Renal Hemodynamics and Renin-Angiotensin-Aldosterone System Profiles in Patients With Heart Failure

The protective effects of SGLT-2 inhibitors, GLP-1 receptor agonists, and RAAS blockers against renal injury in patients with type 2 diabetes

Diabetic kidney disease is one of the most severe complications of type 2 diabetes mellitus. Patients with diabetic kidney disease have a worse prognosis in terms of mortality and morbidity, compared with patients who have diabetes alone. Strict control of blood pressure and blood glucose is the primary method for prevention of initial kidney damage and delaying further progression of existing damage. Other management approaches include the use of exogenous drugs that can effectively protect the kidneys from diabetes, such as sodium-glucose transporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and renin-angiotensin-aldosterone system blockers. These drugs may protect against kidney injury through various molecular mechanisms. This review focuses on renal impairment in patients with type 2 diabetes; it discusses the direct and indirect effects of sodium-glucose transporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and renin-angiotensin-aldosterone system blockers on diabetic kidney disease. Finally, it discusses the effects of combination treatment with two or three types of drugs in patients with chronic kidney disease.

RDW and pro-BNP in predicting short-term mortality in geriatric patients presenting to the emergency department with acute decompensated heart failure

To reveal the ability of Red cell Distribution Width (RDW) to predict short-term mortality in geriatric patients presenting to the emergency department with acute heart failure and compare the results with pro B-type Natriuretic Peptide (pro-BNP). This prospective cohort study was conducted to evaluate the data of patients admitted to the emergency department between August 15th, 2021, and November 15th, 2021. The study population enrolled volunteers aged 65 years and over, who presented with acute heart failure signs and symptoms. Demographics, vital parameters, and laboratory parameters were noted. A total of 424 patients were included in the study. The 30 day-mortality rate of the study cohort was 14.4%. Older age, active malignancy, RDW, C-reactive protein, blood urea nitrogen, and pro-BNP were early independent predictors of short-term mortality. pro-BNP was a better predictor than RDW with a greater area under the curve value (0.841 versus 0.752, p=0.045, DeLong equality test). The created multivariate regression model was able to detect the risk of shortterm mortality with high accuracy (area under the curve: 0.943, accuracy: 0.936, sensitivity: 98.1, specificity: 67.2, p<0.001). Initial RDW and pro-BNP were significantly higher in the mortality group among the geriatric patients with acute decompensated heart failure presenting to the emergency department, and pro- BNP was found to be a better predictor of mortality than RDW. RDW presents as a promising hematological marker that aids in the prognosticating short-term mortality in this patient population.

Comprehensive and Safe Decongestion in Acutely Decompensated Heart Failure

PURPOSE OF THE REVIEW

Progressive intravascular, interstitial, and alveolar fluid overload underlies the transition from compensated to acutely decompensated heart failure and loop diuretics are the mainstay of treatment. Adverse effects and resistance to loop diuretics received much attention while the contribution of a depressed cardiac output to diuretic resistance was downplayed.

RECENT FINDINGS

Analysis of experience with positive inotropic agents, especially dobutamine, indicates that enhancement of cardiac output is not consistently associated with increased renal blood flow. However, urinary output and renal sodium excretion increase likely due to dobutamine-mediated decrease in renal and systemic reduced activation of sympathetic nervous- and renin-angiotensin-aldosterone system. Mechanical circulatory support with left ventricular assist devices ascertained the contribution of low cardiac output to diuretic resistance and the pathogenesis and progression of kidney disease in acutely decompensated heart failure. Diuretic resistance commonly occurs in acutely decompensated heart failure. However, failure to resolve fluid overload despite high doses of loop diuretics should alert to the presence of a low cardiac output state.