Liver dysfunction and its nutritional implications in heart failure

Predictive value of the prognostic nutritional index combined with serum chloride levels for the prognosis of patients with acute decompensated heart failure

BACKGROUND

The prognostic nutritional index (PNI) and serum chloride level are related to adverse outcomes in patients with heart failure. However, little is known about the relationship between the PNI and serum chloride level in predicting the poor prognosis of patients with acute decompensated heart failure (ADHF).

METHODS AND RESULTS

We reviewed 1221 consecutive patients with ADHF admitted to the First Affiliated Hospital of Kunming Medical University from January 2017 to October 2021. After excluding patients with in hospital death, missing follow-up data, missing chloride data, missing lymphocyte (LYM) count data, or missing serum albumin data, 805 patients were included. PNI was calculated using the formula: serum albumin (ALB) (g/L) + 5 × LYM count (10^9/L). Patients were divided into 4 groups according to the quartiles of the PNI, and the highest PNI quartile (PNI Q4: PNI ≥ 47.3) was set as the reference group. The patients in the lowest PNI quartile (PNI Q1: PNI < 40.8) had the lowest cumulative survival rate, and mortality risk decreased progressively through the quartiles (log-rank χ2 142.283, P < 0.0001). Patients with ADHF were divided into 8 groups by quartiles of PNI and median levels of serum chloride. After adjustment, the hazard ratio (HR) for all-cause mortality in ADHF patients in Group 1 was 8.7 times higher than that in the reference Group 8. Furthermore, the addition of serum chloride level and PNI quartile to the Cox model increased the area under the Receiver operating characteristic (ROC) curve by 0.05, and the area under the ROC curve of the new model was higher than that of the original model with traditional risk factors.

CONCLUSIONS

Both the lowest PNI quartiles and low chloride level indicate a higher risk of all-cause death in patients with ADHF.

Chronic heart failure induces early defenestration of liver sinusoidal endothelial cells (LSECs) in mice

AIM

Chronic heart failure (CHF) is often linked to liver malfunction and systemic endothelial dysfunction. However, whether cardio-hepatic interactions in heart failure involve dysfunction of liver sinusoidal endothelial cells (LSECs) is not known. Here we characterize LSECs phenotype in early and end stages of chronic heart failure in a murine model.

METHODS

Right ventricle (RV) function, features of congestive hepatopathy, and the phenotype of primary LSECs were characterized in Tgαq*44 mice, with cardiomyocyte-specific overexpression of the Gαq protein, at the age of 4- and 12-month representative for early and end-stage phases of CHF, respectively.

RESULTS

4- and 12-month-old Tgαq*44 mice displayed progressive impairment of RV function and alterations in hepatic blood flow velocity resulting in hepatic congestion with elevated GGT and bilirubin plasma levels and decreased albumin concentration without gross liver pathology. LSECs isolated from 4- and 12-month-old Tgαq*44 mice displayed significant loss of fenestrae with impaired functional response to cytochalasin B, significant changes in proteome related to cytoskeleton remodeling, and altered vasoprotective function. However, LSECs barrier function and bioenergetics were largely preserved. In 4- and 12-month-old Tgαq*44 mice, LSECs defenestration was associated with prolonged postprandial hypertriglyceridemia and in 12-month-old Tgαq*44 mice with proteomic changes of hepatocytes indicative of altered lipid metabolism.

CONCLUSION

Tgαq*44 mice displayed right-sided HF and altered hepatic blood flow leading to LSECs dysfunction involving defenestration, shift in eicosanoid profile, and proteomic changes. LSECs dysfunction appears as an early and persistent event in CHF, preceding congestive hepatopathy and contributing to alterations in lipoprotein transport and CHF pathophysiology.

Prognostic value of metabolic syndrome in patients with heart failure and malnutrition

BACKGROUND

Malnutrition is severely associated with worst prognosis of patients with heart failure (HF). Malnourished patients with the metabolic syndrome (MS) can result in a double burden of malnutrition. We aimed to investigate the impact of the MS on clinical outcomes in malnourished HF patients.

METHODS

We examined 529 HF patients at risk of malnutrition with a mean age of (66 ± 10) years and 78% (415) were male. Nutritional status defined primarily by the prognostic nutritional index (PNI), with PNI < 40 being defined as malnutrition. The follow-up endpoint was cardiovascular death or all-cause death.

RESULTS

During the 36-month follow-up, survival rates for cardiovascular and all-cause death were significantly lower in the MS group than in the non-MS group (log-rank P < 0.01). Multivariate Cox proportional hazards regression models showed that MS was independently associated with cardiovascular death (HR:1.759, 95%CI:1.351-2.291, p < 0.001) and all-cause death (HR:1.326, 95%CI:1.041-1.689, p = 0.022) in malnourished patients with HF. MS significantly increased the predictive value of cardiovascular death (AUC:0.669, 95%CI:0.623-0.715, p < 0.001) and all-cause death (AUC:0.636, 95%CI:0.585-0.687, p < 0.001) on the basis of established risk factors. The predictive effect of MS on cardiovascular death was independent of sex, age, functional class and left ventricular ejection fraction.

CONCLUSIONS

In malnourished patients with HF, MS is an independent risk factor for cardiovascular and all-cause mortality. MS significantly enhance the predictive value for clinical events in patients.

Prognostic Nutritional Index (PNI) as a Predictor in Patients with Metabolic Syndrome and Heart Failure

Purpose

There is a lack of research on nutritional status and poor prognosis in patients with metabolic syndrome and heart failure. This study evaluated the relationship between nutritional status as defined by the PNI and adverse outcomes in patients with metabolic syndrome and heart failure.

Methods

A total of 1048 heart failure patients with metabolic syndrome admitted to the Heart Center of the First Affiliated Hospital of Xinjiang Medical University from January 2015 to December 2019 were consecutively. PNI was used to assess their nutritional status.

Results

A total of 51.0% of the patients were in the nonmalnutrition group (PNI≥45), 27.9% were in the mild malnutrition group (40≤PNI<45), and 21.1% of patients were in the malnutrition group (PNI<40). At 36 months of follow-up, after adjusting for other confounding factors, malnutrition (PNI<40) was independently associated with all-cause death (HR: 1.787, 95% CI: 1.451-2.201, P<0.001) and cardiovascular death (HR: 1.837, 95% CI: 1.467-2.301, P<0.001). PNI showed additional prognostic predictive value when included in the established risk factor model, both for all-cause death (AUC: 0.620, 95% CI: 0.579-0.661, P<0.001) and cardiovascular death (AUC: 0.596, 95% CI: 0.555-0.636, P<0.001).

Conclusion

In patients with metabolic syndrome and heart failure, malnutrition assessed by PNI is an independent predictor for all-cause death and cardiovascular death, and PNI is negatively correlated with the occurrence of adverse outcomes.

Controlling nutritional status score predicts 2-year outcomes in elderly patients admitted for acute heart failure

BACKGROUND

Heart failure (HF) is a major cause of death among the elderly. Its prevalence increases dramatically with age. The prevalence of malnourished subjects is high in hospitalized elderly patients. We aimed to investigate the prognostic role of malnutrition, assessed by controlling nutritional status (CONUT) score, on adverse clinical outcomes in the elderly admitted for acute HF.

METHODS

We enrolled 293 patients (mean age 84 years; 48% men) consecutively admitted for acute HF to the Internal Medicine or Geriatrics Divisions at the 'IRCCS Sacro Cuore-Don Calabria' Hospital of Negrar (Verona, Italy) from 2013 to 2015. We predicted the risk of all-cause death, re-hospitalizations for HF and non-HF causes, and the composite of all-cause death or hospitalizations over 2-year follow-up. Patients were divided into four groups according to CONUT score: normal-CONUT (0-1; n = 30); mild-CONUT (2-3; n = 56); moderate-CONUT (4-7; n = 171); and severe-CONUT (≥ 8; n = 36).

RESULTS

Higher CONUT scores were associated with older age and lower entry blood pressures. No difference in hemodynamics was noted at the discharge. Kaplan-Meier curves showed a significant association between worsening CONUT scores and risk of all-cause death (p < 0.01), re-hospitalizations (p < 0.01), or both (p < 0.001). Cox regression analysis revealed these significant associations persisted after adjustment for age, sex, pre-existing cardiovascular disease, diabetes, chronic kidney disease, heart rate, systolic blood pressure, and plasma brain natriuretic peptide levels at discharge (all-cause mortality HR = 1.29 (1.00-1.66), p = 0.049; hospitalization for HF HR = 1.36 (1.03-1.81), p = 0.033; hospitalization for non-HF HR = 1.38 (1.03-1.86), p = 0.034; composite outcome HR = 1.33 (1.07-1.64), p = 0.01).

CONCLUSIONS

Malnutrition, assessed by the CONUT score, is common among elderly patients admitted for acute HF and is strongly related to increased long-term risk of all-cause death and re-hospitalizations.

Prognostic value of non-alcoholic fatty liver disease fibrosis score in patients undergoing cardiac resynchronization therapy

BACKGROUND

Cardiac resynchronization therapy (CRT) is an effective option in the treatment of patients with heart failure and wide QRS. Non-alcoholic fatty liver disease (NAFLD) fibrosis score (NFS) has been shown to predict cardiac events in several patient populations. However, the relationship between NFS and response to CRT has not been investigated. The aim of the study was to investigate the predictive role of NFS in the assessment of response after CRT.

METHODS

Three hundred thirty-six patients with heart failure undergoing CRT were prospectively studied. Liver fibrosis were assessed according to the non-alcoholic fatty liver disease fibrosis score (NFS), which includes age, body mass index, impaired fasting glycemia or diabetes mellitus, aspartate aminotransferase /alanine aminotransferase ratio, platelets, and albumin. Echocardiographic response to CRT was defined by a ≥15% reduction in left ventricular end-systolic volume at six months at follow-up.

RESULTS

Two hundred thirty-eight patients (71%) had CRT response after 6 months of follow-up. Receiver-operator characteristic curve analysis showed NFS cutoff value of < -1.12 for predicting CRT response with a sensitivity of 70.4% and a specificity of 52.9%. The patients were also divided into four groups according to the quartiles of NFS. The proportion of response to CRT was increased with lower level of NFS value. Multivariate logistic regression analysis demonstrated the NFS score < -1.12 and LVIDs were independent predictors of the CRT response. In the second model of analysis which included NFS, quartiles demonstrated that fourth NFS quartile and LVIDs were independent predictors of CRT response.

CONCLUSION

Liver fibrosis assessed by NFS can provide valuable information to predict reverse remodeling in patients undergoing CRT. The present study supports monitoring of NFS to improve preoperative risk stratification of these patients.

A novel nomogram for predicting risk of malnutrition in patients with heart failure

Background and aims

This study aimed to explore the risk factors of malnutrition in patients with heart failure and construct a novel nomogram model.

Methods and results

A cross-sectional study based on the STROBE checklist. Patients with heart failure from July 2020 to August 2021 were included. Patients were divided into a malnutrition group and a normal nutrition group based on the Society's recommended AND-ASPEN standard. Logistic regression was used to analyze the independent risk factors for malnutrition. A new prediction model of nomogram was constructed based on the risk factors, and its fit and prediction performance were evaluated. Of 433 patients, 66 (15.2%) had malnutrition and 367 (84.8%) had normal nutrition, Logistic regression analyses showed that the risk factors for malnutrition were total protein, hemoglobin, triglyceride, and glucose levels. The regression model based on the above four variables showed an area under the curve of 0.858. The novel nomogram model had a sensitivity of 78.5% and a specificity of 77.3%. After 2000 bootstrap resampling iterations, AUC was 0.852.

Conclusions

The novel nomogram model can predict the odds of malnutrition in patients with heart failure at the early stage of admission, and can provide a reference for nursing staff to optimize nutritional care for inpatient with heart failure and to develop a discharge nutritional care plan.

Antioxidant effects of Se-glutathione peroxidase in alcoholic liver disease

Oxidative damage induced by ethanol and its metabolites is one of the factors that fuels the development of alcoholic liver disease (ALD). Selenium (Se) is an effective cofactor for glutathione peroxidase (GPx), and has antioxidant effects that improve ALD. In patients with ALD, ethanol-induced oxidative damage inhibits the synthesis of related Se-containing proteins such as: selenoprotein P (Sepp1), albumin (ALB), and GPx in the liver, thus decreasing the overall Se level in patients. Both Se deficiency and excess can affect the expression of GPx, resulting in damage to the antioxidant defense system. This damage enhances oxidative stress by increasing the levels of reactive oxygen species (ROS) in the body, which aggravates the inflammatory response, lipid metabolism disorder, and lipid peroxidation and worsens ALD symptoms. A cascade of oxidative damages caused by ALD will deplete selenium deposition in the body, stimulate the expression of Gpx1, Sepp1, and Gpx4, and thus mobilize systemic selenoproteins, which can restore GPx activity in the hepatocytes of ALD patients, reduce the levels of reactive oxygen species and alleviate oxidative stress, the inflammatory response, lipid metabolism disorder, and lipid peroxidation, thus helping to mitigate ALD. This review provides a reference for future ALD studies that evaluate the regulation of Se levels and contributes to studies on the potential pathological mechanisms of Se imbalance in ALD.

Change in Nutritional Status during Hospitalization and Prognosis in Patients with Heart Failure with Preserved Ejection Fraction

The impact of changes in nutritional status during hospitalization on prognosis in patients with heart failure with preserved ejection fraction (HFpEF) remains unknown. We examined the association between changes in the Geriatric Nutritional Risk Index (GNRI) and prognosis during hospitalization in patients with HFpEF stratified by nutritional status on admission. Nutritional status did and did not worsen in 348 and 349 of 697 patients with high GNRI on admission, and in 142 and 143 of 285 patients with low GNRI on admission, respectively. Kaplan–Meier analysis revealed no difference in risk of the composite endpoint, all-cause death, or heart failure admission between patients with high GNRI on admission whose nutritional status did and did not worsen. In contrast, patients with low GNRI on admission whose nutritional status did not worsen had a significantly lower risk of the composite endpoint and all-cause death than those who did. Multivariable analysis revealed that worsening nutritional status was independently associated with a higher risk of the composite endpoint and all-cause mortality in patients with low GNRI on admission. Changes in nutritional status during hospitalization were thus associated with prognosis in patients with malnutrition on admission, but not in patients without malnutrition among those with HFpEF.

Prevalence and impact of malnutrition on readmission among hospitalized patients with heart failure in China

AIMS

Malnutrition is common in patients with heart failure (HF) and is associated with poorer quality of life and increased mortality; however, an effective screening tool for malnutrition and its impact on the readmission of patients with HF is uncertain. Our objectives were to study (i) the nutritional status of Chinese hospitalized patients with HF and its impact on readmission and (ii) the validity of seven malnutrition screening tools.

METHODS AND RESULTS

In this study, univariate and multivariate analyses of Cox proportional hazards regression were used to determine important predictors of readmission. The endpoint was readmission due to HF or non-HF. A total of 402 patients were included (66.4% male, median age 62 years [range: 20-92 years], median NT-proBNP 5,229 ng/L). During a median follow-up of 159 days, 150 patients (37%) were readmitted to the hospital. After adjusting for confounders, only malnutrition assessed using the Controlling Nutritional Status (CONUT) nutrition score was independently associated with readmission (P = 0.0293). A base model for predicting readmission with a C-statistic of 0.680 and subsequent addition of various nutritional screening tools improved its performance over the base model. Patients with malnutrition had a twofold increased risk of readmission.

CONCLUSIONS

We found that the prevalence of malnutrition among hospitalized patients with HF in China is very high and that malnutrition significantly increases the risk of readmission in these patients. CONUT is a validated screening tool for malnutrition and may provide valuable prognostic information.

Prediction of all-cause mortality with malnutrition assessed by nutritional screening and assessment tools in patients with heart failure：a systematic review

BACKGROUND AND AIMS

In the absence of a gold standard or scientific consensus regarding the nutritional evaluation of heart failure (HF) patients, this study aimed to summarize and systematically evaluate the prognostic value of nutritional screening and assessment tools used for all-cause mortality in HF patients.

METHODS AND RESULTS

Relevant studies were retrieved from major databases (PubMed, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), WanFang Data, and China Biology Medicine disc (CMB)) and searched from the earliest available date until July 2021. If three or more studies used the same tool, meta-analysis using RevMan 5.3 was performed. This systematic review was registered at PROSPERO (number CRD42021275575). A total of 36 articles involving 25,141 HF patients were included for qualitative analysis and 31 studies for quantitative analysis. Meta-analysis of these studies indicated, poor nutritional status evaluated by using 5 nutritional screening tools (Prognostic Nutritional Index (PNI), Geriatric Nutritional Risk Index (GNRI), Controlling Nutritional Status Score (CONUT), Nutritional Risk Index (NRI), and Short Form Mini Nutritional Assessment (MNA-SF)) or 2 nutritional assessment tools (the Mini Nutritional Assessment (MNA) and Generated Subjective Global Assessment (SGA)) predicted all-cause mortality in HF patients. Of all tools analyzed, MNA had the maximum HR for mortality [HR = 2.62, 95%CI 1.11-6.20, P = 0.03] and MNA-SF [HR = 1.94, 95%CI 1.40-2.70, P＜0.001] was the best nutritional screening tools.

CONCLUSION

Poor nutritional status predicted all-cause mortality in HF patients. MNA may be the best nutritional assessment tool, and MNA-SF is most recommended for HF patient nutritional screening. The application value of MNA, especially in patients with reduced left ventricular ejection fraction (LVEF), needs to be further confirmed. The clinical application value of Mini-Nutrition Assessment Special for Heart Failure (MNA-HF) and Global Leadership Initiative on Malnutrition (GLIM) in HF patients needs to be confirmed.

An Up-to-Date Article Regarding Particularities of Drug Treatment in Patients with Chronic Heart Failure

Since the prevalence of heart failure (HF) increases with age, HF is now one of the most common reasons for the hospitalization of elderly people. Although the treatment strategies and overall outcomes of HF patients have improved over time, hospitalization and mortality rates remain elevated, especially in developed countries where populations are aging. Therefore, this paper is intended to be a valuable multidisciplinary source of information for both doctors (cardiologists and general physicians) and pharmacists in order to decrease the morbidity and mortality of heart failure patients. We address several aspects regarding pharmacological treatment (including new approaches in HF treatment strategies [sacubitril/valsartan combination and sodium glucose co-transporter-2 inhibitors]), as well as the particularities of patients (age-induced changes and sex differences) and treatment (pharmacokinetic and pharmacodynamic changes in drugs; cardiorenal syndrome). The article also highlights several drugs and food supplements that may worsen the prognosis of HF patients and discusses some potential drug-drug interactions, their consequences and recommendations for health care providers, as well as the risks of adverse drug reactions and treatment discontinuation, as an interdisciplinary approach to treatment is essential for HF patients.

Association between Preoperative Retrograde Hepatic Vein Flow and Acute Kidney Injury after Cardiac Surgery

Key questions: Is there a predictive value of hepatic venous flow patterns for postoperative acute kidney injury (AKI) after cardiac surgery? Key findings: In patients who underwent cardiac surgery, retrograde hepatic venous waves (A, V) and their respective ratio to anterograde waves showed a strong association with postoperative AKI, defined as the percentage change of the highest postoperative serum creatinine from the baseline preoperative concentration (%ΔCr). The velocity time integral (VTI) of the retrograde A wave and the ratio of the retrograde and anterograde waves’ VTI were independently associated with AKI after adjustment for disease severity. Take-home message: A higher ratio of retrograde/antegrade waves in hepatic venous retrograde waves, which are related to hepatic stasis, may predict AKI after cardiac surgery. Introduction: Hepatic venous flow patterns reflect pressure changes in the right ventricle and are also markers of systemic venous congestion. Pulsatility of the inferior caval vein was used to predict the risk of acute kidney injury (AKI) after cardiac surgery. Aims: Our objective was to evaluate the association between preoperative hepatic venous flow patterns and the risk of AKI in patients after cardiac surgery. Methods: This prospective, observational study included 98 patients without preexisting liver disease who underwent cardiac surgery between 1 January 2018, and 31 March 2020, at a tertiary heart center. In addition to a routine echocardiographic examination, we recorded the maximal velocity and velocity time integral (VTI) of the standard four waves in the common hepatic vein with Doppler ultrasound. Our primary outcome measure was postoperative AKI, defined as the percentage change of the highest postoperative serum creatinine from the baseline preoperative concentration (%ΔCr). The secondary outcome was AKI, defined by KDIGO (Kidney Disease Improving Global Outcomes) criteria. Results: The median age of the patients was 69.8 years (interquartile range [IQR 25−75] 13 years). Seventeen patients (17.3%) developed postoperative AKI based on the KDIGO. The VTI of the retrograde A waves in the hepatic veins showed a strong correlation (B: 0.714; p = 0.0001) with an increase in creatinine levels after cardiac surgery. The velocity time integral (VTI) of the A wave (B = 0.038, 95% CI = 0.025−0.051, p < 0.001) and the ratio of VTI of the retrograde and anterograde waves (B = 0.233, 95% CI = 0.112−0.356, p < 0.001) were independently associated with an increase in creatinine levels. Conclusions: The severity of hepatic venous regurgitation can be a sign of venous congestion and seems to be related to the development of AKI.

Specialized Pro-Resolving Lipid Mediators in Neonatal Cardiovascular Physiology and Diseases

Cardiovascular disease remains a leading cause of mortality worldwide. Unresolved inflammation plays a critical role in cardiovascular diseases development. Specialized Pro-Resolving Mediators (SPMs), derived from long chain polyunsaturated fatty acids (LCPUFAs), enhances the host defense, by resolving the inflammation and tissue repair. In addition, SPMs also have anti-inflammatory properties. These physiological effects depend on the availability of LCPUFAs precursors and cellular metabolic balance. Most of the studies have focused on the impact of SPMs in adult cardiovascular health and diseases. In this review, we discuss LCPUFAs metabolism, SPMs, and their potential effect on cardiovascular health and diseases primarily focusing in neonates. A better understanding of the role of these SPMs in cardiovascular health and diseases in neonates could lead to the development of novel therapeutic approaches in cardiovascular dysfunction.

Higher fatty liver index is associated with increased risk of new onset heart failure in healthy adults: a nationwide population-based study in Korea

Background

Heart failure (HF) is relatively common cardiovascular disease with high mortality and morbidity. Although it is associated with many cardiovascular risk factors, the association between nonalcoholic fatty liver disease (NAFLD), the most common chronic liver disease, and HF has not been evaluated in a large-scale cohort study. Thus, we evaluated the ability of the fatty liver Index (FLI), a surrogate marker of NAFLD, to predict the development of HF in healthy individuals.

Methods

We analyzed the association between the FLI and new-onset HF with multivariate Cox proportional-hazards models in 308,578 healthy persons without comorbidities who underwent the National Health check-ups in the republic of Korea from 2009 to 2014.

Results

A total of 2532 subjects (0.8%) were newly diagnosed with HF during the study period (a median of 5.4 years). We categorized our subjects into quartile groups according to FLI (Q1, 0–4.9; Q2, 5.0–12.5; Q3, 12.6–31.0; and Q4, > 31.0). The cumulative incidence of HF was significantly higher in the highest FLI group than in the lowest FLI group (Q1, 307 [0.4%] and Q4, 890 [1.2%]; P < 0.001). Adjusted hazard ratio (HRs) indicated that the highest FLI group was independently associated with an increased risk for HF (HR between Q4 and Q1, 2.709; 95% confidence interval = 2.380–3.085; P < 0.001). FLI was significantly associated with an increased risk of new-onset HF regardless of their baseline characteristics.

Conclusions

Higher FLI was independently associated with increased risk of HF in a healthy Korean population.

Nutritional status is associated with physical function and disability in older adults with chronic heart failure

BACKGROUND

The association between nutritional status (NS) and physical performance and disability in older adults with chronic heart failure (CHF) is not well established. We aimed at evaluating whether NS, estimated using the Mini Nutritional Assessment (MNA), is associated with gait speed (GS) and disability (ADL/IADL impairment) in this population and to assess whether energy intake (EI) and appendicular skeletal muscle mass index (ASMMI) influence this relationship.

METHODS

In this cross-sectional study we enrolled 88 older adults admitted to a cardiology outpatient clinic for CHF. MNA was analyzed both as continuous and categorical variable (risk of malnutrition [RM]/well-nourished [WN]). The association between NS and GS and disability was assessed using linear and logistic regression models, respectively, crude, adjusted firstly for age, sex, ejection fraction, and mood status, and then for EI and ASMMI.

RESULTS

Mean age was 77.8 years, 73% were men. MNA score was positively associated with GS: β adjusted = 0.022, P = 0.035; the coefficient was unaffected by adjustment for EI and ASMMI (β = 0.022, P = 0.052). Compared to WN, RM participants had a lower gait speed (0.82 vs 0.99 m/s, P = 0.006); the difference was attenuated after adjustment for potential confounders (β - = 0.138, P = 0.055). MNA score was inversely associated with ADL impairment (Adjusted OR: 0.80, 95%CI 0.64-0.98), but not with IADL impairment (Adjusted OR: 0.94, 95%CI 0.78-1.13).

CONCLUSION

Reduced MNA score is associated with poorer physical function and ADL impairment in older adults affected by CHF, independently of EI and ASMMI. Routinely evaluation of NS should be performed in this population.

Pharmacokinetics of single dose sildenafil orally administered in canine models of chronic embolic pulmonary hypertension

Information regarding the pharmacokinetics of oral sildenafil in dogs with pulmonary hypertension is limited. In this study, we examined the pharmacokinetics of oral sildenafil in a canine model of chronic embolic pulmonary hypertension (CEPH). The CEPH model was developed by repeatedly injecting microspheres into the pulmonary arteries. The pharmacokinetics of oral sildenafil at 1, 2 and 4 mg/kg was evaluated using four dogs with pulmonary hypertension in the fasted state. The plasma concentrations of sildenafil were determined using high-performance liquid chromatography, and pharmacokinetic parameters were calculated using a noncompartmental analysis. Sildenafil was well tolerated in this study. Proportional increments in the maximum plasma concentration and area under the curve extrapolated to infinity at drug doses of 1, 2 and 4 mg/kg were detected using a power model analysis. No significant differences were observed among the three doses in the time to maximum plasma concentration. The mean residence time and elimination half-life were slightly but significantly higher at a dose of 4 mg/kg than at a dose of 1 mg/kg.

Positive fluid balance and mortality in adult patients treated with extracorporeal membrane oxygenation: A retrospective study

Background

Intravenous fluid is important for resuscitation and maintenance of circuit flow in patients with extracorporeal membrane oxygenation, but fluid overload is widely recognized as detrimental in critically ill patients. This study aimed to evaluate the association between positive fluid balance and outcomes in adult patients treated with extracorporeal membrane oxygenation.

Methods

This was a retrospective observational study of a tertiary hospital from October 2010 to January 2018. Patients aged ≥18 years who received extracorporeal membrane oxygenation for ≥48 h were included. The fluid balance was determined as the difference between fluid intake and fluid output, and the cumulative fluid balance was calculated as the sum of these values on the preceding days. The primary outcome was hospital mortality.

Results

Of the 123 included extracorporeal membrane oxygenation episodes, 79 were venovenous extracorporeal membrane oxygenation. The hospital mortality rate was 31.7%. Seventy-eight patients underwent continuous renal replacement therapy during their extracorporeal membrane oxygenation course. Non-survivors had a greater cumulative fluid balance (p≤0.001) and a lower cumulative fluid output (p = 0.006) than survivors on day 7. Fluid intake was not significantly different between survivors and non-survivors (p = 0.583). In the multivariate analysis, the cumulative fluid balance (per litre) on day 7, but not on day 3, was associated with increased hospital mortality (adjusted OR: 1.17, 95% CI: 1.06-1.29, p = 0.001).

Conclusions

In adult patients treated with extracorporeal membrane oxygenation, a higher positive cumulative fluid balance on day 7 was associated with increased hospital mortality. The association between positive fluid balance and mortality was mainly influenced by lower fluid output rather than an increase in fluid intake.

Review of nutritional screening and assessment tools and clinical outcomes in heart failure

Recent studies have suggested that undernutrition as defined using multidimensional nutritional evaluation tools may affect clinical outcomes in heart failure (HF). The evidence supporting this correlation is unclear. Therefore, we conducted this systematic review to critically appraise the use of multidimensional evaluation tools in the prediction of clinical outcomes in HF. We performed descriptive analyses of all identified articles involving qualitative analyses. We used STATA to conduct meta-analyses when at least three studies that tested the same type of nutritional assessment or screening tools and used the same outcome were identified. Sensitivity analyses were conducted to validate our positive results. We identified 17 articles with qualitative analyses and 11 with quantitative analysis after comprehensive literature searching and screening. We determined that the prevalence of malnutrition is high in HF (range 16-90 %), particularly in advanced and acute decompensated HF (approximate range 75-90 %). Undernutrition as identified by multidimensional evaluation tools may be significantly associated with hospitalization, length of stay and complications and is particularly strongly associated with high mortality. The meta-analysis revealed that compared with other tools, Mini Nutritional Assessment (MNA) scores were the strongest predictors of mortality in HF [HR (4.32, 95 % CI 2.30-8.11)]. Our results remained reliable after conducting sensitivity analyses. The prevalence of malnutrition is high in HF, particularly in advanced and acute decompensated HF. Moreover, undernutrition as identified by multidimensional evaluation tools is significantly associated with unfavourable prognoses and high mortality in HF.

The impact of non-alcoholic fatty liver disease fibrosis score on cardiac prognosis in patients with chronic heart failure

Liver abnormalities have a strong impact on clinical outcomes in patients with heart failure (HF), and are known as cardio-hepatic syndrome. The non-alcoholic fatty liver disease (NAFLD) fibrosis score (NFS) has been developed to identify liver fibrosis in patients with NAFLD. It remains to be determined whether NFS is associated with cardiovascular prognosis in patients with chronic heart failure (CHF). We calculated NFS in 516 patients with CHF admitted to our hospital. The clinical endpoints were deaths due to progressive HF, myocardial infarction, stroke, and sudden cardiac death, and rehospitalization for worsening HF. There were 173 cardiovascular events noted during a median follow-up of 464 days. Patients with cardiovascular events showed a higher NFS as compared with those without. We divided the patients into four groups according to quartiles of NFS. The proportion of New York Heart Association functional class III/IV and serum brain natriuretic peptide levels were increased with increasing NFS. Kaplan-Meier analysis revealed that cardiovascular event rate was increased with increasing NFS in patients with CHF. In multivariate Cox proportional hazards analysis, NFS was independently associated with cardiovascular events after adjustment for confounding factors. Elevated NFS was associated with unfavorable outcomes in patients with CHF. Liver fibrosis assessed by NFS may provide valuable prognostic information in patients with CHF.

Optimizing Nutrition in Pediatric Heart Failure: The Crisis Is Over and Now It's Time to Feed

Pediatric heart failure is a complex disease occurring when cardiac output is unable to meet the metabolic demands of the body. With improved surgical interventions and medical therapies, survival rates have improved, and care has shifted from focusing on survival to optimizing quality of life and health outcomes. Based on current literature, this review addresses the nutrition needs of infants and children in heart failure and describes the pathophysiology and metabolic implications of this disease. The prevalence of wasting in pediatric heart failure has been reported to be as high as 86%, highlighting the importance of nutrition assessment through all stages of treatment to provide appropriate intake of energy, protein, and micronutrients. The etiology of malnutrition in pediatric heart failure is multifactorial and involves hypermetabolism, decreased intake, increased nutrient losses, inefficient utilization of nutrients, and malabsorption. Children in heart failure often present with tachypnea, tachycardia, fatigue, nausea, and vomiting and consequently may not be able to meet their nutrition requirements through oral intake alone. Nutrition support, including enteral nutrition and parenteral nutrition, should be considered an essential part of routine care. The involvement of multiple allied health professionals may be needed to create a feeding therapy plan to support patients and their families. With appropriate nutrition interventions, clinical outcomes and quality of life can be significantly improved.

Effects of Ganoderma Lucidum shell-broken spore on oxidative stress of the rabbit urinary bladder using an in vivo model of ischemia/reperfusion

Oxidative stress plays an important role in specific disease pathophysiology and the aging process. In the history of human kind, many herbs were utilized for disease prevention and anti-aging treatment. However, there are few direct evidences provided by modern laboratory technology. The current study was designed to evaluate Ganoderma Lucidum's (GL) ability to reduce the damage from in vivo ischemia/reperfusion (I/R) using a rabbit model of I/R that has been effectively utilized to prove the effects of drugs and supplements to reduce oxidative stress. Urinary bladder dysfunction secondary to benign prostatic hyperplasia (BPH) is a major affliction of aging men. One of the major etiologies of obstructive bladder dysfunction (OBD) is oxidative stress induced by I/R. Pharmaceutical studies and clinical research have proven that GL is useful in helping to prevent certain types of pathology and also helpful in prolonging human life in part by acting as an antioxidant. Using an in vivo model of I/R, we have investigated the ability of GL to protect bladder function from oxidative damage mediated by I/R. Our studies demonstrated that ischemia followed by reperfusion resulted in a significant decrease in bladder compliance and decreases in the contractile responses to a variety of forms of contractile stimulation. Pretreatment of rabbits with Ganoderma Lucidum prior to subjecting the rabbits to I/R completely inhibited the negative effects of I/R on both the compliance and contractile responses. These results demonstrate that Ganoderma provides excellent protection of bladder function following I/R (oxidative stress).

Relationship between worsening renal function and long-term cardiovascular mortality in heart failure patients

BACKGROUND

Recently several studies showed that worsening renal function (WRF) during hospitalization might be a strong independent predictor of poor prognosis in decompensated heart failure (HF) patients. However, these studies had a relatively short follow-up duration and their data were limited to in-hospital outcomes. Our purpose was to assess the relationship between WRF and long-term cardiovascular mortality in HF patients.

METHODS

We enrolled decompensated HF patients who were admitted to our hospital between April 2010 and March 2015. WRF was defined as a relative increase in serum creatinine of at least 25% or an absolute increase in serum creatinine ≥0.3mg/dL from the baseline. We assessed the cardiovascular mortality and all-cause mortality in HF patients with WRF (WRF group) and without WRF (no WRF group).

RESULTS

Among 301 patients enrolled, WRF developed in 118 patients (39.2%). During a median follow-up period of 537days [interquartile range, 304.3 to 1025.8days], cardiovascular mortality and all-cause mortality were significantly higher in the WRF group than in the no WRF group (23.2% vs. 6.1%, P<0.001; 30.3% vs. 14.7%, P<0.001, respectively). In the multivariate Cox proportional hazards model, age and serum B-type natriuretic peptide (BNP) level were associated with both cardiovascular death and all-cause death. However, WRF was not the independent predictor of cardiovascular death (P=0.19) nor all-cause death (P=0.57).

CONCLUSIONS

WRF was associated with cardiovascular death in patients with HF. Although not an independent predictor, WRF might be one of useful markers to identify patients who should be followed carefully after discharge.

Echocardiography and NAFLD (non-alcoholic fatty liver disease)

Non-alcoholic-fatty-liver-disease (NAFLD) is associated with atherosclerosis, increased cardiovascular risks and mortality. We investigated if, independently of insulin resistance, diet, physical activity and obesity, fatty liver involvement has any relationship with echocardiographic measurements in NAFLD.

PATIENTS AND METHODS

660 NAFLD and 791 non-NAFLD subjects, referred to the same out-patients medical unit for lifestyle-nutritional prescription, were studied. Congestive heart failure, myocardial infarction, malignancies, diabetes mellitus, extreme obesity, underweight-bad-nourished subjects and renal insufficiency were exclusion criteria. Liver steatosis was assessed by Ultrasound-Bright-Liver-Score (BLS), left ventricular ejection fraction (LVEF), trans-mitral E/A doppler ratio (diastolic relaxation) and left ventricular myocardial mass (LVMM/m(2)) by echocardiography. Doppler Renal artery Resistive Index (RRI), insulin resistance (HOMA) and lifestyle profile were also included in the clinical assessment.

RESULTS

LVMM/m(2) is significantly greater in NAFLD, 101.62±34.48 vs. 88.22±25.61, p<0.0001 both in men and in women. Ejection fraction is slightly smaller only in men with NAFLD; no significant difference was observed for the E/A ratio. BMI (30.42±5.49 vs. 24.87±3.81; p<0.0001) and HOMA (2.90±1.70 vs. 1.85±1.25; p: 0.0001) were significantly greater in NAFLD patients. By Multiple-Linear-Regression, NAFLD and unhealthy dietary profile are associated also in lean non-diabetic subjects with lower systolic function, independently of BMI, dietary profile, physical activity, RRI and insulin resistance.

CONCLUSION

NAFLD may be a meaningful early clue suggestive of diminishing heart function, with similar determining factors. NAFLD is amenable to management and improvement by lifestyle change counseling, addressing a dual target: reducing fatty liver, which is easily monitored by ultrasound, and, independently, maintaining a normal heart function.

Liquid chromatography-tandem mass spectrometry method for simultaneous quantification of bisoprolol, ramiprilat, propranolol and midazolam in rat dried blood spots

Dried blood spot (DBS) sampling represents a suitable method for pharmacokinetic studies in rats, particularly if serial sampling is needed. To study the pharmacokinetics of drugs in a rat heart failure (HF) model, we developed and validated a method for the simultaneous determination of bisoprolol, ramiprilat, propranolol and midazolam in DBS samples. Bisoprolol and ramipril are widely used in the treatment of HF, and midazolam and propranolol are markers of hepatic metabolism, which can be altered in HF. A 20μL sample of rat blood was pipetted onto Whatman 903 Protein Saver Card and allowed to dry. The whole spot was excised and 300μL of solvent (methanol with 10% ultrapure water and 0.1% formic acid) was added. After mixing and incubating the sample in an ultrasonic bath, a mixture of isotopically labeled internal standards was added. After centrifugation, the extracts were cleaned on an Ostro™ plate and analyzed using liquid chromatography-tandem mass spectroscopy. The method was successfully validated. No significant interference was observed in the retention times of analytes or internal standards. The intraday and interday accuracy and precision were within a ±15% interval. The method was linear in the range 5-250μg/L and the lower limit of quantification was 5μg/L for all four analytes. The absolute matrix effect ranged from 98.7% for midazolam to 121% for ramiprilat. The recovery was lowest for ramiprilat and highest for propranolol. Samples were stable at all tested temperatures. The method has been used successfully in a real-time pharmacokinetic study in rats.

New Approaches to Treating Cardiac Cachexia in the Older Patient

Congestive heart failure (CHF) is a leading cause of morbidity and mortality in the elderly, accounting for more hospitalizations than any other condition. Advanced stages of congestive heart failure can be associated with serious complications such as cardiac cachexia (defined here as unintentional weight loss of more than 6% in 6 months). Cardiac cachexia and the associated progressive weight loss are sometimes overlooked by older patients, their families and care providers. A delay in the diagnosis can result in further loss of vital organ tissue, progressive weakness, fall-related injuries and even long-term care institutionalization and/or death. During the past several years, researchers have begun to broaden their understanding of this common, morbid and often fatal condition, and these findings will help to characterize the features that assist in its diagnosis, minimize its exacerbation, delay the progressive decline, and educate clinicians about the potential management options.

Pharmacokinetics of drugs in cachectic patients: a systematic review

Cachexia is a weight-loss process caused by an underlying chronic disease such as cancer, chronic heart failure, chronic obstructive pulmonary disease, or rheumatoid arthritis. It leads to changes in body structure and function that may influence the pharmacokinetics of drugs. Changes in gut function and decreased subcutaneous tissue may influence the absorption of orally and transdermally applied drugs. Altered body composition and plasma protein concentration may affect drug distribution. Changes in the expression and function of metabolic enzymes could influence the metabolism of drugs, and their renal excretion could be affected by possible reduction in kidney function. Because no general guidelines exist for drug dose adjustments in cachectic patients, we conducted a systematic search to identify articles that investigated the pharmacokinetics of drugs in cachectic patients.

Hepatic function and the cardiometabolic syndrome

Despite skeletal muscle being considered by many as the source of insulin resistance, physiology tells us that the liver is a central and cardinal regulator of glucose homeostasis. This is sometimes underestimated because, in contrast with muscle, investigations of liver function are technically very difficult. Nevertheless, recent experimental and clinical research has demonstrated clearly that, due in part to its anatomic position, the liver is exquisitely sensitive to insulin and other hormonal and neural factors, either by direct intrahepatic mechanisms or indirectly by organ cross-talk with muscle or adipose tissue. Because the liver receives absorbed nutrients, these have a direct impact on liver function, whether via a caloric excess or via the nature of food components (eg, fructose, many lipids, and trans fatty acids). An emerging observation with a possibly great future is the increase in intestinal permeability observed as a consequence of high fat intake or bacterial modifications in microbiota, whereby substances normally not crossing the gut gain access to the liver, where inflammation, oxidative stress, and lipid accumulation leads to fatty liver, a situation observed very early in the development of diabetes. The visceral adipose tissue located nearby is another main source of inflammatory substances and oxidative stress, and also acts on hepatocytes and Kupffer cells, resulting in stimulation of macrophages. Liberation of these substances, in particular triglycerides and inflammation factors, into the circulation leads to ectopic fat deposition and vascular damage. Therefore, the liver is directly involved in the development of the prediabetic cardiometabolic syndrome. Treatments are mainly metformin, and possibly statins and vitamin D. A very promising avenue is treatment of the leaky gut, which appears increasingly to be an important causal factor in hepatic insulin resistance and steatosis.