorly understood, and there are few effective treatments available. Despite an heterogenous onset, congestion is the leading contributor to hospitalization, making it a crucial therapeutic target. Complete decongestion, nevertheless, may be hard to achieve, especially in patients with reduced end organ perfusion. In order to promote a personalised pathophysiological-based therapy for patients with AHF, we will address in this review the pathophysiological principles that underlie the clinical symptoms of AHF as well as examine how to assess them in clinical practice, suggesting that gaining a deeper understanding of pathophysiology might result in significant improvements in HF therapy.

Renal Protection and Hemodynamic Improvement by Impella® Microaxial Pump in Patients with Cardiogenic Shock

Acute kidney injury is one of the most frequent and prognostically relevant complications in cardiogenic shock. The purpose of this study was to evaluate the potential effect of the Impella® pump on hemodynamics and renal organ perfusion in patients with myocardial infarction complicating cardiogenic shock. Between January 2020 and February 2022 patients with infarct-related cardiogenic shock supported with the Impella® pump were included in this single-center prospective short-term study. Changes in hemodynamics on different levels of Impella® support were documented with invasive pulmonal arterial catheter. As far as renal function is concerned, renal perfusion was assessed by determining the renal resistive index (RRI) using Doppler sonography. A total of 50 patients were included in the analysis. The increase in the Impella® output by a mean of 1.0 L/min improved the cardiac index (2.7 ± 0.86 to 3.3 ± 1.1 p < 0.001) and increased central venous oxygen saturation (62.6 ± 11.8% to 67.4 ± 10.5% p < 0.001). On the other side, the systemic vascular resistance (1035 ± 514 N·s/m5 to 902 ± 371 N·s/m5p = 0.012) and the RRI were significantly reduced (0.736 ± 0.07 to 0.62 ± 0.07 p < 0.001). Furthermore, in the overall cohort, a baseline RRI ≥ 0.8 was associated with a higher frequency of renal replacement therapy (71% vs. 39% p = 0.04), whereas the consequent reduction of the RRI below 0.7 during Impella® support improved the glomerular filtration rate (GFR) during hospital stay (15 ± 3 days; 53 ± 16 mL/min to 83 ± 16 mL/min p = 0.04). Impella® support in patients with cardiogenic shock seems to improve hemodynamics and renal organ perfusion. The RRI, a well-known parameter for the early detection of acute kidney injury, can be directly influenced by the Impella® flow rate. Thus, a targeted control of the RRI by the Impella® pump could mediate renal organ protection.

Effects of Genistein on Common Kidney Diseases

Genistein is a naturally occurring phytoestrogen (soy or soybean products) that is classified as an isoflavone, and its structure is similar to that of endogenous estrogens; therefore, genistein can exert an estrogen-like effect via estrogen receptors. Additionally, genistein is a tyrosine kinase inhibitor, which enables it to block abnormal cell growth and proliferation signals through the inhibition of tyrosine kinase. Genistein is also an angiogenesis inhibitor and an antioxidant. Genistein has effects on kidney cells, some of the kidney’s physiological functions, and a variety of kidney diseases. First, genistein exerts a protective effect on normal cells by reducing the inflammatory response, inhibiting apoptosis, inhibiting oxidative stress, inhibiting remodeling, etc., but after cell injury, the protective effect of genistein decreases or even has the opposite effect. Second, genistein can regulate renin intake to maintain blood pressure balance, regulate calcium uptake to regulate Ca²⁺ and Pi balances, and reduce vasodilation to promote diuresis. Third, genistein has beneficial effects on a variety of kidney diseases (including acute kidney disease, kidney cancer, and different chronic kidney diseases), such as reducing symptoms, delaying disease progression, and improving prognosis. Therefore, this paper reviews animal and human studies on the protective effects of genistein on the kidney in vivo and in vitro to provide a reference for clinical research in the future.

Hospitalization Outcomes Related to Acute Kidney Injury in Inpatients With Acute Myocardial Infarction: A Cross-Sectional Nationwide Study

Objective

To delineate the differences in demographic characteristics and hospitalization outcomes in patients with acute myocardial infarction by comorbid acute kidney injury (AKI) and to explore the risk factors for in-hospital mortality due to AKI in acute myocardial infarction (AMI) inpatients.

Methods

We conducted a retrospective cross-sectional study using a nationwide inpatient sample and included 77,585 adult inpatients with AMI and further divided by the presence of a co-diagnosis of AKI. A logistic regression model was used to evaluate the odds ratio (OR) of the association between in-hospital mortality and AKI and other comorbidities.

Results

The prevalence of AKI in AMI inpatients during hospitalization was 11.69%. Among AMI inpatients with AKI, it was prevalent in males (73.9%) and whites (48.8%). Patients with AKI had a higher prevalence of complicated comorbid hypertension (58.7%), diabetes with complications (34.8%), cardiogenic shock (17.4%), and drug abuse (12.3%). Male patients had lower odds of in-hospital mortality (OR 0.69; 95% Cl 0.61-0.79) compared to females. Hispanics had a higher association with mortality (OR 1.45; 95% Cl 1.21-1.74) than whites and other races/ethnicities. Patients who developed cardiogenic shock were at 17 times higher odds of in-hospital mortality (OR 17.25; 95% CI 15.14-19.67), followed by AKI (OR 4.64; 95% CI 4.06-5.31), and alcohol abuse (OR 1.29; 95% CI 1.03-1.64). The in-hospital mortality rate among AMI inpatients with AKI (7.6%) was significantly higher compared to that seen in the non-AKI cohort (0.9%).

Conclusion

AMI inpatients with AKI during hospitalization was prevalent in males and whites. Among the demographic risk factors, females and Hispanics had a higher likelihood of in-hospital mortality during the inpatient management of AMI. Cardiogenic shock and AKI increased the odds of in-hospital mortality compared to other comorbidities in AMI inpatients.

Laboratory Predictors of Prognosis in Cardiogenic Shock Complicating Acute Myocardial Infarction

Cardiogenic shock is a state of reduced cardiac output leading to hypotension, pulmonary congestion, and hypoperfusion of tissues and vital organs. Despite the advances in intensive care over the last years, the morbidity and mortality of patients remain high. The available studies of patients with cardiogenic shock suggest a connection between clinical variables, the level of biomarkers, the results of imaging investigations, strategies of management and the outcome of this group of patients. The management of patients with cardiogenic shock initially complicating acute myocardial infarction is challenging, and the number of studies in this area is growing fast. The purpose of this review is to summarize the currently available evidence on cardiogenic shock initially complicating acute myocardial infarction with particular attention to predictors of prognosis, focusing on laboratory variables (established and new), and to discuss the practical implementation. Currently available scoring systems developed during the past few decades predict the clinical outcome of this group of patients using some of the established biomarkers among other variables. With the new laboratory biomarkers that have shown their predictive value in cardiogenic shock outcomes, a new design of scoring systems would be of interest. Identifying high-risk patients offers the opportunity for early decision-making.

Development and External Validation of a Nomogram for Predicting Acute Kidney Injury in Cardiogenic Shock Patients in Intensive Care Unit

Background

The aim of this study was to construct and external validate a nomogram for predicting cardiogenic shock acute kidney injury (CS-AKI) in patients in intensive care unit (ICU).

Methods

All patients diagnosed with CS from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database and the eICU Collaborative Research Database (eICU-CRD) were included in this study. Least absolute shrinkage and selection operator (LASSO) regression and recursive feature elimination for support vector machine (SVM-RFE) were used to determine the overlapping clinical features associated with CS-AKI. The predictive nomogram was established based on the significant clinical parameters and externally verified in this study.

Results

LASSO regression and SVM-RFE demonstrated that Charlson Comorbidity Index (CCI), usage of mechanical ventilation, SOFA score, white blood cell, albumin, eGFR, anion gap, and positive fluid balance were closely associated with CS-AKI in the training cohort. The predictive nomogram based on the eight parameters showed good predictive performance as calculated by C-index were 0.823 (95% confidence index, 95% CI 0.798-0.849), 0.819 (95% CI 0.769-0.849), and 0.733 (95% CI 0.704-0.763) in the training set, in the internal validation set and in the external validation sets, respectively. Moreover, the nomogram exhibited not only encouraging calibration ability but also great clinical utility in the training set and in the validation sets.

Conclusion

CCI, usage of mechanical ventilation, SOFA score, white blood cell, albumin, eGFR, anion gap, and positive fluid balance were closely associated with CS-AKI. The predictive nomogram for CS-AKI manifested well-predictive ability for the identification of ICU patients with CS-AKI.

Beyond the Cardiorenal Syndrome: Pathophysiological Approaches and Biomarkers for Renal and Cardiac Crosstalk

Cardiorenal syndrome encompasses complex multifactorial facets and carries significant morbidity and mortality worldwide. The bi-directional relationship between the heart and kidneys, where dysfunction in one organ worsens the function of the other, has been the leading motor for research in the last few years. In the pathophysiological process, small noncoding RNAs, epigenetics, vascular growth factors, oxidative stress, hemodynamic factors, and biomarkers play a pivotal role in the development of cardiorenal syndrome. It is therefore important to elucidate all the mechanisms in order to provide diagnostic and treatments tools. This review summarizes the hemodynamic and non-hemodynamic pathways along with biomarkers that could be the next target for diagnosis, treatment, and prognosis in cardiorenal syndrome.

Acute Kidney Injury in Cardiogenic Shock: An Updated Narrative Review

Acute myocardial infarction with cardiogenic shock (AMI-CS) is associated with high mortality and morbidity despite advancements in cardiovascular care. AMI-CS is associated with multiorgan failure of non-cardiac organ systems. Acute kidney injury (AKI) is frequently seen in patients with AMI-CS and is associated with worse mortality and outcomes compared to those without. The pathogenesis of AMI-CS associated with AKI may involve more factors than previously understood. Early use of renal replacement therapies, management of comorbid conditions and judicious fluid administration may help improve outcomes. In this review, we seek to address the etiology, pathophysiology, management, and outcomes of AKI complicating AMI-CS.

Risk stratification in cardiogenic shock: a focus on the available evidence

Cardiogenic shock is a clinical syndrome which is defined as the presence of primary cardiac disorder that results in hypotension together with signs of organ hypoperfusion in the state of normovolaemia or hypervolaemia. It represents a complex life-threatening condition, characterized by a high mortality rate, that requires urgent diagnostic assessment as well as treatment; therefore, it is of paramount important to advocate for a thorough risk stratification. In fact, the early identification of patients that could benefit the most from more aggressive and invasive approaches could facilitate a more efficient resource allocation. This review attempts to critically analyse the current evidence on prognosis in cardiogenic shock, focusing in particular on clinical, laboratoristic and echocardiographic prognostic parameters. Furthermore, it focuses also on the available prognostic scores, highlighting the strengths and the possible pitfalls. Finally, it provides insights into future direction that could be followed in order to ameliorate risk stratification in this delicate subset of patients.

Cardiac Surgery-Related Acute Kidney Injury _ Risk Factors, Clinical Course, Management Suggestions

OBJECTIVE

Acute kidney injury (AKI) is a common complication after cardiac surgery (CS). Because a therapeutic regimen remains scarce, the early implementation of preventive strategies is crucial. The authors investigated risk factors and the typical clinical course of CS-associated AKI (CS-AKI) to derive strategies for perioperative clinical routines.

DESIGN

Retrospective data analysis.

SETTING

The data were collected from clinical routines in a maximum care university hospital.

PARTICIPANTS

Patients.

INTERVENTIONS

The authors retrospectively analyzed data from 538 patients who underwent CS.

MEASUREMENTS AND MAIN RESULTS

The median age of the 466 patients included was 66.6 years; 65.7% were men. AKI occurred in 131 (28.1%) patients, mainly (89.0%) starting postoperatively within 72 hours p. Thirty-one (6.7%) patients showed Kidney Disease Improving Global Outcome AKI stage 3. AKI was significantly more frequent in patients with chronic kidney disease (p < 0.001), emergency admission (p < 0.001), heart failure (p < 0.001), and postoperative complications (p < 0.001). In a multivariate analysis, postoperative CS-AKI risk significantly decreased with each 1 or 10 mL/min preoperative glomerular filtration rate (GFR) (odds ratio, 0.962 and 0.677; 95% confidence interval, 0.947-0.977 and 0.577-0.793; p < 0.001 and p < 0.0001). Only in patients who developed Kidney Disease Improving Global Outcome AKI stage 3, an early postoperative trend to decreased GFR and increased creatinine levels was observed.

CONCLUSIONS

Especially in patients with preexisting CKD and signs of CS-AKI occurring on the day of surgery, close monitoring of renal function should be performed for at least 72 hours after CS to detect an onset of AKI early and initiate renal protective strategies. Optimal preoperative fluid management might prevent postoperative AKI.

Timing of Impella implantation and outcomes in cardiogenic shock or high-risk percutaneous coronary revascularization

Objective

To evaluate the role of the microaxial percutaneous mechanical circulatory support device (Impella® pump) implantation pre‐percutaneous coronary intervention (PCI) versus during/after PCI in cardiogenic shock (CS) and high‐risk PCI populations.

Background

A better understanding of the safety and effectiveness of the Impella and the role of timing of this support initiation in specific clinical settings is of utmost clinical relevance.

Methods

A total of 365 patients treated with Impella 2.5/CP in the 17 centers of the IMP‐IT Registry were included. Through propensity‐score weighting (PSW) analysis, 1‐year clinical outcomes were assessed separately in CS and HR‐PCI patients, stratified by timing of Impella support.

Results

Pre‐procedural insertion was associated with an improvement in 1‐year survival in patients with CS due to acute myocardial infarction (AMI) treated with PCI (p = .04 before PSW, p = .009 after PSW) and HR‐PCI (p < .01 both before and after PSW). Among patients undergoing HR‐PCI, early Impella support was also associated with a lower rate of the composite of mortality, re‐hospitalization for heart failure, and need for left‐ventricular assist device/heart transplantation at 1‐year (p = .04 before PSW, p = .01 after PSW). Furthermore, Impella use during/after PCI was associated with an increased in‐hospital life‐threatening and severe bleeding among patients with AMI‐CS receiving PCI (7 vs. 16%, p = .1) and HR‐PCI (1 vs. 9%, p = .02).

Conclusions

Our findings suggested a survival benefit and reduced rates of major bleeding when a pre‐PCI Impella implantation instead of during‐after procedure was used in the setting of HR‐PCI and AMI‐CS.

Grb2 Induces Cardiorenal Syndrome Type 3: Roles of IL-6, Cardiomyocyte Bioenergetics, and Akt/mTOR Pathway

Cardiorenal syndrome type 3 (CRS-3) is damage to the heart following acute kidney injury (AKI). Although many experiments have found that inflammation, oxidative stress, and cardiomyocyte death are involved in cardiomyocyte pathophysiological alterations during CRS-3, they lack a non-bias analysis to figure out the primary mediator of cardiac dysfunction. Herein proteomic analysis was operated in CRS-3 and growth factor receptor-bound protein 2 (Grb2) was identified as a regulator involving AKI-related myocardial damage. Increased Grb2 was associated with cardiac diastolic dysfunction and mitochondrial bioenergetics impairment; these pathological changes could be reversed through the administration of a Grb2-specific inhibitor during AKI. Molecular investigation illustrated that augmented Grb2 promoted cardiomyocyte mitochondrial metabolism disorder through inhibiting the Akt/mTOR signaling pathway. Besides that, Mouse Inflammation Array Q1 further identified IL-6 as the upstream stimulator of Grb2 upregulation after AKI. Exogenous administration of IL-6 induced cardiomyocyte damage and mitochondrial bioenergetics impairment, whereas these effects were nullified in cardiomyocytes pretreated with Grb2 inhibitor. Our results altogether identify CRS-3 to be caused by the upregulations of IL-6/Grb2 which contribute to cardiac dysfunction through inhibiting the Akt/mTOR signaling pathway and inducing cardiomyocyte mitochondrial bioenergetics impairment. This finding provides a potential target for the clinical treatment of patients with CRS-3.