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Wu L, Rodriguez M, Hachem KE, Tang WHW, Krittanawong C. Management of patients with heart failure and chronic kidney disease. Heart Fail Rev 2024; 29:989-1023. [PMID: 39073666 DOI: 10.1007/s10741-024-10415-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2024] [Indexed: 07/30/2024]
Abstract
Chronic kidney disease (CKD) and heart failure are often co-existing conditions due to a shared pathophysiological process involving neurohormonal activation and hemodynamic maladaptation. A wide range of pharmaceutical and interventional tools are available to patients with CKD, consisting of traditional ones with decades of experience and newer emerging therapies that are rapidly reshaping the landscape of medical care for this population. Management of patients with heart failure and CKD requires a stepwise approach based on renal function and the clinical phenotype of heart failure. This is often challenging due to altered drug pharmacokinetics interactions with various degrees of kidney function and frequent adverse effects from the therapy that lead to poor patient tolerance. Despite a great body of clinical evidence and guidelines that have offered various treatment options for patients with heart failure and CKD, respectively, patients with CKD are still underrepresented in heart failure clinical trials, especially for those with advanced CKD and end-stage renal disease (ESRD). Future studies are needed to better understand the generalizability of these therapeutic options among heart failures with different stages of CKD.
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Affiliation(s)
- Lingling Wu
- Cardiovascular Division, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mario Rodriguez
- John T Milliken Department of Medicine, Division of Cardiovascular disease, Section of Advanced Heart Failure and Transplant, Barnes-Jewish Hospital, Washington University in St. Louis School of Medicine, St. Louis, USA
| | - Karim El Hachem
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland, Clinic, Cleveland, OH, USA
| | - Chayakrit Krittanawong
- Cardiology Division, Section of Cardiology, NYU Langone Health and NYU School of Medicine, 550 First Avenue, New York, NY, 10016, USA.
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2
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Martinez-Morata I, Domingo-Relloso A, Zhang Y, Fretts AM, Pichler G, Garcia Pinilla JM, Umans JG, Cole SA, Sun Y, Shimbo D, Navas-Acien A, Devereux RB. Heart Failure Risk Prediction in a Population With a High Burden of Diabetes: Evidence From the Strong Heart Study. J Am Heart Assoc 2024:e033772. [PMID: 39166432 DOI: 10.1161/jaha.123.033772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 06/06/2024] [Indexed: 08/23/2024]
Abstract
BACKGROUND Despite the high burden of diabetes and cardiovascular risk factors in American Indian communities in the United States, prospective studies of heart failure (HF) in this population group are scarce, and the generalizability of previous HF risk scales may be limited. We developed a parsimonious HF risk prediction equation that accounts for relevant risk factors affecting American Indian communities, focusing on diabetes and kidney damage. METHODS AND RESULTS A total of 3059 participants from the SHS (Strong Heart Study) (56±8 years of age, 58% women) were included. Five hundred seven developed HF. Progressively adjusted Cox proportional hazards models were used to identify risk factors for HF and HF subtypes. Predictors of risk at 5 and 10 years included older age (hazard ratio [HR], 1.79 [95% CI, 1.43-2.25]; HR, 1.68 [95% CI, 1.44-1.95]), smoking (HR, 2.26 [95% CI, 1.23-4.13]; HR, 2.08 [95% CI, 1.41-3.06]), macroalbuminuria (HR, 8.38 [95% CI, 4.44-15.83]; HR, 5.20 [95% CI, 3.42-7.9]), microalbuminuria (HR, 2.72 [95% CI, 1.51-4.90]; HR, 1.92 [95% CI, 1.33, 2.78]), and previous myocardial infarction (HR, 6.58 [95% CI, 2.54-17.03]; HR, 3.87 [95% CI, 2.29-6.54]), respectively. These predictors, together with diabetes diagnosis and glycated hemoglobin were significant at 10 and 28 years. High discrimination performance was achieved (C index, 0.81 [95% CI, 0.76-0.84]; C index, 0.78 [95% CI, 0.75-0.81]; and C index, 0.77 [95% CI, 0.74-0.78] at 5, 10, and up to 28 years of follow up, respectively). Some associations varied across HF subtypes, although diabetes, albuminuria, and previous myocardial infarction were associated with all subtypes. CONCLUSIONS This prospective study of HF risk factors in American Indian communities identifies that smoking, body mass index, and indicators of diabetes control and kidney damage (glycated hemoglobin and albuminuria) are major determinants of HF. Our findings can improve HF risk assessment in populations with a high burden of diabetes.
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Affiliation(s)
- Irene Martinez-Morata
- Department of Environmental Health Sciences Mailman School of Public Health Columbia University New York NY USA
| | - Arce Domingo-Relloso
- Department of Environmental Health Sciences Mailman School of Public Health Columbia University New York NY USA
- Department of Biostatistics Mailman School of Public Health Columbia University New York NY USA
| | - Ying Zhang
- Center for American Indian Health Research, Department of Biostatistics and Epidemiology University of Oklahoma Health Sciences Center Oklahoma City OK USA
| | - Amanda M Fretts
- Cardiovascular Health Research Unit, Department of Epidemiology University of Washington Seattle WA USA
| | - Gernot Pichler
- Department of Cardiology Karl Landsteiner Institute for Cardiovascular and Critical Care Research, Clinic Floridsdorf Vienna Austria
| | - Jose Manuel Garcia Pinilla
- Cardiology Department Hospital Universitario Virgen de la Victoria, IBIMA-BIONAND, University of Malaga Malaga Spain
- Ciber-Cardiovascular Instituto de Salud Carlos III Madrid Spain
- Medicine and Dematology Department University of Malaga Malaga Spain
| | - Jason G Umans
- MedStar Health Research Institute Hyattsville MD USA
- Georgetown-Howard Universities Center for Clinical and Translational Science Washington DC USA
| | - Shelley A Cole
- Population Health Program Texas Biomedical Research Institute San Antonio TX USA
| | - Yifei Sun
- Department of Biostatistics Mailman School of Public Health Columbia University New York NY USA
| | - Daichi Shimbo
- Department of Medicine Columbia University Irving Medical Center New York NY USA
| | - Ana Navas-Acien
- Department of Environmental Health Sciences Mailman School of Public Health Columbia University New York NY USA
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3
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Stefanou E, Tountas C, Ioannidis E, Kole C. Biomarkers in cardiorenal syndrome, a potential use in precision medicine. J Nephrol 2024:10.1007/s40620-024-02047-x. [PMID: 39153147 DOI: 10.1007/s40620-024-02047-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 07/21/2024] [Indexed: 08/19/2024]
Abstract
Cardiorenal syndrome refers to the interrelated dysfunction of the heart or kidney resulting in a cascade of feedback mechanisms, hemodynamic, neurohormonal, and immunological and/or biochemical feedback pathways causing damage in the other organ. Cardiorenal syndrome is categorized into five clinical subtypes depending on the perceived primary precipitant of organ injury and is associated with high morbidity and mortality. Therefore, the development of tools for the earliest identification of cardiorenal syndrome in hospitalized patients is of extremely high significance to ameliorate the prognosis and outcome of these patients. There is increasing interest in identifying molecules serving as biomarkers, reflecting hemodynamic changes, heart and kidney damage and/or dysfunction and oxidative stress-induced cell damage or changes in the extracellular matrix of both the heart and kidneys. Biomarkers provide important insights into the pathophysiology of cardiorenal syndrome and are invaluable tools to predict the decrease in renal function during cardiac dysfunction and vice versa. Based on the pathophysiological mechanisms of cardiorenal syndrome, we reviewed and evaluated the available literature on serum and urinary biomarkers as predictors of kidney and/or heart injury. In addition, heart- and kidney-specific biomarkers were also evaluated based on their reference to kidney and cardiac (dys)function respectively, and whether they would provide any prediction and prognostication of cardiorenal syndrome. In this article, we discuss the current knowledge on the pathophysiology of different types of cardiorenal syndrome, examine the clinical utility of candidate biomarkers in the early diagnosis of cardiorenal syndrome, and guide treatment by evaluating the respective roles of the involved pathophysiological pathways.
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Affiliation(s)
- Eleni Stefanou
- Artificial Kidney Unit, General Hospital of Messinia, Kalamata, Greece
| | - Christos Tountas
- Cardiology Department, Sismanogleio General Hospital of Attica, Athens, Greece
| | - Emmanouil Ioannidis
- Cardiology Department, Sismanogleio General Hospital of Attica, Athens, Greece
| | - Christo Kole
- Cardiology Department, Sismanogleio General Hospital of Attica, Athens, Greece.
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4
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Ma C, Cheng B, Zhou L, Cai S, Qin B, Sun J, Li M, Zhang S, Chen Y, Bao Q, Zhu P, Xu G, Wang S. Association between insulin resistance and vascular damage in an adult population in China: a cross-sectional study. Sci Rep 2024; 14:18472. [PMID: 39122757 PMCID: PMC11315910 DOI: 10.1038/s41598-024-69338-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 08/02/2024] [Indexed: 08/12/2024] Open
Abstract
There is a relative scarcity of large-scale population studies investigating the relationship between the insulin resistance index of homeostasis model assessment (HOMA-IR) and vascular damage. Therefore, we assessed the association between HOMA-IR and vascular damage in adults aged 18 years and older in China. A total of 17,985 research subjects were included. Vascular damage markers and relevant laboratory tests were measured. HOMA-IR was calculated as (fasting insulin * fasting blood glucose)/22.5. Vascular damage included arteriosclerosis (ba-PWV > 1800 cm/s), peripheral artery disease (ABI < 0.9), and microalbuminuria (UACR > 30 mg/g). The relationship between HOMA-IR and vascular damage was analyzed using the RCS. The restricted cubic spline (RCS) analysis suggested that HOMA-IR was nonlinearly associated with arteriosclerosis (P for no-liner < 0.01), peripheral artery disease (P for no-liner < 0.01), and microalbuminuria (P for no-liner < 0.01). Further segmented regression analyses revealed that in study subjects with HOMA-IR < 5, we found that HOMA-IR was associated with an increased OR for arteriosclerosis (OR: 1.36, 95% CI (1.28, 1.45), P < 0.01), peripheral artery disease (OR: 1.33, 95% CI (1.10, 1.60), P < 0.01) and microalbuminuria (OR: 1.59, 95% CI (1.49, 1.70), P < 0.01). HOMA-IR is an independent risk factor for vascular damage, both macrovascular and microvascular. The phenomenon of saturation of HOMA-IR with vascular damage needs further investigation.
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Affiliation(s)
- Cong Ma
- Chinese PLA General Hospital and Medical School of Chinese PLA, Beijing, China
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China
- Department of Health Management, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Bokai Cheng
- Chinese PLA General Hospital and Medical School of Chinese PLA, Beijing, China
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China
- Department of Nephrology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Lin Zhou
- Chinese PLA General Hospital and Medical School of Chinese PLA, Beijing, China
- Department of Geriatrics, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China
| | - Shuang Cai
- Chinese PLA General Hospital and Medical School of Chinese PLA, Beijing, China
- Department of Geriatrics, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China
| | - Bangguo Qin
- Chinese PLA General Hospital and Medical School of Chinese PLA, Beijing, China
- Department of Geriatrics, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China
| | - Jin Sun
- Chinese PLA General Hospital and Medical School of Chinese PLA, Beijing, China
- Department of Geriatrics, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China
| | - Man Li
- Chinese PLA General Hospital and Medical School of Chinese PLA, Beijing, China
- Department of Geriatrics, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China
| | - Shuaishuai Zhang
- Chinese PLA General Hospital and Medical School of Chinese PLA, Beijing, China
- Department of Geriatrics, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China
| | - Yue Chen
- Chinese PLA General Hospital and Medical School of Chinese PLA, Beijing, China
- Department of Geriatrics, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China
| | - Qiligeer Bao
- Chinese PLA General Hospital and Medical School of Chinese PLA, Beijing, China
- Department of Geriatrics, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China
| | - Ping Zhu
- Chinese PLA General Hospital and Medical School of Chinese PLA, Beijing, China.
- Department of Geriatrics, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China.
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China.
| | - Guogang Xu
- Chinese PLA General Hospital and Medical School of Chinese PLA, Beijing, China.
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China.
- Department of Health Management, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China.
| | - Shuxia Wang
- Chinese PLA General Hospital and Medical School of Chinese PLA, Beijing, China.
- Department of Geriatrics, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China.
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28, Fu Xing Road, Haidian District, Beijing, 100853, China.
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5
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Xu X, Cai L, Zhu X, Wang H, Chen T, Zhu H, Lin K. The impact of urinary albumin-creatinine ratio and glomerular filtration rate on long-term mortality in patients with heart failure: The National Health and Nutrition Examination Survey 1999-2018. Nutr Metab Cardiovasc Dis 2024; 34:1477-1487. [PMID: 38418348 DOI: 10.1016/j.numecd.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/15/2023] [Accepted: 01/10/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND AND AIMS The urinary albumin‒creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR) are important markers of renal dysfunction, but few studies have simultaneously examined their impact on long-term mortality in patients with heart failure (HF). METHODS AND RESULTS This study included patients with HF from the National Health and Nutrition Survey from 1999 to 2018. The fully adjusted Cox proportional risk model was adopted, and propensity score matching (PSM) was also used for risk adjustment. Among 988 patients, a median follow-up of 7.75 years was recorded. A higher UACR corresponded to a higher risk of cardiovascular death (P < 0.001 for trend). No statistically significant difference was found in the trend of eGFR risk stratification on the risk of cardiovascular death (P = 0.09 for trend). After PSM, the results showed that when grouped by UACR, the high-risk group had a higher risk of cardiovascular death regardless of a cutoff value of 30 or 300 mg/g (all P < 0.05). When grouped by eGFR, regardless of a cutoff value of 45 or 30 mL/min/1.73 m2, compared to the low-risk group, the high-risk group did not have a statistically significant increase in cardiovascular death (P = 0.086 and P = 0.093, respectively). The subgroup analysis of the main outcome showed an interaction between the UACR and eGFR (P = 0.044). CONCLUSIONS Both the UACR and eGFR are markers for predicting the progression of HF, but the UACR may be a more important indicator than the eGFR, and they synergistically and complementarily reflect the long-term cardiovascular risk of HF patients.
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Affiliation(s)
- Xiaoqun Xu
- Centre of Laboratory Medicine, Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China
| | - Long Cai
- Centre of Laboratory Medicine, Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China
| | - Xinyu Zhu
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Hanxin Wang
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Tielong Chen
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Houyong Zhu
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Kaiqing Lin
- Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China.
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6
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Llàcer P, Cobo Marcos M, de la Espriella R, Gayán Ordás J, Zegri I, Fort A, Rodríguez Chavarri A, Méndez A, Blázquez Z, Caravaca Pérez P, Rubio Gracia J, Fernández C, Recio-Mayoral A, Pomares A, García Pinilla JM, Vazquez López-Ibor J, Castro A, Soler MJ, Górriz JL, Bascompte Claret R, Fluvià P, Manzano L, Núñez J. Congestion as a crucial factor determining albuminuria in patients with cardiorenal disease. Clin Kidney J 2024; 17:sfae140. [PMID: 38835512 PMCID: PMC11145452 DOI: 10.1093/ckj/sfae140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Indexed: 06/06/2024] Open
Abstract
Background Albuminuria could potentially emerge as a novel marker of congestion in acute heart failure. However, the current evidence linking albuminuria and congestion in patients with congestive heart failure (CHF) remains somewhat scarce. This study aimed to evaluate the prevalence of albuminuria in a cohort of patients with CHF, identify the independent factors associated with albuminuria and analyse the correlation with different congestion parameters. Methods This is a subanalysis of the Spanish Cardiorenal Registry, in which we enrolled 864 outpatients with heart failure and a value of urinary albumin:creatinine ratio (UACR) at the first visit. Results The median age was 74 years, 549 (63.5%) were male and 438 (50.7%) had a reduced left ventricular ejection fraction. A total of 350 patients (40.5%) had albuminuria. Among these patients, 386 (33.1%) had a UACR of 30-300 mg/g and 64 (7.4%) had a UACR >300 mg/g. In order of importance, the independent variables associated with higher UACR were estimated glomerular filtration rate determined by the Chronic Kidney Disease Epidemiology Collaboration equation (R2 = 57.6%), systolic blood pressure (R2 = 21.1%), previous furosemide equivalent dose (FED; R2 = 7.5%), antigen carbohydrate 125 (CA125; R2 = 6.1%), diabetes mellitus (R2 = 5.6%) and oedema (R2 = 1.9%). The combined influence of oedema, elevated CA125 levels and the FED accounted for 15.5% of the model's variability. Conclusions In patients with chronic stable heart failure, the prevalence of albuminuria is high. The risk factors of albuminuria in this population are chronic kidney disease and hypertension. Congestion parameters are also associated with increased albuminuria.
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Affiliation(s)
- Pau Llàcer
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
- Department of Medicine and Medical Specialties, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, Madrid, Spain
| | - Marta Cobo Marcos
- Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Madrid, Spain
| | | | - Jara Gayán Ordás
- Department of Cardiology, Hospital Universitario Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida, Lleida, Spain
| | - Isabel Zegri
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Aleix Fort
- Department of Cardiology, Hospital Universitari Dr Josep Trueta, Girona, Spain
| | | | - Ana Méndez
- Department of Cardiology, Hospital Universitario Vall d’Hebron, Barcelona, Spain
| | - Zorba Blázquez
- Department of Cardiology, Hospital Universtiario Gregorio Marañón, Madrid, Spain
| | | | - Jorge Rubio Gracia
- Department of Internal Medicine, Hospital Universitario Lozano Blesa, University of Zaragoza, Zaragoza, Spain
| | - Cristina Fernández
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
- Department of Medicine and Medical Specialties, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, Madrid, Spain
| | | | - Antonia Pomares
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | - Almudena Castro
- Department of Cardiology, Hospital Universitario La Paz, Madrid, Spain
| | - Maria Jose Soler
- Department of Nephrology, Hospital Universitario Vall d´Hebron, Barcelona, Spain
| | - Jose Luis Górriz
- Department of Nephrology, Hospital Clínico Universitario Valencia, University of Valencia, Valencia, Spain
| | - Ramón Bascompte Claret
- Department of Cardiology, Hospital Universitario Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida, Lleida, Spain
| | - Paula Fluvià
- Department of Cardiology, Hospital Universitari Dr Josep Trueta, Girona, Spain
| | - Luis Manzano
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
- Department of Medicine and Medical Specialties, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, Madrid, Spain
| | - Julio Núñez
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Madrid, Spain
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
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7
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Bonacchi G, Rossi VA, Garofalo M, Mollace R, Uccello G, Pieragnoli P, Checchi L, Perrotta L, Voltolini L, Ricciardi G, Beltrami M. Pathophysiological Link and Treatment Implication of Heart Failure and Preserved Ejection Fraction in Patients with Chronic Kidney Disease. Biomedicines 2024; 12:981. [PMID: 38790943 PMCID: PMC11117953 DOI: 10.3390/biomedicines12050981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 05/26/2024] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) results from a complex interplay of age, genetic, cardiac remodeling, and concomitant comorbidities including hypertension, obesity, diabetes, and chronic kidney disease (CKD). Renal failure is an important comorbidity of HFpEF, as well as a major pathophysiological mechanism for those patients at risk of developing HFpEF. Heart failure (HF) and CKD are intertwined conditions sharing common disease pathways; the so-called "kidney tamponade", explained by an increase in intracapsular pressure caused by fluid retention, is only the latest model to explain renal injury in HF. Recognizing the different phenotypes of HFpEF remains a real challenge; the pathophysiological mechanisms of renal dysfunction may differ across the HF spectrum, as well as the prognostic role. A better understanding of the role of cardiorenal interactions in patients with HF in terms of symptom status, disease progression, and prognosis remains essential in HF management. Historically, patients with HF and CKD have been scarcely represented in clinical trial populations. Current concerns affect the practical approach to HF treatment, and, in this context, physicians are frequently hesitant to prescribe and titrate both new and old treatments. Therefore, the extensive application of HF drugs in diverse HF subtypes with numerous comorbidities and different renal dysfunction etiologies remains a controversial matter of discussion. Numerous recently introduced drugs, such as sodium-glucose-linked transporter 2 inhibitors (SGLT2i), constitute a new therapeutic option for patients with HF and CKD. Because of their protective vascular and hormonal actions, the use of these agents may be safely extended to patients with renal dysfunction in the long term. The present review delves into the phenotype of patients with HFpEF and CKD from a pathophysiological perspective, proposing a treatment approach that suggests a practical stepwise algorithm for the proper application of life-saving therapies in clinical practice.
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Affiliation(s)
- Giacomo Bonacchi
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy;
| | | | - Manuel Garofalo
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
| | - Rocco Mollace
- Department of Experimental Medicine, Tor Vergata University, 00133 Rome, Italy;
- Cardiology Unit, Humanitas Gavazzeni, 24125 Bergamo, Italy
| | - Giuseppe Uccello
- Division of Cardiology, “A. Manzoni” Hospital—ASST Lecco, 23900 Lecco, Italy;
| | - Paolo Pieragnoli
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
| | - Luca Checchi
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
| | - Laura Perrotta
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
| | - Luca Voltolini
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy;
- Thoracic Surgery Unit, Careggi University Hospital, 50134 Florence, Italy
| | - Giuseppe Ricciardi
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
| | - Matteo Beltrami
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy;
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
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8
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Yan L, Hu X, Wu S, Chen L, Zhao S. Association between grip strength and albuminuria in the general United States population: NHANES 2011-2014. Front Public Health 2024; 12:1353881. [PMID: 38706553 PMCID: PMC11066252 DOI: 10.3389/fpubh.2024.1353881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 04/08/2024] [Indexed: 05/07/2024] Open
Abstract
Background Grip strength has been shown to be associated with chronic renal insufficiency, but the relationship between grip strength and albuminuria has not been confirmed. In this study, we used NHANES data to explore the association between grip strength and albuminuria in a US population. Methods In this analytical study, we utilized data sourced from the National Health and Nutrition Examination Survey (NHANES), specifically spanning the years 2011 to 2014. The dataset included 9,638 participants aged 20 years or older. After adjusting for potential confounders, multiple regression models were developed to infer the interrelationship between grip strength and albumin to creatinine ratio (ACR), and subgroup analyses were conducted. Results After adjusting for all covariates, ACR by 0.49 mg/g [-0.49 (95% CI: -0.93, -0.04)] for each 1 kg increase in grip strength decreased. Subgroup analysis showed that gender, age, hyperlipidemia, hypertension, diabetes mellitus, smoking, alcohol consumption and body mass index did not influence the negative correlation between grip strength and albuminuria. Conclusion There is a negative correlation between grip strength and albuminuria in the general U.S. population.
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Affiliation(s)
| | | | | | | | - Shunying Zhao
- Department of Cardiosurgery Intensive Care Unit, Ningbo Medical Centre Li Huili Hospital, Ningbo, China
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9
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Katsuya T, Inobe Y, Uchiyama K, Nishikawa T, Hirano K, Kato M, Fukui T, Hatta T, Iwasaki A, Ishii H, Sugiura T, Taguchi T, Tanabe A, Sugimoto K, Shimosawa T. Exploratory study on the relationship between urinary sodium/potassium ratio, salt intake, and the antihypertensive effect of esaxerenone: the ENaK Study. Hypertens Res 2024; 47:835-848. [PMID: 38212366 PMCID: PMC10994843 DOI: 10.1038/s41440-023-01519-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 10/30/2023] [Accepted: 11/05/2023] [Indexed: 01/13/2024]
Abstract
Excessive salt intake is one of the causes of hypertension, and reducing salt intake is important for managing the risk of hypertension and subsequent cardiovascular events. Esaxerenone, a mineralocorticoid receptor blocker, has the potential to exert an antihypertensive effect in hypertensive patients with excessive salt intake, but evidence is still lacking, especially in clinical settings. We aimed to determine if baseline sodium/potassium ratio and baseline estimated 24-h urinary sodium excretion can predict the antihypertensive effect of esaxerenone in patients with essential hypertension inadequately controlled with an angiotensin receptor blocker (ARB) or a calcium channel blocker (CCB). This was an exploratory, open-label, interventional study with a 4-week observation period and a 12-week treatment period. Esaxerenone was orally administered once daily in accordance with the Japanese package insert. In total, 126 patients met the eligibility criteria and were enrolled (ARB subcohort, 67; CCB subcohort, 59); all were included in the full analysis set (FAS) and safety analysis. In the FAS, morning home systolic blood pressure (SBP)/diastolic blood pressure (DBP) significantly decreased from baseline to end of treatment (primary efficacy endpoint) (-11.9 ± 10.9/ - 6.4 ± 6.8 mmHg, both p < 0.001); a similar trend was observed in both subcohorts. Significant reductions were also shown in bedtime home and office SBP/DBP (all p < 0.001). Each BP change was consistent regardless of the urinary sodium/potassium ratio or estimated 24-h urinary sodium excretion at baseline. The urinary albumin-creatinine ratio (UACR) and N-terminal pro-brain natriuretic peptide (NT-proBNP) significantly decreased from baseline to Week 12 in the total population and both subcohorts. No new safety concerns were raised. Esaxerenone significantly decreased morning home, bedtime home, and office BP; UACR; and NT-proBNP in this patient population, regardless of concomitant ARB or CCB use. The antihypertensive effect of esaxerenone was independent of the urinary sodium/potassium ratio and estimated 24-h urinary sodium excretion at baseline.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Toshiyuki Sugiura
- Medical Corporation Association Koukeikai Sugiura Clinic, Kawaguchi, Japan
| | | | | | | | - Tatsuo Shimosawa
- Department of Clinical Laboratory, School of Medicine, International University of Health and Welfare, Narita, Japan
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10
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Streng KW, Hillege HL, Ter Maaten JM, van Veldhuisen DJ, Dickstein K, Samani NJ, Ng LL, Metra M, Filippatos GS, Ponikowski P, Zannad F, Anker SD, van der Meer P, Lang CC, Voors AA, Damman K. Urinary Marker Profiles in Heart Failure with Reduced Versus Preserved Ejection Fraction. J Cardiovasc Transl Res 2024; 17:3-12. [PMID: 36795286 PMCID: PMC10896953 DOI: 10.1007/s12265-023-10356-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 01/18/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Recent data suggest different causes of renal dysfunction between heart failure with reduced (HFrEF) versus preserved ejection fraction (HFpEF). We therefore studied a wide range of urinary markers reflecting different nephron segments in heart failure patients. METHODS In 2070, in chronic heart failure patients, we measured several established and upcoming urinary markers reflecting different nephron segments. RESULTS Mean age was 70 ± 12 years, 74% was male and 81% (n = 1677) had HFrEF. Mean estimated glomerular filtration rate (eGFR) was lower in patients with HFpEF (56 ± 23 versus 63 ± 23 ml/min/1.73 m2, P = 0.001). Patients with HFpEF had significantly higher values of NGAL (58.1 [24.0-124.8] versus 28.1 [14.6-66.9] μg/gCr, P < 0.001) and KIM-1 (2.28 [1.49-4.37] versus 1.79 [0.85-3.49] μg/gCr, P = 0.001). These differences were more pronounced in patients with an eGFR > 60 ml/min/1.73m2. CONCLUSIONS HFpEF patients showed more evidence of tubular damage and/or dysfunction compared with HFrEF patients, in particular when glomerular function was preserved.
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Affiliation(s)
- Koen W Streng
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Hans L Hillege
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Jozine M Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Kenneth Dickstein
- University of Bergen, 5007, Bergen, Norway
- Stavanger University Hospital, Stavanger, Norway
| | - Nilesh J Samani
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
| | - Leong L Ng
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
| | - Marco Metra
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Gerasimos S Filippatos
- Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- University of Cyprus, Nicosia, Cyprus
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Cardiology Department, Military Hospital, Wroclaw, Poland
| | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques Plurithe´Matique 1433, F-CRIN INI-CRCT, INSERM U1116, Universite´ de Lorraine, CHRU de Nancy, Nancy, France
| | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK) and Berlin-Brandenburg Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Peter van der Meer
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Chim C Lang
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, DD1 9SY, Dundee, Scotland
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands.
| | - Kevin Damman
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
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11
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Yoshihara F, Imazu M, Sakuma I, Hiroi Y, Hara H, Okazaki O, Ishiguro C, Izumi C, Noguchi T, Shiraiwa T, Nishioka N, Fujii K, Iwakura K, Tomonaga O, Kobayashi K, Takihata M, Yumoto K, Takase H, Himi T, Shimizu I, Murakami T, Wagatsuma K, Sato K, Hiramatsu T, Akabame S, Hata S, Asakura M, Kawabata T, Omae K, Ito S, Kitakaze M. DAPagliflozin for the attenuation of albuminuria in Patients with h Ea Rt failure and type 2 diabetes (DAPPER study): a multicentre, randomised, open-label, parallel-group, standard treatment-controlled trial. EClinicalMedicine 2023; 66:102334. [PMID: 38192595 PMCID: PMC10772256 DOI: 10.1016/j.eclinm.2023.102334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 01/10/2024] Open
Abstract
Background Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the urinary albumin-to-creatinine ratio (UACR) in patients with elevated levels of albuminuria in the presence or absence of heart failure (HF) or type 2 diabetes mellitus (T2D). However, these effects have not yet been reported in the presence of both HF and T2D. This lack of evidence prompted us to conduct a clinical trial on the effects of dapagliflozin on UACR in patients with HF and T2D. Methods DAPPER is a multicentre, randomised, open-labeled, parallel-group, standard treatment-controlled trial that enrolled patients at 18 medical facilities in Japan. Eligible participants with both HF and T2D and aged between 20 and 85 years were randomly assigned to a dapagliflozin or control (anti-diabetic drugs other than SGLT 2 inhibitors) group with a 1:1 allocation. The primary outcome was changes in UACR from baseline after a two-year observation, and secondary endpoints were cardiovascular (CV) events and parameters related to HF. This trial was registered with the UMIN-CTR registry, UMIN000025102 and the Japan Registry of Clinical Trials, jRCTs051180135. Findings Between 12 May 2017 and 31 March 2020, 294 patients were randomly assigned to the dapagliflozin group (n = 146) or control group (n = 148). The mean age of patients was 72.1 years and 29% were female. The mean glycated hemoglobin value was 6.9%, mean NT-proBNP was 429.1 pg/mL, mean estimated GFR was 65.7 mL/min/1.73 m2, and median UACR was 25.0 (8.8-74.6) mg/g Cr in the dapagliflozin group and 25.6 (8.2-95.0) mg/g Cr in the control group. Of the 146 patients in the dapagliflozin group, 122 completed the study, and 107 (87.7%) were taking 5 mg of dapagliflozin daily at the end of the observation period. The primary outcome did not significantly differ between the dapagliflozin and control groups. Among the secondary endpoints, the mean decrease in left ventricular end-diastolic dimensions as one of the echocardiographic parameters was larger in the dapagliflozin group than in the control group. The composite endpoint, defined as CV death or hospitalisation for CV events, hospitalisation for HF events, hospitalisation for all causes, and an additional change in prescriptions for heart failure in a two-year observation, was less frequent in the dapagliflozin group than in the control group. Interpretation Although dapagliflozin at a dose of 5 mg daily did not reduce urinary albumin excretion in patients with HF and T2D from that in the controls, our findings suggest that dapagliflozin decreased CV events and suppressed left ventricular remodeling. Funding AstraZeneca KK, Ono Pharmaceutical Co., Ltd.
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Affiliation(s)
- Fumiki Yoshihara
- Division of Nephrology and Hypertension, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | - Miki Imazu
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | - Ichiro Sakuma
- Division of Cardiology/Internal Medicine, Caress Sapporo Hokko Memorial Clinic, Sapporo, Japan
| | - Yukio Hiroi
- Department of Cardiology, National Centre for Global Health and Medicine, Tokyo, Japan
| | - Hisao Hara
- Department of Cardiology, National Centre for Global Health and Medicine, Tokyo, Japan
| | | | | | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | - Toshihiko Shiraiwa
- General Internal Medicine, Hypertension and Diabetes Centre, Shiraiwa Medical Clinic, Kashiwara, Japan
| | - Norio Nishioka
- General Internal Medicine, Cardiology and Cardiac Rehabilitation Centre, Shiraiwa Medical Clinic, Kashiwara, Japan
| | - Kenshi Fujii
- Division of Cardiology, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Katsuomi Iwakura
- Division of Cardiology, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Osamu Tomonaga
- Diabetes and Lifestyle Centre, Tomonaga Clinic, Tokyo, Japan
| | - Koichi Kobayashi
- Department of Cardiology, TOYOTA Memorial Hospital, Toyota, Japan
| | | | - Kazuhiko Yumoto
- Department of Cardiology, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan
| | - Hiroyuki Takase
- Department of Internal Medicine, JA Shizuoka Kohseiren Enshu Hospital, Hamamatsu, Shizuoka, Japan
| | | | - Ikki Shimizu
- Department of Diabetes, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Tsutomu Murakami
- Department of Cardiology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Kenji Wagatsuma
- Tsukuba Heart Centre, Tsukuba Memorial Hospital, Tsukuba, Ibaragi, Japan
| | - Katsuhiko Sato
- Cardiovascular Medicine, Sapporo Cardio Vascular Clinic, Sapporo, Japan
| | | | - Satoshi Akabame
- Department of Cardiovascular Medicine, Kyoto Okamoto Memorial Hospital, Kyoto, Japan
| | - Shiro Hata
- Clinical Cardiology, Sasebo City General Hospital, Sasebo, Nagasaki, Japan
| | - Masanori Asakura
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University Hospital, Nishinomiya, Hyogo, Japan
| | - Takanori Kawabata
- Department of Data Science, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | - Katsuhiro Omae
- Department of Data Science, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | - Shin Ito
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | - Masafumi Kitakaze
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
- Hanwa Memorial Hospital, Osaka, Japan
- The Osaka Medical Research Foundation for Intractable Diseases, Osaka, Japan
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12
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Li S, Li N, Li L, Zhan J. Sex Difference in the Association Between Serum Versican and Albuminuria in Patients with Type 2 Diabetes Mellitus. Diabetes Metab Syndr Obes 2023; 16:3631-3639. [PMID: 38028986 PMCID: PMC10648950 DOI: 10.2147/dmso.s434287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/01/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Diabetic kidney disease (DKD) is one of the major microvascular complications of diabetes. DKD is associated with oxidative stress and inflammation. Versican (VCAN), a chondroitin sulphate proteoglycan, has been proven to participate in oxidative stress and inflammation. This study aimed to explore the overall and sex-based relationship between serum VCAN levels and albuminuria in patients with type 2 diabetes mellitus (T2DM). Methods 428 patients with T2DM and 84 healthy individuals were enrolled. Patients with diabetes were separated into normal albuminuria, microalbuminuria, and macroalbuminuria groups, according to their urinary albumin/creatinine ratio (UACR). Serum VCAN levels were tested using an enzyme-linked immunosorbent assay. Results Compared with males, female patients were older, and had higher total cholesterol and high-density lipoprotein cholesterol, but lower body mass index, diastolic blood pressure, glycated hemoglobin A1, alanine aminotransferase, urinary albumin (UA), and serum creatinine (SCr) (P < 0.05). The VCAN levels in male patients with T2DM were significantly higher than those in the healthy individuals. Male patients with T2DM with albuminuria (micro and macro) had higher levels of VCAN than in patients with normal albuminuria; the highest level was seen in patients with macroalbuminuria (P < 0.05). In male patients with T2DM, serum VCAN correlated positively with systolic blood pressure, blood urea nitrogen, UA, SCr, and UACR, but correlated negatively with the estimated glomerular filtration rate. The area under the receiver operating characteristic curve of serum VCAN to diagnose albuminuria was 0.702, with a corresponding cut-off value of 0.399 ng/mL (P < 0.001). However, the association between serum VCAN and UACR was not observed in female patients with T2DM. Conclusion Serum VCAN levels correlated positively with the severity of albuminuria in male patients with T2DM.
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Affiliation(s)
- Shuang Li
- Department of Geriatrics, The Second Xiangya Hospital, Institute of Aging and Age-Related Disease Research, Central South University, Changsha, Hunan, 410011, People’s Republic of China
| | - Niman Li
- Department of Geriatrics, The Second Xiangya Hospital, Institute of Aging and Age-Related Disease Research, Central South University, Changsha, Hunan, 410011, People’s Republic of China
| | - Linsen Li
- Department of Geriatrics, The Second Xiangya Hospital, Institute of Aging and Age-Related Disease Research, Central South University, Changsha, Hunan, 410011, People’s Republic of China
| | - Junkun Zhan
- Department of Geriatrics, The Second Xiangya Hospital, Institute of Aging and Age-Related Disease Research, Central South University, Changsha, Hunan, 410011, People’s Republic of China
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13
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Gan S, Zhao L, Salman O, Wang Z, Ebert C, Azzo JD, Dib MJ, Zamani P, Cohen JB, Kammerhoff K, Schafer P, Seiffert DA, Ramirez-Valle F, Gordon DA, Cvijic ME, Gunawardhana K, Liu L, Chang CP, Cappola TP, Chirinos JA. Proteomic Correlates of the Urinary Protein/Creatinine Ratio in Heart Failure With Preserved Ejection Fraction. Am J Cardiol 2023; 206:312-319. [PMID: 37734292 PMCID: PMC10874232 DOI: 10.1016/j.amjcard.2023.08.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/21/2023] [Accepted: 08/21/2023] [Indexed: 09/23/2023]
Abstract
Proteinuria is common in heart failure with preserved ejection fraction (HFpEF), but its biologic correlates are poorly understood. We assessed the relation between 49 plasma proteins and the urinary protein/creatinine ratio (UPCR) in 365 participants in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial. Linear regression and network analysis were used to represent relations between protein biomarkers and UPCR. Higher UPCR was associated with older age, a greater proportion of female gender, smaller prevalence of previous myocardial infarction, and greater prevalence of diabetes, insulin use, smoking, and statin use, in addition to a lower estimated glomerular filtration rate, hematocrit, and diastolic blood pressure. Growth differentiation factor 15 (GDF-15; β = 0.15, p <0.0001), followed by N-terminal proatrial natriuretic peptide (NT-proANP; β = 0.774, p <0.0001), adiponectin (β = 0.0005, p <0.0001), fibroblast growth factor 23 (FGF-23, β = 0.177; p <0.0001), and soluble tumor necrosis factor receptors I (β = 0.002, p <0.0001) and II (β = 0.093, p <0.0001) revealed the strongest associations with UPCR. Network analysis showed that UPCR is linked to various proteins primarily through FGF-23, which, along with GDF-15, indicated node characteristics with strong connectivity, whereas UPCR did not. In a model that included FGF-23 and UPCR, the former was predictive of the risk of death or heart-failure hospital admission (standardized hazard ratio 1.83, 95% confidence interval 1.49 to 2.26, p <0.0001) and/or all-cause death (standardized hazard ratio 1.59, 95% confidence interval 1.22 to 2.07, p = 0.0005), whereas UPCR was not prognostic. Proteinuria in HFpEF exhibits distinct proteomic correlates, primarily through its association with FGF-23, a well-known prognostic marker in HFpEF. However, in contrast to FGF-23, UPCR does not hold independent prognostic value.
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Affiliation(s)
- Sushrima Gan
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Cardiovascular Medicine, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lei Zhao
- Bristol-Myers Squibb Company, Lawrenceville, New Jersey
| | - Oday Salman
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Cardiovascular Medicine, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zhaoqing Wang
- Bristol-Myers Squibb Company, Lawrenceville, New Jersey
| | | | - Joe David Azzo
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Cardiovascular Medicine, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marie Joe Dib
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Cardiovascular Medicine, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Payman Zamani
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Cardiovascular Medicine, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology, and Informatics
| | | | - Peter Schafer
- Bristol-Myers Squibb Company, Lawrenceville, New Jersey
| | | | | | | | | | | | - Laura Liu
- Bristol-Myers Squibb Company, Lawrenceville, New Jersey
| | | | - Thomas P Cappola
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Cardiovascular Medicine, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julio A Chirinos
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Cardiovascular Medicine, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania.
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14
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Delalić Đ, Brežni T, Prkačin I. Diagnostic value and utility of commonly used biomarkers of cardiac and renal function in cardiorenal syndromes: a narrative review. Biochem Med (Zagreb) 2023; 33:030502. [PMID: 37545695 PMCID: PMC10373058 DOI: 10.11613/bm.2023.030502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 06/15/2023] [Indexed: 08/08/2023] Open
Abstract
Cardiorenal syndrome (CRS), first defined in 2004 as a consequence of the interactions between the kidneys and other circulatory departments leading to acute heart failure, has since been recognized as a complex clinical entity that is hard to define, diagnose and classify. The framework for the classification of CRS according to pathophysiologic background was laid out in 2008, dividing CRS into five distinct phenotypes. However, determining the timing of individual organ injuries and making a diagnosis of either renal or cardiac failure remains an elusive task. In clinical practice, the diagnosis and phenotyping of CRS is mostly based on using laboratory biomarkers in order to directly or indirectly estimate the degree of end-organ functional decline. Therefore, a well-educated clinician should be aware of the effects that the reduction of renal and cardiac function has on the diagnostic and predictive value and properties of the most commonly used biomarkers (e.g. troponins, N-terminal pro-brain natriuretic peptide, serum creatinine etc). They should also be acquainted, on a basic level, with emerging biomarkers that are specific to either the degree of glomerular integrity (cystatin C) or tubular injury (neutrophil gelatinase-associated lipocalin). This narrative review aims to provide a scoping overview of the different roles that biomarkers play in both the diagnosis of CRS and the prognosis of the disease in patients who have been diagnosed with it, along with highlighting the most important pitfalls in their interpretation in the context of impaired renal and/or cardiac function.
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Affiliation(s)
- Điđi Delalić
- University of Zagreb School of Medicine, Zagreb, Croatia
| | - Tanja Brežni
- Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | - Ingrid Prkačin
- University of Zagreb School of Medicine, Zagreb, Croatia
- Emergency Internal Medicine Clinic, Clinical Hospital Merkur, Zagreb, Croatia
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15
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Triantafyllou A, Anyfanti P, Koletsos N, Malliora A, Lamprou S, Dipla K, Gkaliagkousi E. Clinical Significance of Altered Vascular Morphology and Function in Normotension. Curr Hypertens Rep 2023; 25:287-297. [PMID: 37392357 PMCID: PMC10505095 DOI: 10.1007/s11906-023-01251-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 07/03/2023]
Abstract
PURPOSE OF REVIEW To review current literature examining the presence of subclinical micro- and macrovascular alterations in normotensive individuals and their clinical significance in terms of hypertension prediction. Emphasis is placed on alterations that can be detected in peripheral vascular beds using non-invasive, easily applicable methodology, as these are in general easier to capture and evaluate in clinical practice compared to more complex invasive or functional tests. RECENT FINDINGS Arterial stiffness, increased carotid intima-media thickness, and altered retinal microvascular diameters predict the progression from the normotensive to the hypertensive state. By contrast, there is substantial lack of relevant prospective studies for skin microvascular alterations. Although conclusions regarding causality cannot be safely deduced from available studies, detection of morphological and functional vascular alterations in normotensive individuals emerges as a sensitive indicator of progression to hypertension and hence increased CVD risk. An increasing amount of evidence suggests that early detection of subclinical micro- and macrovascular alterations would be clinically useful for the early identification of individuals at high risk for future hypertension onset. Methodological issues and gaps in knowledge need to be addressed before detection of such changes could guide the development of strategies to prevent new-onset hypertension in normotensive individuals.
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Affiliation(s)
- A Triantafyllou
- Third Department of Internal Medicine, Papageorgiou General Hospital, Aristotle University of Thessaloniki, 56429, Thessaloniki, Greece.
| | - P Anyfanti
- Second Medical Department, Hippokration Hospital, Aristotle University of Thessaloniki, 54642, Thessaloniki, Greece
| | - N Koletsos
- Third Department of Internal Medicine, Papageorgiou General Hospital, Aristotle University of Thessaloniki, 56429, Thessaloniki, Greece
| | - A Malliora
- Third Department of Internal Medicine, Papageorgiou General Hospital, Aristotle University of Thessaloniki, 56429, Thessaloniki, Greece
| | - S Lamprou
- Third Department of Internal Medicine, Papageorgiou General Hospital, Aristotle University of Thessaloniki, 56429, Thessaloniki, Greece
| | - K Dipla
- Physiology & Biochemistry Laboratory, Department of Sport Sciences at Serres, Aristotle University of Thessaloniki, 62100, Serres, Greece
| | - E Gkaliagkousi
- Third Department of Internal Medicine, Papageorgiou General Hospital, Aristotle University of Thessaloniki, 56429, Thessaloniki, Greece
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16
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Kario K, Nishizawa M, Kato M, Ishii H, Uchiyama K, Nagai M, Takahashi N, Asakura T, Shiraiwa T, Yoshida T, Kaneshiro M, Taguchi T, Shiosakai K, Sugimoto K. Nighttime home blood pressure lowering effect of esaxerenone in patients with uncontrolled nocturnal hypertension: the EARLY-NH study. Hypertens Res 2023; 46:1782-1794. [PMID: 37173430 PMCID: PMC10319630 DOI: 10.1038/s41440-023-01292-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 05/15/2023]
Abstract
There is limited evidence on the blood pressure (BP)-lowering effect of esaxerenone on home BP, including nighttime BP. Using two newly developed nocturnal home BP monitoring devices (brachial and wrist), this multicenter, open-label, prospective study investigated the nighttime home BP-lowering effect of esaxerenone in patients with uncontrolled nocturnal hypertension being treated with an angiotensin receptor blocker (ARB) or calcium-channel blocker (CCB). In total, 101 patients were enrolled. During the 12-week study period, change in nighttime home systolic/diastolic BP from baseline to end of treatment measured by the brachial device was -12.9/-5.4 mmHg in the total population and -16.2/-6.6 and -10.0/-4.4 mmHg in the ARB and CCB subcohorts, respectively (all p < 0.001). For the wrist device, the change was -11.7/-5.4 mmHg in the total population and -14.6/-6.2 and -8.3/-4.5 mmHg in each subcohort, respectively (all p < 0.001). Similar significant reductions were shown for morning and bedtime home BP and office BP. Urinary albumin-to-creatinine ratio, N-terminal pro-brain natriuretic peptide, and cardio-ankle vascular index improved in the total population and each subcohort. Incidences of treatment-emergent adverse events (TEAEs) and drug-related TEAEs were 38.6% and 16.8%, respectively; most were mild or moderate. The most frequent drug-related TEAEs were associated with serum potassium elevation (hyperkalemia, 9.9%; blood potassium increased, 3.0%); however, no new safety concerns were raised. Esaxerenone was effective in lowering nighttime home BP as well as morning and bedtime home BP and office BP, safe, and showed organ-protective effects in patients with uncontrolled nocturnal hypertension. Caution is warranted regarding elevated serum potassium levels. This study investigated the effect of esaxerenone on nighttime home BP and organ damage (UACR and NT-proBNP) in patients with uncontrolled nocturnal hypertension despite treatment with an ARB or CCB. Our results show that safe 24-h BP control and organ protection are possible with esaxerenone.
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Affiliation(s)
- Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan.
| | | | | | | | | | - Michiaki Nagai
- Department of Cardiology, Hiroshima City Asa Hospital, Hiroshima, Japan
| | | | - Taro Asakura
- Tsuruma Kaneshiro Diabetes Clinic, Yamato, Japan
| | | | - Tetsuro Yoshida
- Department of Cardiovascular Medicine, Onga Nakama Medical Association Onga Hospital, Onga, Japan
| | | | - Takashi Taguchi
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | | | - Kotaro Sugimoto
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
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17
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Borg R, Kriegbaum M, Grand MK, Lind B, Andersen CL, Persson F. Chronic kidney disease in primary care: risk of cardiovascular events, end stage kidney disease and death. BMC PRIMARY CARE 2023; 24:128. [PMID: 37344787 DOI: 10.1186/s12875-023-02077-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 06/08/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND The prevalence of chronic kidney disease (CKD) is increasing globally. Early diagnosis in primary care may have a role in ensuring proper intervention. We aimed to determine the prevalence and outcome of CKD in primary care. METHODS We performed an observational cohort study in primary care in Copenhagen (2001-2015). Outcomes were stroke, myocardial infarction (MI), heart failure (HF), peripheral artery disease (PAD), all-cause- and cardiovascular mortality. We combined individuals with normal kidney function and CKD stage 2 as reference. We conducted cause-specific Cox proportional regressions to calculate the hazard ratios for outcomes according to CKD group. We explored the associations between kidney function and the outcomes examined using eGFR as a continuous variable modelled with penalised splines. All models were adjusted for age, gender, diabetes, hypertension, existing CVD, heart failure, LDL cholesterol and use of antihypertensive treatment. RESULTS We included 171,133 individuals with at least two eGFR measurements of which the majority (n = 157,002) had eGFR > 60 ml/min/1.73m2 at index date, and 0.05% were in CKD stage 5. Event rates were low in eGFR > 60 ml/min/1.73m2 but increased in those with higher stages of CKD. In adjusted analyses we observed an increase in hazard rates for every outcome with every increment in CKD stage. Compared to the reference group, individuals in CKD stage 4 had double the hazard rate of PAD, MI, cardiovascular and all-cause mortality. CONCLUSIONS Our data from a large primary care cohort demonstrate an early increase in the risk of adverse outcomes already at CKD stage 3. This underlines the importance of studying early intervention in primary care.
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Affiliation(s)
- Rikke Borg
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Margit Kriegbaum
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Mia Klinten Grand
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Bent Lind
- Department of Clinical Biochemistry, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Christen Lykkegaard Andersen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Hematology, Copenhagen University Hospital, Copenhagen, Denmark
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18
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Claure-Del Granado R, Chávez-Íñiguez JS. Renal Biomarkers in Cardiovascular Patients with Acute Kidney Injury: A Case Report and Literature Review. Diagnostics (Basel) 2023; 13:diagnostics13111922. [PMID: 37296774 DOI: 10.3390/diagnostics13111922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/08/2023] [Accepted: 05/13/2023] [Indexed: 06/12/2023] Open
Abstract
Biomarkers have become important tools in the diagnosis and management of cardiorenal syndrome (CRS), a complex condition characterized by dysfunction in both the cardiovascular and renal systems. Biomarkers can help identify the presence and severity of CRS, predict its progression and outcomes, and facilitate personalized treatment options. Several biomarkers, including natriuretic peptides, troponins, and inflammatory markers, have been extensively studied in CRS, and have shown promising results in improving diagnosis and prognosis. In addition, emerging biomarkers, such as kidney injury molecule-1 and neutrophil gelatinase-associated lipocalin, offer potential for early detection and intervention of CRS. However, the use of biomarkers in CRS is still in its infancy, and further research is needed to establish their utility in routine clinical practice. This review highlights the role of biomarkers in the diagnosis, prognosis, and management of CRS, and discusses their potential as valuable clinical tools for personalized medicine in the future.
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Affiliation(s)
- Rolando Claure-Del Granado
- Division of Nephrology, Hospital Obrero No 2-CNS, Cochabamba, Bolivia
- Instituto de Investigaciones Biomédicas e Investigación Social de la Facultad de Medicina (IIBISMED), Facultad de Medicina, Universidad Mayor de San Simon, Cochabamba C.P. 3119, Bolivia
| | - Jonathan S Chávez-Íñiguez
- Division of Nephrology, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara C.P. 44280, Mexico
- University of Guadalajara Health Sciences Center, Guadalajara C.P. 44340, Mexico
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19
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Gronda EG, Vanoli E, Iacoviello M, Urbinati S, Caldarola P, Colivicchi F, Gabrielli D. Renal effects of SGLT2 inhibitors in cardiovascular patients with and without chronic kidney disease: focus on heart failure and renal outcomes. Heart Fail Rev 2023; 28:723-732. [PMID: 35098383 PMCID: PMC8801273 DOI: 10.1007/s10741-021-10211-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 11/30/2022]
Abstract
The kidney has a prominent role in maintaining glucose homeostasis by using glucose as a metabolic substrate. This occurs by generating glucose through gluconeogenesis, and by reuptaking filtered glucose through the sodium-glucose cotransporters SGLT1 and SGLT2 located in the proximal tubule. In recent studies, the administration of sodium-glucose cotransporters inhibitors demonstrated that inhibition of renal glucose reabsorption significantly reduces adverse renal events and heart failure exacerbations, in type 2 diabetic patients with and without cardiovascular damage as well as in advanced chronic kidney disease and heart failure patients with reduced ejection fraction with and without diabetes. The benefit was consistent throughout the different investigated clinical conditions, ameliorating overall patient outcome. The efficacy of sodium glucose cotransporters inhibitors was prominently linked to the limitation of renal damage as highlighted by the significant reduction on global mortality achieved in the studies investigating diabetic and not diabetic populations with advanced chronic kidney disease. Both studies were halted at the interim analysis because of unquestionable evidence of treatment benefit. In current review, we examine the role of SGLT2 and SGLT1 in the regulation of renal glucose reabsorption in health and disease and the effect of SGLT2 inhibition on clinical outcomes of populations with different cardiovascular conditions investigated with large-scale outcome trials.
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Affiliation(s)
- Edoardo G Gronda
- Dipartimento Di Medicina E Specialità Mediche, Programma Cardiorenale, Dialisi e Trapianto Renale Dell'Adulto, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico - Via Francesco Sforza, 35, U.O.C. Nefrologia, 20122, Milan, Italy.
- U.O.C. Cardiologia-UTIC, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy.
| | - Emilio Vanoli
- U.O. Cardiologia Riabilitativa Ospedale Sacra Famiglia Fatebenefratelli, Erba, Italy
- Molecular Medicine Dept, University of Pavia, Pavia, Italy
| | - Massimo Iacoviello
- Dipartimento Di Scienze Mediche E Chirurgiche, AOU Policlinico Riuniti Di Foggia, Università Degli Studi, Foggia, S.C. Cardiologia, Italy
| | | | | | | | - Domenico Gabrielli
- U.O.C. Cardiologia, Presidio Ospedaliero San Filippo Neri, ASL Roma 1, Roma, Italy
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20
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Gallo G, Lanza O, Savoia C. New Insight in Cardiorenal Syndrome: From Biomarkers to Therapy. Int J Mol Sci 2023; 24:5089. [PMID: 36982164 PMCID: PMC10049666 DOI: 10.3390/ijms24065089] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/28/2023] [Accepted: 03/02/2023] [Indexed: 03/09/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - Carmine Savoia
- Clinical and Molecular Medicine Department, Faculty of Medicine and Psychology, Sant’Andrea Hospital, Sapienza University of Rome, 00189 Rome, Italy
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21
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Recent Developments in the Evaluation and Management of Cardiorenal Syndrome: A Comprehensive Review. Curr Probl Cardiol 2023; 48:101509. [PMID: 36402213 DOI: 10.1016/j.cpcardiol.2022.101509] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022]
Abstract
Cardiorenal syndrome (CRS) is an increasingly recognized diagnostic entity associated with high morbidity and mortality among acutely ill heart failure (HF) patients with acute and/ or chronic kidney diseases (CKD). While traditionally viewed as a state of decline in glomerular filtration rate (GFR) due to decreased renal perfusion, mainly due to therapeutic interventions to relieve congestive in HF, recent insights into the underlying pathophysiologic mechanisms of CRS led to a broader definition and further classification of CRS into 5 distinct types. In this comprehensive review, we discuss the classification of CRS, highlighting the underlying common pathogenetic pathways of heart failure and kidney injury, including increased congestion, neurohormonal dysregulation, oxidative stress as well as inflammation, and cytokine storm that are particularly evident in COVID-19 patients with multiorgan failure and also in those with other disorders including sepsis, systemic lupus erythematosus and amyloidosis. In this review we also present the recent advances in the diagnostic strategies of CRS including cardiac and renal biomarkers as well as advanced cardiac and renal imaging techniques that are available to aid in the diagnosis as well as in the prognostication of this disorder. Finally, we discuss the various therapeutic options available to-date, including fluid optimization, hemofiltration, renal replacement therapy as well as the role of SGLT2 inhibitors in light of recent data from RCTs. It is important to note that, CRS population are either excluded or underrepresented, at best, in major RCTs and therefore, therapeutic recommendations are largely extrapolated from HF and CKD clinical trials.
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22
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Pugliese NR, Masi S, Taddei S. Rethinking albuminuria as a marker to drive treatment in congestive heart failure. Eur Heart J 2023; 44:381-382. [PMID: 36369982 DOI: 10.1093/eurheartj/ehac612] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nicola Riccardo Pugliese
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126 Pisa, Italy
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126 Pisa, Italy
| | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126 Pisa, Italy
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23
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Zhong S, Cai Q, Zhong L, Wang Y, Liang F, Deng Z, Li S, Zha D, Qiu W, Wu J. Low-Intensity Focused Ultrasound Ameliorates Ischemic Heart Failure Related to the Cholinergic Anti-Inflammatory Pathway. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:463-475. [PMID: 36444908 DOI: 10.1002/jum.16140] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 07/30/2022] [Accepted: 11/13/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES This study aims to determine the effect of low-intensity focused ultrasound (LIFU) in ischemic heart failure (IHF) and explore the potential neuroimmune mechanism. METHODS Sprague-Dawley rats were subjected to ultrasound (US) with specific parameters, and electrocardiograms were recorded to analyze the effect of LIFU and/or vagal denervation on heart rate. Thereafter, myocardial infarction (MI) was induced by left anterior artery ligation, and LIFU was performed three times a day for 25 days after MI. Echocardiography, Masson staining, and ELISA were used to evaluate the effect of LIFU on the structure and function of the heart. Finally, ELISA, flow cytometry, qRT-PCR, and Western blot analysis were performed to determine the effect of LIFU on the inflammation and the expression of the cholinergic anti-inflammatory pathway (CAP)-related mediators. RESULTS LIFU reduced heart rate in rats (control vs LIFU, P < .01), and vagotomy (VT) eliminated this effect of LIFU on heart rate (VT vs LIFU + VT, P > .01). LIFU-ameliorated IHF in terms of cardiac structure and function (MI vs MI + LIFU, P < .01), but VT abrogated the beneficial effect of LIFU (MI + VT vs MI + LIFU + VT, P > .01). After the treatment of LIFU, decreased levels of inflammatory cytokines, increased proportion of anti-inflammatory macrophages, and increased expression of CAP-related mediators (MI vs MI + LIFU, P < .01). CONCLUSIONS LIFU ameliorates IHF whereas the CAP plays a promising role. LIFU has the potential to be a novel nonpharmacological and noninvasive therapy for the treatment of coronary artery disease and other cardiovascular diseases.
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Affiliation(s)
- Shenrong Zhong
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Cardiology, Meizhou People's Hospital, Meizhou, China
| | - Qianyun Cai
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Longhe Zhong
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yuegang Wang
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fengchu Liang
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhe Deng
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shasha Li
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Daogang Zha
- Department of General Practice, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Weibao Qiu
- Shenzhen Key Laboratory of Ultrasound Imaging and Therapy, Chinese Academy of Sciences, Shenzhen, China
| | - Juefei Wu
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Shock and Microcirculation, Guangzhou, China
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24
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Boorsma EM, ter Maaten JM, Damman K, van Essen BJ, Zannad F, van Veldhuisen DJ, Samani NJ, Dickstein K, Metra M, Filippatos G, Lang CC, Ng L, Anker SD, Cleland JG, Pellicori P, Gansevoort RT, Heerspink HJL, Voors AA, Emmens JE. Albuminuria as a marker of systemic congestion in patients with heart failure. Eur Heart J 2023; 44:368-380. [PMID: 36148485 PMCID: PMC9890244 DOI: 10.1093/eurheartj/ehac528] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 08/12/2022] [Accepted: 09/12/2022] [Indexed: 02/05/2023] Open
Abstract
AIMS Albuminuria is common in patients with heart failure and associated with worse outcomes. The underlying pathophysiological mechanism of albuminuria in heart failure is still incompletely understood. The association of clinical characteristics and biomarker profile with albuminuria in patients with heart failure with both reduced and preserved ejection fractions were evaluated. METHODS AND RESULTS Two thousand three hundred and fifteen patients included in the index cohort of BIOSTAT-CHF were evaluated and findings were validated in the independent BIOSTAT-CHF validation cohort (1431 patients). Micro-albuminuria and macro-albuminuria were defined as urinary albumincreatinine ratio (UACR) 30 mg/gCr and 300 mg/gCr in spot urines, respectively. The prevalence of micro- and macro-albuminuria was 35.4 and 10.0, respectively. Patients with albuminuria had more severe heart failure, as indicated by inclusion during admission, higher New York Heart Association functional class, more clinical signs and symptoms of congestion, and higher concentrations of biomarkers related to congestion, such as biologically active adrenomedullin, cancer antigen 125, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) (all P 0.001). The presence of albuminuria was associated with increased risk of mortality and heart failure (re)hospitalization in both cohorts. The strongest independent association with log UACR was found for log NT-proBNP (standardized regression coefficient 0.438, 95 confidence interval 0.350.53, P 0.001). Hierarchical clustering analysis demonstrated that UACR clusters with markers of congestion and less with indices of renal function. The validation cohort yielded similar findings. CONCLUSION In patients with new-onset or worsening heart failure, albuminuria is consistently associated with clinical, echocardiographic, and circulating biomarkers of congestion.
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Affiliation(s)
- Eva M Boorsma
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Jozine M ter Maaten
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Kevin Damman
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Bart J van Essen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Faiez Zannad
- Department of Cardiovascular Disease, Université de Lorraine, Inserm INI-CRCT, CHRU, 30 rue Lionnois, 54000 Nancy, France
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Nilesh J Samani
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University Road, Leicester LE1 7RH, UK
| | - Kenneth Dickstein
- Stavanger University Hospital, Gerd-Ragna Bloch Thorsens Gate 8, 4011 Stavanger, Norway
| | - Marco Metra
- Division of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Piazza Mercato, 15, 25122 Brescia, Italy
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Heart Failure Unit, Athens University Hospital Attikon, 13Α, Navarinou str., 10680 Athens, Greece
| | - Chim C Lang
- Division of Molecular and Clinical Medicine, Medical Research Institute, Ninewells Hospital & Medical School, University of Dundee, James Arrott Drive, Dundee DD2 1UB, UK
| | - Leong Ng
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University Road, Leicester LE1 7RH, UK
| | - Stefan D Anker
- Department of Cardiology (CVK), Charité Universitätsmedizin, Charite Square 1, Berlin 10117, Germany
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin, Friedrichstr. 134, Berlin 10117, Germany
- German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin, Potsdamer Str., Berlin 5810785, Germany
| | - John G Cleland
- National Heart and Lung Institute, Royal Brompton & Harefield Hospitals, Imperial College, Guy Dovehouse Street, London SW3 6LY, UK
| | - Pierpaolo Pellicori
- National Heart and Lung Institute, Royal Brompton & Harefield Hospitals, Imperial College, Guy Dovehouse Street, London SW3 6LY, UK
| | - Ron T Gansevoort
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, The Netherlands
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, The Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Johanna E Emmens
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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25
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Łagosz P, Biegus J, Urban S, Zymliński R. Renal Assessment in Acute Cardiorenal Syndrome. Biomolecules 2023; 13:biom13020239. [PMID: 36830608 PMCID: PMC9953721 DOI: 10.3390/biom13020239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/20/2023] [Accepted: 01/25/2023] [Indexed: 01/28/2023] Open
Abstract
Cardiorenal syndrome (CRS) is a complex, heterogeneous spectrum of symptoms that has kept cardiologists awake for decades. The heart failure (HF) population being burdened with multimorbidity poses diagnostic and therapeutic challenges even for experienced clinicians. Adding deteriorated renal function to the equation, which is one of the strongest predictors of adverse outcome, we measure ourselves against possibly the biggest problem in modern cardiology. With the rapid development of new renal assessment methods, we can treat CRS more effectively than ever. The presented review focuses on explaining the pathophysiology, recent advances and current practices of monitoring renal function in patients with acute CRS. Understanding the dynamic interaction between the heart and the kidney may improve patient care and support the selection of an effective and nephroprotective treatment strategy.
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Affiliation(s)
- Piotr Łagosz
- Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Poland
- Institute of Heart Diseases, University Clinical Hospital, 50-556 Wroclaw, Poland
- Correspondence:
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Poland
- Institute of Heart Diseases, University Clinical Hospital, 50-556 Wroclaw, Poland
| | - Szymon Urban
- Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Poland
| | - Robert Zymliński
- Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Poland
- Institute of Heart Diseases, University Clinical Hospital, 50-556 Wroclaw, Poland
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26
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Khan MS, Shahid I, Anker SD, Fonarow GC, Fudim M, Hall ME, Hernandez A, Morris AA, Shafi T, Weir MR, Zannad F, Bakris GL, Butler J. Albuminuria and Heart Failure: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 81:270-282. [PMID: 36653095 DOI: 10.1016/j.jacc.2022.10.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/03/2022] [Indexed: 01/18/2023]
Abstract
Although chronic kidney disease is characterized by low glomerular filtration rate (GFR) or albuminuria, estimated GFR (eGFR) is more widely utilized as a marker of risk profile in cardiovascular diseases, including heart failure (HF). The presence and magnitude of albuminuria confers a strong prognostic association in forecasting risk of incident HF as well as its progression, irrespective of eGFR. Despite the high prevalence of albuminuria in HF, whether it adds incremental prognostic information in clinical practice and serves as an independent risk marker, and whether there are any therapeutic implications of assessing albuminuria in patients with HF is less well-established. In this narrative review, we assess the potential role of albuminuria in risk profiling for development and progression of HF, strengths and limitations of utilizing albuminuria as a risk marker, its ability to serve in HF risk prediction models, and the implications of adopting albuminuria as an effective parameter in cardiovascular trials and practice.
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Affiliation(s)
- Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA. https://twitter.com/ShahzebkhanMD
| | - Izza Shahid
- Division of Preventive Cardiology, Department of Cardiology, Houston Methodist Academic Institute, Houston, Texas, USA
| | - Stefan D Anker
- Department of Cardiology (CVK), Charité-Universitätsmedizin Berlin; Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research, Berlin, Germany
| | - Gregg C Fonarow
- Division of Cardiology, University of California, Los Angeles, California, USA
| | - Marat Fudim
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Michael E Hall
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Adrian Hernandez
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Alanna A Morris
- Division of Cardiology, Emory University, Atlanta, Georgia, USA
| | - Tariq Shafi
- Division of Nephrology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Matthew R Weir
- Division of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Faiez Zannad
- Université de Lorraine, CIC Inserm, CHRU, Nancy, France
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA; Baylor Scott and White Research Institute, Dallas, Texas, USA.
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Ferreira JP, Zannad F, Butler J, Filippatos G, Pocock SJ, Brueckmann M, Steubl D, Schueler E, Anker SD, Packer M. Association of Empagliflozin Treatment With Albuminuria Levels in Patients With Heart Failure: A Secondary Analysis of EMPEROR-Pooled. JAMA Cardiol 2022; 7:1148-1159. [PMID: 36129693 PMCID: PMC9494272 DOI: 10.1001/jamacardio.2022.2924] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Albuminuria, routinely assessed as spot urine albumin-to-creatinine ratio (UACR), indicates structural damage of the glomerular filtration barrier and is associated with poor kidney and cardiovascular outcomes. Sodium-glucose cotransporter-2 (SGLT2) inhibitors have been found to reduce UACR in patients with type 2 diabetes, but its use in patients with heart failure (HF) is less well studied. Objective To analyze the association of empagliflozin with study outcomes across baseline levels of albuminuria and change in albuminuria in patients with HF across a wide range of ejection fraction levels. Design, Setting, and Participants This post hoc analysis included all patients with HF from the EMPEROR-Pooled analysis using combined individual patient data from the international multicenter randomized double-blind parallel-group, placebo-controlled EMPEROR-Reduced and EMPEROR-Preserved trials. Participants in the original trials were excluded from this analysis if they were missing baseline UACR data. EMPEROR-Preserved was conducted from March 27, 2017, to April 26, 2021, and EMPEROR-Reduced was conducted from April 6, 2017, to May 28, 2020. Data were analyzed from January to June 2022. Interventions Randomization to empagliflozin or placebo. Main Outcomes and Measures New-onset macroalbuminuria and regression to normoalbuminuria and microalbuminuria. Results A total of 9673 patients were included (mean [SD] age, 69.9 [10.4] years; 3551 [36.7%] female and 6122 [63.3%] male). Of these, 5552 patients had normoalbuminuria (UACR <30 mg/g) and 1025 had macroalbuminuria (UACR >300 mg/g). Compared with normoalbuminuria, macroalbuminuria was associated with younger age, races other than White, obesity, male sex, site region other than Europe, higher levels of N-terminal pro-hormone brain natriuretic peptide and high-sensitivity troponin T, higher blood pressure, higher New York Heart Association class, greater HF duration, more frequent previous HF hospitalizations, diabetes, hypertension, lower eGFR, and less frequent use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and mineralocorticoid receptor antagonists. An increase in events was observed in individuals with higher UACR levels. The association of empagliflozin with cardiovascular mortality or HF hospitalization was consistent across UACR categories (hazard ratio [HR], 0.80; 95% CI, 0.69-0.92 for normoalbuminuria; HR, 0.74; 95% CI, 0.63-0.86 for microalbuminuria; HR, 0.78; 95% CI, 0.63-0.98 for macroalbuminuria; interaction P trend = .71). Treatment with empagliflozin was associated with lower incidence of new macroalbuminuria (HR, 0.81; 95% CI, 0.70-0.94; P = .005) and an increase in rate of remission to sustained normoalbuminuria or microalbuminuria (HR, 1.31; 95% CI, 1.07-1.59; P = .009) but not with a reduction in UACR in the overall population; however, UACR was reduced in patients with diabetes, who had higher UACR levels than patients without diabetes (geometric mean for diabetes at baseline, 0.91; 95% CI, 0.85-0.98 and for no diabetes at baseline, 1.08; 95% CI, 1.01-1.16; interaction P = .008). Conclusions and Relevance In this post hoc analysis of a randomized clinical trial, compared with placebo, empagliflozin was associated with reduced HF hospitalizations or cardiovascular death irrespective of albuminuria levels at baseline, reduced progression to macroalbuminuria, and reversion of macroalbuminuria. Trial Registration ClinicalTrials.gov Identifiers: NCT03057977 and NCT03057951.
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Affiliation(s)
- João Pedro Ferreira
- Université de Lorraine, Inserm, Centre d’Investigations Cliniques Plurithématique 1433, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France,Department of Surgery and Physiology, Cardiovascular Research and Development Center, University of Porto, Porto, Portugal
| | - Faiez Zannad
- Université de Lorraine, Inserm, Centre d’Investigations Cliniques Plurithématique 1433, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas,University of Mississippi Medical Center, Jackson
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Stuart J. Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Martina Brueckmann
- Boehringer Ingelheim International, Ingelheim, Germany,First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Dominik Steubl
- Boehringer Ingelheim International, Ingelheim, Germany,Department of Nephrology, Hospital rechts der Isar, Technical University Munich, Munich, Germany
| | | | - Stefan D. Anker
- Department of Cardiology Berlin Institute of Health Center for Regenerative Therapies German Centre for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany,Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Milton Packer
- Baylor Scott and White Research Institute, Dallas, Texas,Imperial College, London, United Kingdom
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Kramer T, Brinkkoetter P, Rosenkranz S. Right Heart Function in Cardiorenal Syndrome. Curr Heart Fail Rep 2022; 19:386-399. [PMID: 36166185 PMCID: PMC9653308 DOI: 10.1007/s11897-022-00574-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2022] [Indexed: 11/29/2022]
Abstract
Purpose of Review Since CRS is critically dependent on right heart function and involved in interorgan crosstalk, assessment and monitoring of both right heart and kidney function are of utmost importance for clinical outcomes. This systematic review aims to comprehensively report on novel diagnostic and therapeutic paradigms that are gaining importance for the clinical management of the growing heart failure population suffering from CRS. Recent Findings Cardiorenal syndrome (CRS) in patients with heart failure is associated with poor outcome. Although systemic venous congestion and elevated central venous pressure have been recognized as main contributors to CRS, they are often neglected in clinical practice. The delicate hemodynamic balance in CRS is particularly determined by the respective status of the right heart. Summary The consideration of hemodynamic and CRS profiles is advantageous in tailoring treatment for better preservation of renal function. Assessment and monitoring of right heart and renal function by known and emerging tools like renal Doppler ultrasonography or new biomarkers may have direct clinical implications.
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Affiliation(s)
- Tilmann Kramer
- Klinik III Für Innere Medizin, Herzzentrum Der Universität Zu Köln, Köln, Germany. .,Cologne Cardiovascular Research Center (CCRC), Klinikum Der Universität Zu Köln, Köln, Germany.
| | - Paul Brinkkoetter
- Cologne Cardiovascular Research Center (CCRC), Klinikum Der Universität Zu Köln, Köln, Germany.,Klinik II Für Innere Medizin, Nephrologie, Universität Zu Köln, Köln, Germany.,Center for Molecular Medicine Cologne (CMMC), Universität Zu Köln, Köln, Germany
| | - Stephan Rosenkranz
- Klinik III Für Innere Medizin, Herzzentrum Der Universität Zu Köln, Köln, Germany.,Cologne Cardiovascular Research Center (CCRC), Klinikum Der Universität Zu Köln, Köln, Germany.,Center for Molecular Medicine Cologne (CMMC), Universität Zu Köln, Köln, Germany
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Bozkurt B, Nair AP, Misra A, Scott CZ, Mahar JH, Fedson S. Neprilysin Inhibitors in Heart Failure: The Science, Mechanism of Action, Clinical Studies, and Unanswered Questions. JACC. BASIC TO TRANSLATIONAL SCIENCE 2022; 8:88-105. [PMID: 36777165 PMCID: PMC9911324 DOI: 10.1016/j.jacbts.2022.05.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/18/2022] [Accepted: 05/18/2022] [Indexed: 11/16/2022]
Abstract
This article provides a contemporary review and a new perspective on the role of neprilysin inhibition in heart failure (HF) in the context of recent clinical trials and addresses potential mechanisms and unanswered questions in certain HF patient populations. Neprilysin is an endopeptidase that cleaves a variety of peptides such as natriuretic peptides, bradykinin, adrenomedullin, substance P, angiotensin I and II, and endothelin. It has a broad role in cardiovascular, renal, pulmonary, gastrointestinal, endocrine, and neurologic functions. The combined angiotensin receptor and neprilysin inhibitor (ARNi) has been developed with an intent to increase vasodilatory natriuretic peptides and prevent counterregulatory activation of the angiotensin system. ARNi therapy is very effective in reducing the risks of death and hospitalization for HF in patients with HF and New York Heart Association functional class II to III symptoms, but studies failed to show any benefits with ARNi when compared with angiotensin-converting enzyme inhibitors or angiotensin receptor blocker in patients with advanced HF with reduced ejection fraction or in patients following myocardial infarction with left ventricular dysfunction but without HF. These raise the questions about whether the enzymatic breakdown of natriuretic peptides may not be a very effective solution in advanced HF patients when there is downstream blunting of the response to natriuretic peptides or among post-myocardial infarction patients in the absence of HF when there may not be a need for increased natriuretic peptide availability. Furthermore, there is a need for additional studies to determine the long-term effects of ARNi on albuminuria, obesity, glycemic control and lipid profile, blood pressure, and cognitive function in patients with HF.
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Key Words
- ACE, angiotensin-converting enzyme
- ANP, atrial natriuretic peptide
- ARB, angiotensin receptor blocker
- ARN, angiotensin receptor–neprilysin
- ARNi
- Aβ, amyloid beta
- BNP, brain natriuretic peptide
- BP, blood pressure
- CSF, cerebrospinal fluid
- EF, ejection fraction
- FDA, U.S. Food and Drug Administration
- GFR, glomerular filtration rate
- HF, heart failure
- HFpEF, heart failure with preserved ejection fraction
- HFrEF, heart failure with reduced ejection fraction
- LV, left ventricular
- LVEF, left ventricular ejection fraction
- MI, myocardial infarction
- NEP inhibitor
- NT-proBNP, N-terminal pro–brain natriuretic peptide
- NYHA, New York Heart Association
- PDE, phosphodiesterase
- RAAS, renin-angiotensin-aldosterone system
- UACR, urinary albumin/creatine ratio
- angiotensin receptor–neprilysin inhibitor
- cGMP, cyclic guanosine monophosphate
- eGFR, estimated glomerular filtration rate
- heart failure
- neprilysin
- neprilysin inhibitor
- sacubitril
- sacubitril/valsartan
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Affiliation(s)
- Biykem Bozkurt
- Winters Center for Heart Failure Research, Cardiovascular Research Institute, Baylor College of Medicine, DeBakey Veterans Affairs Medical Center, Houston Texas, USA
- Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston Texas, USA
- Address for correspondence: Dr Biykem Bozkurt, MEDVAMC, 2002 Holcombe Boulevard, Houston, Texas, 77030, USA.
| | - Ajith P. Nair
- Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Arunima Misra
- Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston Texas, USA
| | - Claire Z. Scott
- Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jamal H. Mahar
- Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Savitri Fedson
- Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston Texas, USA
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Chung EYM, Trinh K, Li J, Hahn SH, Endre ZH, Rogers NM, Alexander SI. Biomarkers in Cardiorenal Syndrome and Potential Insights Into Novel Therapeutics. Front Cardiovasc Med 2022; 9:868658. [PMID: 35669475 PMCID: PMC9163439 DOI: 10.3389/fcvm.2022.868658] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/29/2022] [Indexed: 11/13/2022] Open
Abstract
Heart and kidney failure often co-exist and confer high morbidity and mortality. The complex bi-directional nature of heart and kidney dysfunction is referred to as cardiorenal syndrome, and can be induced by acute or chronic dysfunction of either organ or secondary to systemic diseases. The five clinical subtypes of cardiorenal syndrome are categorized by the perceived primary precipitant of organ injury but lack precision. Traditional biomarkers such as serum creatinine are also limited in their ability to provide an early and accurate diagnosis of cardiorenal syndrome. Novel biomarkers have the potential to assist in the diagnosis of cardiorenal syndrome and guide treatment by evaluating the relative roles of implicated pathophysiological pathways such as hemodynamic dysfunction, neurohormonal activation, endothelial dysfunction, inflammation and oxidative stress, and fibrosis. In this review, we assess the utility of biomarkers that correlate with kidney and cardiac (dys)function, inflammation/oxidative stress, fibrosis, and cell cycle arrest, as well as emerging novel biomarkers (thrombospondin-1/CD47, glycocalyx and interleukin-1β) that may provide prediction and prognostication of cardiorenal syndrome, and guide potential development of targeted therapeutics.
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Affiliation(s)
- Edmund Y. M. Chung
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW, Australia
- *Correspondence: Edmund Y. M. Chung,
| | - Katie Trinh
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, Westmead, NSW, Australia
| | - Jennifer Li
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, Westmead, NSW, Australia
| | | | - Zoltan H. Endre
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW, Australia
- Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Natasha M. Rogers
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, Westmead, NSW, Australia
- Department of Renal Medicine, Westmead Hospital, Westmead, NSW, Australia
| | - Stephen I. Alexander
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW, Australia
- Department of Nephrology, The Children’s Hospital at Westmead, Westmead, NSW, Australia
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Saely CH, Maechler M, Vonbank A, Sprenger L, Mader A, Larcher B, Zanolin-Purin D, Leiherer A, Muendlein A, Drexel H. Single and joint impact of type 2 diabetes and of congestive heart failure on albuminuria: Data from subgroup analysis and data on moderate albuminuria. Data Brief 2022; 40:107817. [PMID: 35071710 PMCID: PMC8762350 DOI: 10.1016/j.dib.2022.107817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 11/07/2022] Open
Abstract
We investigated 180 consecutive patients with congestive heart failure (CHF), of whom 83 had type 2 diabetes (T2DM) and 97 did not have diabetes as well as 223 controls without CHF, of whom 39 had T2DM and 184 did not have diabetes. Data was recorded by standardized interviews and by standardized examination protocols at our institution and were extracted from medical records. Here, we analyzed data on gender differences. Further, we examined the effect of CHF and T2DM on moderate albuminuria, i.e. on an albumin-creatinine ratio (ACR) of 30–300 mg/g. Table 1 shows baseline characteristics of our patients stratified by gender. Table 2 gives ACRs and prevalence rates of albuminuria separately for men and women. In logistic regression analyses adjusting for age, sex, body mass index, LDL cholesterol, history of smoking, history of hypertension, use of statins, ACE inhibitors/angiotensin II receptor blockers, aldosterone antagonists and other antihypertensive medication CHF and T2DM predicted the prevalence of albuminuria in a mutually independent manner in men (OR 4.93 [95% CI 1.76–13.85]; p = 0.002 and OR 2.38 [1.11–5.11]; p = 0.027, respectively), as well as in women (OR 5.66 [95% CI 1.76–18.20]; p = 0.004 and OR 3.53 [1.38–9.08]; p = 0.009, respectively). There was no significant interaction between gender and CHF or T2DM regarding the presence of albuminuria (p = 0.933 and 0.533, respectively), indicating that the association of CHF and T2DM with albuminuria did not differ significantly between men and women. In multivariate analysis of covariance, CHF and T2DM proved to be independent predictors of ACR in women after adjustment for age, sex, body mass index, LDL cholesterol, history of smoking, history of hypertension, use of statins, ACE inhibitors/angiotensin II receptor blockers, aldosterone antagonists and other antihypertensive medication (F = 5.38; p = 0.022 and F = 4.95; p = 0.028, respectively); for men the corresponding F-values were 2.70; p = 0.102 and 3.12; p = 0.079, respectively. There was no significant interaction between gender and CHF or T2DM regarding ACR (p = 0.464 and 0.202, respectively), indicating that the association of CHF and T2DM with the ACR did not differ significantly between men and women. Regarding moderate albuminuria, both CHF and T2DM predicted moderate albuminuria adjusted in a mutually independent manner after the adjustments described above, with ORs of 4.75 [95% CI 2.16–10.45]; p< 0.001 and OR 2.08 [1.13–3.83]; p=0.018, respectively. The data set presented here could be reused with similar patient cohorts for pooled analysis.
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Matsumoto Y, Orihara Y, Asakura M, Min KD, Okuhara Y, Azuma K, Nishimura K, Sunayama I, Kashiwase K, Naito Y, Goda A, Ishihara M. Urine albumin-to-creatinine ratio on admission predicts early rehospitalization in patients with acute decompensated heart failure. Heart Vessels 2022; 37:1184-1194. [PMID: 35034172 DOI: 10.1007/s00380-022-02025-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/07/2022] [Indexed: 12/13/2022]
Abstract
Detecting high-risk patients for early rehospitalization is crucial in heart failure patient care. An association of albuminuria with cardiovascular events is well known. However, its predictive impact on rehospitalization for acute decompensated heart failure (ADHF) remains unknown. In this study, 190 consecutive patients admitted due to ADHF between 2017 and April 2019 who underwent urinalysis were enrolled. Among them, 140 patients from whom urine albumin-to-creatinine ratio (UACR) was measured with spot urine samples on admission were further analyzed. The association between UACR and rehospitalization due to HF during 1 year after discharge was evaluated. The mean age of 140 participants was 77.6 years and 55% were men. Only 18% (n = 25) of patients presented with normoalbuminuria (UACR < 30 mg/g∙creatinine), whereas 59% (n = 83) and 23% (n = 32) showed microalbuminuria (UACR 30-300 mg/g·creatinine) and macroalbuminuria (UACR > 300 mg/g·creatinine), respectively. The level of UACR on admission was correlated with the risk of subsequent rehospitalization due to HF (p = 0.017). The receiver operating characteristic analysis indicated that the best cut-off values for the UACR and B-type natriuretic peptide (BNP) levels to predict ADHF rehospitalization were 50 mg/g·creatinine and 824 pg/ml, respectively. When the patients were divided into four groups using both cut-off values, the individual predictive impacts of UACR and BNP on rehospitalization were comparable. Patients with both elevated UACR and BNP levels had a higher rate of HF rehospitalization than those with elevated BNP levels alone (p < 0.05). The combination of both values enabled more accurate prediction of HF rehospitalization than BNP levels alone. In conclusion, UACR could be a new useful biomarker to predict HF rehospitalization in patients with ADHF, especially in combination with the levels of BNP, and should be further evaluated in a prospective study.
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Affiliation(s)
- Yuki Matsumoto
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Yoshiyuki Orihara
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Masanori Asakura
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.
| | - Kyung-Duk Min
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Yoshitaka Okuhara
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Kohei Azuma
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Koichi Nishimura
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Isamu Sunayama
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Kazunori Kashiwase
- Cardiovascular Division, National Hospital Organization, Osaka-Minami Medical Center, Osaka, Japan
| | - Yoshiro Naito
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Akiko Goda
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Masaharu Ishihara
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
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Alataş ÖD, Biteker M, Demir A, Yıldırım B, Acar E, Gökçek K, Gökçek A. Microalbuminúria e seu Significado Prognóstico em Pacientes com Insuficiência Cardíaca Aguda com Fração de Ejeção Preservada, Intermediária e Reduzida. Arq Bras Cardiol 2021; 118:703-709. [PMID: 35137781 PMCID: PMC9007018 DOI: 10.36660/abc.20201144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 05/12/2021] [Indexed: 12/20/2022] Open
Abstract
Fundamento A prevalência e o significado da microalbuminúria não foram bem estudados em pacientes com diferentes subtipos de insuficiência cardíaca. Objetivo A prevalência e o significado da microalbuminúria não foram bem estudados em pacientes com diferentes subtipos de insuficiência cardíaca. Portanto, nosso objetivo foi investigar a frequência e o valor prognóstico da microalbuminúria em pacientes hospitalizados por insuficiência cardíaca aguda (ICA) com fração de ejeção preservada (ICFEp), fração de ejeção de faixa média (ICFEfm) e fração de ejeção reduzida (ICFEr). Métodos Todos os pacientes adultos consecutivos encaminhados ao hospital devido a ICA entre junho de 2016 e junho de 2019 foram inscritos. A microalbuminúria é definida como o nível de albumina urinária para relação de creatinina (AURC) na faixa de 30–300 mg/g. A mortalidade hospitalar foi o critério de valoração deste estudo. Resultados Dos 426 pacientes com ICA (idade média de 70,64 ± 10,03 anos, 53,3% do sexo feminino), 50% tinham ICFEr, 38,3% tinham ICFEp e 11,7% tinham ICFEfm na apresentação. A prevalência de microalbuminúria foi de 35,2%, 28,8% e 28,0% em ICFEr, ICFEp e ICFEfm, respectivamente. Um total de 19 (4,5%) pacientes morreram durante o curso intra-hospitalar, e a mortalidade intra-hospitalar foi maior em pacientes com ICFEr (6,6%) em comparação com pacientes com ICFEr (2,5%) e ICFEfm (2,0%). A análise multivariada mostrou que a presença de microalbuminúria previu mortalidade intra-hospitalar em pacientes com ICFEr e ICFEfm, mas não em ICFEp. Conclusão Embora a microalbuminúria fosse comum em todos os subgrupos de pacientes com ICA, descobriu-se que ela prediz o prognóstico apenas em pacientes com ICFEr e ICFEfm.
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Cho IJ, Kang SM. Angiotensin receptor-neprilysin inhibitor in patients with heart failure and chronic kidney disease. Kidney Res Clin Pract 2021; 40:555-565. [PMID: 34922429 PMCID: PMC8685363 DOI: 10.23876/j.krcp.21.900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 10/29/2021] [Indexed: 12/11/2022] Open
Abstract
Despite significant advances in the management of heart failure with reduced ejection fraction (HFrEF), there remains an enormous health problem with high morbidity and mortality over the last few decades. The neprilysin inhibitor enhances the activity of natriuretic peptides, producing vasodilation, natriuresis, and diuresis. Angiotensin receptor blockers inhibit the renin-angiotensin-aldosterone system. Sacubitril/valsartan, a first-in-class angiotensin receptor-neprilysin inhibitor (ARNI), has been shown to improve cardiovascular outcomes in HFrEF and delay the progression of chronic kidney disease (CKD) in patients with HFrEF. The PARADIGM-HF study showed a reduction in diuretic need in the ARNI group. While the use of diuretics is effective in volume control in patients with HFrEF, their use has the potential to adversely affect renal function. Therefore, ARNI therapy could benefit patients with heart failure and CKD by reducing cardiovascular morbidity and mortality and possibly retarding the progression of CKD, although more clinical evidence is required in patients with severe CKD and end-stage renal disease.
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Affiliation(s)
- In-Jeong Cho
- Division of Cardiology, Department of Internal Medicine, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Seok-Min Kang
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Saely CH, Maechler M, Vonbank A, Sprenger L, Mader A, Larcher B, Zanolin-Purin D, Leiherer A, Muendlein A, Drexel H. Single and joint impact of type 2 diabetes and of congestive heart failure on albuminuria. J Diabetes Complications 2021; 35:108046. [PMID: 34598838 DOI: 10.1016/j.jdiacomp.2021.108046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/27/2021] [Accepted: 09/07/2021] [Indexed: 12/31/2022]
Abstract
AIMS Albuminuria is a characteristic feature of diabetic nephropathy, and urine albumin excretion is also increased in patients with congestive heart failure (CHF). However, no data are available on the single and joint associations of type 2 diabetes mellitus (T2DM) and CHF with albuminuria. This issue was addressed in the present study. METHODS We investigated 4 groups of patients: 180 patients with CHF, of whom 83 had T2DM (CHF+/T2DM+) and 97 did not have diabetes (CHF+/T2DM-) and 223 controls without CHF, of whom 39 had T2DM (CHF-/T2DM+) and 184 did not have diabetes (CHF-/T2DM-). RESULTS The albumin-creatinine ratio (ACR) was 9.2 [5.7-16.9] mg/g in CHF-/T2DM- patients. Compared to this group it was higher in CHF-/T2DM+ patients (16.1 [7.7-27.8] mg/g; p = 0.004), in CHF+/T2DM- patients (22.0 [9.0-76.8] mg/g; p < 0.001) and in CHF+/T2DM+ patients (66.2 [16.0-177.0] mg/g; p < 0.001), in whom in turn it was higher than in CHF-/T2DM+ (p < 0.001) or in CHF+/T2DM- (p = 0.001) patients. The ACR did not differ significantly between CHF-/T2DM+ and CHF+/T2DM- patients (p = 0.188). In multivariate analysis of covariance, CHF and T2DM proved to be independent predictors of ACR after multivariate adjustment (F = 5.68; p = 0.018 and F = 4.79; p = 0.029, respectively). CONCLUSIONS We conclude that T2DM and CHF are mutually independent determinants of albuminuria.
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Affiliation(s)
- Christoph H Saely
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Carinagasse 47, AT-6800 Feldkirch, Austria; Private University of the Principality of Liechtenstein, Dorfstrasse 24, FL-9495 Triesen, Liechtenstein; Department of Medicine I, Academic Teaching Hospital Feldkirch, Carinagasse 47, AT-6800 Feldkirch, Austria
| | - Maximilian Maechler
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Carinagasse 47, AT-6800 Feldkirch, Austria; Private University of the Principality of Liechtenstein, Dorfstrasse 24, FL-9495 Triesen, Liechtenstein; Department of Medicine I, Academic Teaching Hospital Feldkirch, Carinagasse 47, AT-6800 Feldkirch, Austria
| | - Alexander Vonbank
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Carinagasse 47, AT-6800 Feldkirch, Austria; Private University of the Principality of Liechtenstein, Dorfstrasse 24, FL-9495 Triesen, Liechtenstein; Department of Medicine I, Academic Teaching Hospital Feldkirch, Carinagasse 47, AT-6800 Feldkirch, Austria
| | - Lukas Sprenger
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Carinagasse 47, AT-6800 Feldkirch, Austria; Private University of the Principality of Liechtenstein, Dorfstrasse 24, FL-9495 Triesen, Liechtenstein; Department of Medicine I, Academic Teaching Hospital Feldkirch, Carinagasse 47, AT-6800 Feldkirch, Austria
| | - Arthur Mader
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Carinagasse 47, AT-6800 Feldkirch, Austria; Private University of the Principality of Liechtenstein, Dorfstrasse 24, FL-9495 Triesen, Liechtenstein; Department of Medicine I, Academic Teaching Hospital Feldkirch, Carinagasse 47, AT-6800 Feldkirch, Austria
| | - Barbara Larcher
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Carinagasse 47, AT-6800 Feldkirch, Austria; Private University of the Principality of Liechtenstein, Dorfstrasse 24, FL-9495 Triesen, Liechtenstein; Department of Medicine I, Academic Teaching Hospital Feldkirch, Carinagasse 47, AT-6800 Feldkirch, Austria
| | - Daniela Zanolin-Purin
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Carinagasse 47, AT-6800 Feldkirch, Austria; Private University of the Principality of Liechtenstein, Dorfstrasse 24, FL-9495 Triesen, Liechtenstein
| | - Andreas Leiherer
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Carinagasse 47, AT-6800 Feldkirch, Austria
| | - Axel Muendlein
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Carinagasse 47, AT-6800 Feldkirch, Austria
| | - Heinz Drexel
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Carinagasse 47, AT-6800 Feldkirch, Austria; Private University of the Principality of Liechtenstein, Dorfstrasse 24, FL-9495 Triesen, Liechtenstein; Department of Medicine I, Academic Teaching Hospital Feldkirch, Carinagasse 47, AT-6800 Feldkirch, Austria; Drexel University College of Medicine, 2900 W Queen Ln, PA 19129, Philadelphia, USA.
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Koniari I, Artopoulou E, Velissaris D, Ainslie M, Mplani V, Karavasili G, Kounis N, Tsigkas G. Biomarkers in the clinical management of patients with atrial fibrillation and heart failure. J Geriatr Cardiol 2021; 18:908-951. [PMID: 34908928 PMCID: PMC8648548 DOI: 10.11909/j.issn.1671-5411.2021.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Atrial fibrillation (AF) and heart failure (HF) are two cardiovascular diseases with an increasing prevalence worldwide. These conditions share common pathophysiologiesand frequently co-exit. In fact, the occurrence of either condition can 'cause' the development of the other, creating a new patient group that demands different management strategies to that if they occur in isolation. Regardless of the temproral association of the two conditions, their presence is linked with adverse cardiovascular outcomes, increased rate of hospitalizations, and increased economic burden on healthcare systems. The use of low-cost, easily accessible and applicable biomarkers may hasten the correct diagnosis and the effective treatment of AF and HF. Both AF and HF effect multiple physiological pathways and thus a great number of biomarkers can be measured that potentially give the clinician important diagnostic and prognostic information. These will then guide patient centred therapeutic management. The current biomarkers that offer potential for guiding therapy, focus on the physiological pathways of miRNA, myocardial stretch and injury, oxidative stress, inflammation, fibrosis, coagulation and renal impairment. Each of these has different utility in current clinincal practice.
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Affiliation(s)
- Ioanna Koniari
- Manchester Heart Institute, Manchester University Foundation Trust, Manchester, United Kingdom
| | - Eleni Artopoulou
- Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | | | - Mark Ainslie
- Manchester Heart Institute, Manchester University Foundation Trust, Manchester, United Kingdom
- Division of Cardiovascular Sciences, University of Manchester
| | - Virginia Mplani
- Department of Cardiology, University Hospital of Patras, Patras, Greece
| | - Georgia Karavasili
- Manchester Heart Institute, Manchester University Foundation Trust, Manchester, United Kingdom
| | - Nicholas Kounis
- Department of Cardiology, University Hospital of Patras, Patras, Greece
| | - Grigorios Tsigkas
- Department of Cardiology, University Hospital of Patras, Patras, Greece
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Kaneko T, Kodani E, Fujii H, Asai R, Seki M, Nakazato R, Nakamura H, Sasabe H, Tamura Y. Anemia and atrial fibrillation as independent risk factors for new-onset chronic kidney disease: the TAMA-MED Project-CKD and AF. Clin Kidney J 2021; 14:2221-2226. [PMID: 34603698 PMCID: PMC8483686 DOI: 10.1093/ckj/sfab014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Indexed: 11/16/2022] Open
Abstract
Background Various risk factors have been identified for the new onset or rapid deterioration of chronic kidney disease (CKD). However, it is thought that many risk factors that have not yet been clarified remain. Methods Based on the results of specific annual health checkups at Tama City (n = 18 383) in 2017 and 2018, we analyzed the factors that cause new-onset CKD and the risk factors that rapidly worsen renal function. For new-onset CKD, proteinuria and estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 were examined separately. Rapid deterioration of renal function was defined as an eGFR ≥25% less than the previous year. Results Multivariate analysis showed that in addition to age and impaired glucose tolerance, anemia and atrial fibrillation (AF) were risk factors for the new appearance of proteinuria. Risk factors for a decrease in eGFR to <60 mL/min/1.73 m2 were age and hyperuricemia. Age, systolic hypertension, urinary protein and urinary occult blood, high triglycerides and anemia were significant risk factors for the rapid deterioration of renal function in patients with CKD Stage ≥3. Conclusions From the results of specific annual health checkups at Tama City, AF, anemia and hyperuricemia were identified as risk factors for new-onset CKD over a short period of 1 year. Anemia was also a factor for the rapid deterioration of kidney function in subjects with renal dysfunction.
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Affiliation(s)
- Tomohiro Kaneko
- Department of Nephrology, Nippon Medical School Tama-Nagayama Hospital, Tokyo, Japan
| | - Eitaro Kodani
- Department of Cardiovascular Medicine, Nippon Medical School Tama-Nagayama Hospital, Tokyo, Japan.,TAMA CITY Medical Association, Tokyo, Japan
| | - Hitomi Fujii
- TAMA CITY Medical Association, Tokyo, Japan.,Tama-Center Mirai Clinic, Tokyo, Japan
| | - Risa Asai
- Department of Nephrology, Nippon Medical School Tama-Nagayama Hospital, Tokyo, Japan
| | - Miyako Seki
- Department of Nephrology, Nippon Medical School Tama-Nagayama Hospital, Tokyo, Japan
| | - Rei Nakazato
- Department of Nephrology, Nippon Medical School Tama-Nagayama Hospital, Tokyo, Japan
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Nickel NP, Galura GM, Zuckerman MJ, Hakim MN, Alkhateeb H, Mukherjee D, Austin ED, Heresi GA. Liver abnormalities in pulmonary arterial hypertension. Pulm Circ 2021; 11:20458940211054304. [PMID: 34707859 PMCID: PMC8544777 DOI: 10.1177/20458940211054304] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/13/2021] [Indexed: 12/17/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a cardiopulmonary disease with high mortality. In recent years, it has been recognized that PAH is a multi-organ system disease, involving the systemic circulation, kidneys, skeletal muscles, and the central nervous system, among others. Right heart failure produces congestive hepatopathy, a disease state that has direct consequences on liver biochemistry, histology, and systemic glucose and lipid metabolism. This article aims to summarize the consequences of congestive hepatopathy with an emphasis on liver biochemistry, histology, and PAH-targeted therapy. Furthermore, PAH-specific changes in glucose and lipid metabolism will be discussed.
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Affiliation(s)
- Nils P. Nickel
- Division of Pulmonary and Critical Care Medicine, Texas Tech
University Health Sciences Center, El Paso, TX, USA
| | - Gian M. Galura
- Division of Gastroenterology, Texas Tech University Health
Sciences Center, El Paso, TX, USA
| | - Marc J. Zuckerman
- Division of Gastroenterology, Texas Tech University Health
Sciences Center, El Paso, TX, USA
| | - M. Nawar Hakim
- Department of Pathology, Texas Tech University Health Sciences
Center, El Paso, TX, USA
| | - Haider Alkhateeb
- Division of Cardiovascular Medicine, Texas Tech University
Health Sciences Center, El Paso, TX, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Medicine, Texas Tech University
Health Sciences Center, El Paso, TX, USA
| | - Eric D. Austin
- Division of Pediatric Pulmonary Medicine, Vanderbilt University,
Nashville, TN, USA
| | - Gustavo A. Heresi
- Division of Pulmonary and Critical Care Medicine, Cleveland
Clinic, OH, USA
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Oeun B, Hikoso S, Nakatani D, Mizuno H, Suna S, Kitamura T, Okada K, Dohi T, Sotomi Y, Kida H, Sunaga A, Sato T, Nakagawa A, Nakagawa Y, Hayashi T, Yano M, Tamaki S, Yasumura Y, Yamada T, Sakata Y. Prognostic significance of dipstick proteinuria in heart failure with preserved ejection fraction: insight from the PURSUIT-HFpEF registry. BMJ Open 2021; 11:e049371. [PMID: 34526341 PMCID: PMC8444246 DOI: 10.1136/bmjopen-2021-049371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE The semiquantitative urine dipstick test is a simple and convenient method that is available in the smallest community-based healthcare clinics. We sought to clarify the prognostic significance of dipstick proteinuria in patients with heart failure (HF) with preserved ejection fraction (HFpEF). DESIGN A Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with preserved Ejection Fraction (PURSUIT-HFpEF) registry. PARTICIPANTS AND SETTING We assessed 851 discharged-alive patients in the PURSUIT-HFpEF registry who were initially hospitalised due to an acute decompensated HFpEF (EF≥50%) and elevated N-terminal-pro-brain natriuretic peptide (≥400 ng/L) at Osaka University Hospital and other 30 affiliated hospitals in the Kansai region of Japan. Patients received a urine dipstick test, and were divided into two groups according to the absence or presence of proteinuria. A trace or more of dipstick proteinuria was defined as the presence of proteinuria. MAIN OUTCOME MEASURES A composite of cardiac death or HF rehospitalisation. RESULTS Median age was 83 years and 473 patients (55.6%) were female. Five hundred and two patients (59%) were proteinuria (-) and 349 patients (41%) were proteinuria (+). The composite endpoint and HF rehospitalisation occurred more often in proteinuria (+) individuals than proteinuria (-) individuals (log-rank p=0.006 and p=0.007, respectively); but cardiac death did not (log-rank p=0.139). Multivariable Cox regression analysis showed that the presence of proteinuria was associated with the composite endpoint (HR: 1.47, 95% CI 1.07 to 2.01, p=0.016), and HF rehospitalisation (HR: 1.48, 95% CI 1.07 to 2.05, p=0.020), but not with cardiac death (HR: 1.52, 95% CI 0.83 to 2.76, p=0.172). CONCLUSIONS Dipstick proteinuria may be a prognostic marker in patients with HFpEF. Evaluation of proteinuria by a urine dipstick test may be a simple but useful method for risk stratification in HFpEF. UMIN-CTR ID UMIN000021831.
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Affiliation(s)
- Bolrathanak Oeun
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shungo Hikoso
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Daisaku Nakatani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hiroya Mizuno
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shinichiro Suna
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tetsuhisa Kitamura
- Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Katsuki Okada
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tomoharu Dohi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hirota Kida
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Akihiro Sunaga
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Taiki Sato
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Akito Nakagawa
- Division of Cardiology, Amagasaki Chuo Hospital, Amagasaki, Japan
- Department of Medical Informatics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yusuke Nakagawa
- Division of Cardiology, Kawanishi City Hospital, Kawanishi, Japan
| | | | - Masamichi Yano
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Japan
| | - Shunsuke Tamaki
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Yoshio Yasumura
- Division of Cardiology, Amagasaki Chuo Hospital, Amagasaki, Japan
| | - Takahisa Yamada
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
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Goffredo G, Barone R, Di Terlizzi V, Correale M, Brunetti ND, Iacoviello M. Biomarkers in Cardiorenal Syndrome. J Clin Med 2021; 10:jcm10153433. [PMID: 34362216 PMCID: PMC8348334 DOI: 10.3390/jcm10153433] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 07/29/2021] [Indexed: 01/16/2023] Open
Abstract
Cardiorenal syndrome is a clinical manifestation of the bidirectional interaction between the heart and kidney diseases. Over the last years, in patients with cardiovascular diseases, several biomarkers have been studied in order to better assess renal function as well as to identify patients prone to experiencing chronic or acute worsening of renal function. The aim of this review is to focus on the possible clinical usefulness of the most recent biomarkers in the setting of cardiorenal syndrome.
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Affiliation(s)
- Giovanni Goffredo
- Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy; (G.G.); (R.B.); (V.D.T.); (M.C.); (N.D.B.)
- Cardiology Unit, University Policlinic Hospital Riuniti, Viale Luigi Pinto 1, 71122 Foggia, Italy
| | - Roberta Barone
- Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy; (G.G.); (R.B.); (V.D.T.); (M.C.); (N.D.B.)
- Cardiology Unit, University Policlinic Hospital Riuniti, Viale Luigi Pinto 1, 71122 Foggia, Italy
| | - Vito Di Terlizzi
- Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy; (G.G.); (R.B.); (V.D.T.); (M.C.); (N.D.B.)
- Cardiology Unit, University Policlinic Hospital Riuniti, Viale Luigi Pinto 1, 71122 Foggia, Italy
| | - Michele Correale
- Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy; (G.G.); (R.B.); (V.D.T.); (M.C.); (N.D.B.)
- Cardiology Unit, University Policlinic Hospital Riuniti, Viale Luigi Pinto 1, 71122 Foggia, Italy
| | - Natale Daniele Brunetti
- Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy; (G.G.); (R.B.); (V.D.T.); (M.C.); (N.D.B.)
- Cardiology Unit, University Policlinic Hospital Riuniti, Viale Luigi Pinto 1, 71122 Foggia, Italy
| | - Massimo Iacoviello
- Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy; (G.G.); (R.B.); (V.D.T.); (M.C.); (N.D.B.)
- Cardiology Unit, University Policlinic Hospital Riuniti, Viale Luigi Pinto 1, 71122 Foggia, Italy
- Correspondence:
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Fibrosis, the Bad Actor in Cardiorenal Syndromes: Mechanisms Involved. Cells 2021; 10:cells10071824. [PMID: 34359993 PMCID: PMC8307805 DOI: 10.3390/cells10071824] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/08/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023] Open
Abstract
Cardiorenal syndrome is a term that defines the complex bidirectional nature of the interaction between cardiac and renal disease. It is well established that patients with kidney disease have higher incidence of cardiovascular comorbidities and that renal dysfunction is a significant threat to the prognosis of patients with cardiac disease. Fibrosis is a common characteristic of organ injury progression that has been proposed not only as a marker but also as an important driver of the pathophysiology of cardiorenal syndromes. Due to the relevance of fibrosis, its study might give insight into the mechanisms and targets that could potentially be modulated to prevent fibrosis development. The aim of this review was to summarize some of the pathophysiological pathways involved in the fibrotic damage seen in cardiorenal syndromes, such as inflammation, oxidative stress and endoplasmic reticulum stress, which are known to be triggers and mediators of fibrosis.
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Ibrahim NE, Felker GM. Don't Be So Fast to Discard That Clean Catch! JACC-HEART FAILURE 2021; 9:624-626. [PMID: 34246605 DOI: 10.1016/j.jchf.2021.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 05/18/2021] [Indexed: 11/15/2022]
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Martin N, Manoharan K, Davies C, Lumbers RT. Beta-blockers and inhibitors of the renin-angiotensin aldosterone system for chronic heart failure with preserved ejection fraction. Cochrane Database Syst Rev 2021; 5:CD012721. [PMID: 34022072 PMCID: PMC8140651 DOI: 10.1002/14651858.cd012721.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Beta-blockers and inhibitors of the renin-angiotensin-aldosterone system improve survival and reduce morbidity in people with heart failure with reduced left ventricular ejection fraction (LVEF); a review of the evidence is required to determine whether these treatments are beneficial for people with heart failure with preserved ejection fraction (HFpEF). OBJECTIVES To assess the effects of beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists in people with HFpEF. SEARCH METHODS We updated searches of CENTRAL, MEDLINE, Embase, and one clinical trial register on 14 May 2020 to identify eligible studies, with no language or date restrictions. We checked references from trial reports and review articles for additional studies. SELECTION CRITERIA: We included randomised controlled trials with a parallel group design, enrolling adults with HFpEF, defined by LVEF greater than 40%. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 41 randomised controlled trials (231 reports), totalling 23,492 participants across all comparisons. The risk of bias was frequently unclear and only five studies had a low risk of bias in all domains. Beta-blockers (BBs) We included 10 studies (3087 participants) investigating BBs. Five studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 30 years to 81 years. A possible reduction in cardiovascular mortality was observed (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.62 to 0.99; number needed to treat for an additional benefit (NNTB) 25; 1046 participants; three studies), however, the certainty of evidence was low. There may be little to no effect on all-cause mortality (RR 0.82, 95% CI 0.67 to 1.00; 1105 participants; four studies; low-certainty evidence). The effects on heart failure hospitalisation, hyperkalaemia, and quality of life remain uncertain. Mineralocorticoid receptor antagonists (MRAs) We included 13 studies (4459 participants) investigating MRA. Eight studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 54.5 to 80 years. Pooled analysis indicated that MRA treatment probably reduces heart failure hospitalisation (RR 0.82, 95% CI 0.69 to 0.98; NNTB = 41; 3714 participants; three studies; moderate-certainty evidence). However, MRA treatment probably has little or no effect on all-cause mortality (RR 0.91, 95% CI 0.78 to 1.06; 4207 participants; five studies; moderate-certainty evidence) and cardiovascular mortality (RR 0.90, 95% CI 0.74 to 1.11; 4070 participants; three studies; moderate-certainty evidence). MRA treatment may have little or no effect on quality of life measures (mean difference (MD) 0.84, 95% CI -2.30 to 3.98; 511 participants; three studies; low-certainty evidence). MRA treatment was associated with a higher risk of hyperkalaemia (RR 2.11, 95% CI 1.77 to 2.51; number needed to treat for an additional harmful outcome (NNTH) = 11; 4291 participants; six studies; high-certainty evidence). Angiotensin-converting enzyme inhibitors (ACEIs) We included eight studies (2061 participants) investigating ACEIs. Three studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 70 to 82 years. Pooled analyses with moderate-certainty evidence suggest that ACEI treatment likely has little or no effect on cardiovascular mortality (RR 0.93, 95% CI 0.61 to 1.42; 945 participants; two studies), all-cause mortality (RR 1.04, 95% CI 0.75 to 1.45; 1187 participants; five studies) and heart failure hospitalisation (RR 0.86, 95% CI 0.64 to 1.15; 1019 participants; three studies), and may result in little or no effect on the quality of life (MD -0.09, 95% CI -3.66 to 3.48; 154 participants; two studies; low-certainty evidence). The effects on hyperkalaemia remain uncertain. Angiotensin receptor blockers (ARBs) Eight studies (8755 participants) investigating ARBs were included. Five studies used a placebo comparator and in three the comparator was usual care. The mean age of participants ranged from 61 to 75 years. Pooled analyses with high certainty of evidence suggest that ARB treatment has little or no effect on cardiovascular mortality (RR 1.02, 95% 0.90 to 1.14; 7254 participants; three studies), all-cause mortality (RR 1.01, 95% CI 0.92 to 1.11; 7964 participants; four studies), heart failure hospitalisation (RR 0.92, 95% CI 0.83 to 1.02; 7254 participants; three studies), and quality of life (MD 0.41, 95% CI -0.86 to 1.67; 3117 participants; three studies). ARB was associated with a higher risk of hyperkalaemia (RR 1.88, 95% CI 1.07 to 3.33; 7148 participants; two studies; high-certainty evidence). Angiotensin receptor neprilysin inhibitors (ARNIs) Three studies (7702 participants) investigating ARNIs were included. Two studies used ARBs as the comparator and one used standardised medical therapy, based on participants' established treatments at enrolment. The mean age of participants ranged from 71 to 73 years. Results suggest that ARNIs may have little or no effect on cardiovascular mortality (RR 0.96, 95% CI 0.79 to 1.15; 4796 participants; one study; moderate-certainty evidence), all-cause mortality (RR 0.97, 95% CI 0.84 to 1.11; 7663 participants; three studies; high-certainty evidence), or quality of life (high-certainty evidence). However, ARNI treatment may result in a slight reduction in heart failure hospitalisation, compared to usual care (RR 0.89, 95% CI 0.80 to 1.00; 7362 participants; two studies; moderate-certainty evidence). ARNI treatment was associated with a reduced risk of hyperkalaemia compared with valsartan (RR 0.88, 95% CI 0.77 to 1.01; 5054 participants; two studies; moderate-certainty evidence). AUTHORS' CONCLUSIONS There is evidence that MRA and ARNI treatment in HFpEF probably reduces heart failure hospitalisation but probably has little or no effect on cardiovascular mortality and quality of life. BB treatment may reduce the risk of cardiovascular mortality, however, further trials are needed. The current evidence for BBs, ACEIs, and ARBs is limited and does not support their use in HFpEF in the absence of an alternative indication. Although MRAs and ARNIs are probably effective at reducing the risk of heart failure hospitalisation, the treatment effect sizes are modest. There is a need for improved approaches to patient stratification to identify the subgroup of patients who are most likely to benefit from MRAs and ARNIs, as well as for an improved understanding of disease biology, and for new therapeutic approaches.
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Affiliation(s)
- Nicole Martin
- Institute of Health Informatics Research, University College London, London, UK
| | | | - Ceri Davies
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - R Thomas Lumbers
- Institute of Health Informatics, University College London, London, UK
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Wang Y, Zhao X, Zhai M, Fan C, Huang Y, Zhou Q, Tian P, An T, Zhang Y, Zhang J. Elevated urinary albumin concentration predicts worse clinical outcomes in hospitalized acute decompensated heart failure patients. ESC Heart Fail 2021; 8:3037-3048. [PMID: 34008352 PMCID: PMC8318403 DOI: 10.1002/ehf2.13399] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/17/2021] [Accepted: 04/21/2021] [Indexed: 01/14/2023] Open
Abstract
Objective To investigate the prognostic value of elevated urinary albumin concentration (UAC) in hospitalized acute decompensated heart failure (ADHF) patients. Methods We measured UAC at baseline in 1818 hospitalized ADHF patients who were admitted to our Heart Failure Center. All patients were followed up for a median period of 937.5 days. The primary endpoint was a composite of all‐cause death or heart transplantation (HTx) or left ventricular assist device (LVAD) implantation. Results In total, 41.5% of ADHF patients had albuminuria (UAC ≥ 20 mg/L). The median value of UAC was 15.5 mg/L. A total of 679 patients died or underwent HTx/LVAD during follow‐up. The median UAC was significantly lower in non‐HTx/LVAD survivors (14.3 mg/L) than in those who died or underwent HTx/LVAD (18.0 mg/L, P < 0.001). Compared with patients without albuminuria (reference, n = 1064), those with albuminuria had a 1.47‐fold higher risk of all‐cause death or HTx/LVAD (95% confidence interval [CI]:1.26–1.71, P < 0.001), with hazard ratios (HRs) of 1.42 (95% CI: 1.21–1.66) and 1.74 (95% CI: 1.33–2.26) in patients with microalbuminuria (20 mg/L ≤ UAC < 200 mg/L, n = 617) and macroalbuminuria (UAC ≥ 200 mg/L, n = 137), respectively (both P < 0.001). After adjustment for significant clinical risk factors, the albuminuria group had a higher risk of primary adverse events than the non‐albuminuria group (HR = 1.28, 95% CI: 1.09–1.50, P = 0.003), with HRs of 1.27 [95% CI: 1.07–1.49] and 1.36 [95% CI: 1.01–1.84] in patients with microalbuminuria and macroalbuminuria, respectively (P = 0.006 and P = 0.041). The adjusted risk of primary adverse events also increased with the degree of albuminuria in the test for trend (HR = 1.21, 95% CI: 1.06–1.37, P for trend = 0.004). In the subgroup analysis, albuminuria had a significantly greater prognostic value for patients with left ventricular ejection fraction ≥ 40%, eGFR ≥ 60 mL/min/1.73 m2, BUN/creatinine ratio ≥ 20 or NT‐proBNP < 2098 pg/mL. Conclusion The presence of albuminuria evaluated by UAC predicts adverse clinical outcomes in hospitalized ADHF patients.
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Affiliation(s)
- Yunhong Wang
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuemei Zhao
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mei Zhai
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chaomei Fan
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Huang
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiong Zhou
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Pengchao Tian
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao An
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuhui Zhang
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian Zhang
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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45
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Liang W, Liu Q, Wang QY, Yu H, Yu J. Albuminuria and Dipstick Proteinuria for Predicting Mortality in Heart Failure: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2021; 8:665831. [PMID: 34055938 PMCID: PMC8155471 DOI: 10.3389/fcvm.2021.665831] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/29/2021] [Indexed: 12/26/2022] Open
Abstract
Background: Research suggest that albuminuria is not only an independent risk factor for the development of heart failure but may also act as a biomarker for predicting adverse outcomes. To date, no study has synthesized evidence on its role as a prognostic indicator. Thus, the current study aimed to quantitatively assess the prognostic utility of albuminuria as well as dipstick proteinuria in predicting mortality in heart failure patients. Methods: PubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar databases were searched up to October 10, 2020. All studies reporting multivariable-adjusted hazard ratios (HR) for albuminuria or dipstick proteinuria for mortality and/or hospitalization in heart failure patients were included. Results: Eleven studies were included. Seven assessed albuminuria and five assessed dipstick proteinuria. Our analysis revealed a statistically significant increased risk of all-cause mortality with microalbuminuria (HR: 1.54; 95% CI, 1.23-1.93; I 2 = 79%; p = 0.0002) and macroalbuminuria (HR: 1.76; 95% CI, 1.21-2.56; I 2 = 88%; p = 0.003) in heart failure patients. The risk of all-cause mortality and hospitalization was also significantly increased with macroalbuminuria. Microalbuminuria was associated with significantly increased cardiovascular mortality and combined cardiovascular mortality and hospitalization. Positive dipstick test for proteinuria was significantly associated with mortality in heart failure (HR: 1.54; 95% CI, 1.28-1.84; I 2 = 67%; p < 0.00001). Conclusion: Both microalbuminuria and macroalbuminuria are predictors of mortality in patients with heart failure. Dipstick proteinuria may be used as a rapid screening test to predict mortality in these patients.
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Affiliation(s)
- Wei Liang
- Department of Cardiology, Lanzhou University Second Hospital, Lanzhou, China
| | - Qian Liu
- Research Center, Gansu Provincial Maternal and Child Care Hospital, Lanzhou, China
| | - Qiong-Ying Wang
- Department of Cardiology, Lanzhou University Second Hospital, Lanzhou, China
| | - Heng Yu
- Department of Cardiology, Lanzhou University Second Hospital, Lanzhou, China
| | - Jing Yu
- Department of Cardiology, Lanzhou University Second Hospital, Lanzhou, China
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46
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Anyfanti P, Sampani E, Tsapas A. Fluid volume regulation in patients with heart failure. Lancet Diabetes Endocrinol 2021; 9:257-258. [PMID: 33864808 DOI: 10.1016/s2213-8587(21)00080-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Panagiota Anyfanti
- Second Medical Department, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece.
| | - Erasmia Sampani
- Second Medical Department, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Apostolos Tsapas
- Second Medical Department, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
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47
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Prenesti E, Berto S, Gosmaro F, Bagnati M, Bellomo G. Biomolecules Responsible for the Total Antioxidant Capacity (TAC) of Human Plasma in Healthy and Cardiopathic Individuals: A Chemical Speciation Model. Antioxidants (Basel) 2021; 10:antiox10050656. [PMID: 33922717 PMCID: PMC8145038 DOI: 10.3390/antiox10050656] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 12/13/2022] Open
Abstract
(1) Background: Much effort has been expended to investigate the antioxidant capacity of human plasma, attempting to clarify the roles of both metabolic and food substances in determining defenses against oxidative stress. The relationship between the total antioxidant capacity (TAC) and the concentrations of redox-active biomolecules in the human plasma of healthy and cardiopathic individuals was investigated in the present study to develop a chemical speciation model. (2) Methods: Plasma was collected from 85 blood donors and from 25 cardiovascular surgery patients. The TAC was measured using the CUPRAC-BCS (CUPric Reducing Antioxidant Capacity — Bathocuproinedisulfonic acid) method. Biomolecule concentrations were determined via visible spectrophotometry or HPLC/RP techniques. The relationship between the TAC and the concentrations was defined by applying a multiple regression analysis. The significance of the variables was first tested, and chemical models were proposed for the two datasets. The model equation is TAC=∑iβi·Ai, where βi and [Ai] are the electronic exchange and the molar concentrations of the ith antioxidant component, respectively. (3) Results: The major contributions to the TAC, ~80%, come from endogenous compounds in both healthy and cardiopathic individuals, whereas the contributions from exogenous compounds were different between the two datasets. In particular, γ-tocopherol showed a different role in the chemical models developed for the two groups.
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Affiliation(s)
- Enrico Prenesti
- Department of Chemistry, University of Turin, Via Pietro Giuria 5, 10125 Turin, Italy; (E.P.); (F.G.)
| | - Silvia Berto
- Department of Chemistry, University of Turin, Via Pietro Giuria 5, 10125 Turin, Italy; (E.P.); (F.G.)
- Correspondence:
| | - Fabio Gosmaro
- Department of Chemistry, University of Turin, Via Pietro Giuria 5, 10125 Turin, Italy; (E.P.); (F.G.)
- Istituto Professionale di Stato per Servizi Alberghieri e Ristorazione G. Giolitti, Piazza IV Novembre, 12080 Mondovì, Italy
| | - Marco Bagnati
- Clinical Chemical Analysis Laboratory of the University Hospital “Maggiore della Carità”, University of Eastern Piedmont Amedeo Avogadro, C.so Giuseppe Mazzini, 18, 28100 Novara, Italy; (M.B.); (G.B.)
| | - Giorgio Bellomo
- Clinical Chemical Analysis Laboratory of the University Hospital “Maggiore della Carità”, University of Eastern Piedmont Amedeo Avogadro, C.so Giuseppe Mazzini, 18, 28100 Novara, Italy; (M.B.); (G.B.)
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48
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Chrysant SG, Chrysant GS. The pathophysiology and management of diuretic resistance in patients with heart failure. Hosp Pract (1995) 2021; 50:93-101. [PMID: 33596757 DOI: 10.1080/21548331.2021.1893065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES The objectives of the study are to investigate the causes of diuretic resistance in patients with advanced congestive heart failure (CHF), since diuretics are the cornerstone of treatment of these patients. Several studies have shown that diuretic resistance in patients with advanced CHF is common, ranging from 25% to 50% in hospitalized patients. METHODS In order to get a current perspective as to the magnitude of diuretic resistance in such patients, a focused Medline search of the English language literature was conducted between 2015 and 2020 using the search terms, CHF, diuretics, treatment, resistance, frequency, and 30 papers with pertinent information were selected. RESULTS The analysis of data from the selected papers demonstrated that diuretic resistance is common in hospitalized patients with advanced CHF and frequently associated with renal failure, which is secondary to CHF. CONCLUSIONS Diuretic resistance appears to be common in patients with advanced CHF and it is mostly due to decreased cardiac output, low blood pressure, decreased glomerular filtration rate, decreased filtration of sodium, and increased tubular reabsorption of sodium. Diuretic resistance in such patients can be overcome with the combination of loop diuretics with thiazide and thiazide-like diuretics, aldosterone antagonists, as well as other agents. The data from these studies in combination with collateral literature will be discussed in this review.
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Affiliation(s)
- Steven G Chrysant
- Department of cardiology, University of Oklahoma Health Sciences Center, Oklahoma, United States.,Department of cardiology, INTEGRIS Baptist Medical Center, Oklahoma, United States
| | - George S Chrysant
- Department of cardiology, University of Oklahoma Health Sciences Center, Oklahoma, United States.,Department of cardiology, INTEGRIS Baptist Medical Center, Oklahoma, United States
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Deferrari G, Cipriani A, La Porta E. Renal dysfunction in cardiovascular diseases and its consequences. J Nephrol 2021; 34:137-153. [PMID: 32870495 PMCID: PMC7881972 DOI: 10.1007/s40620-020-00842-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 08/12/2020] [Indexed: 12/13/2022]
Abstract
It is well known that the heart and kidney and their synergy is essential for hemodynamic homeostasis. Since the early XIX century it has been recognized that cardiovascular and renal diseases frequently coexist. In the nephrological field, while it is well accepted that renal diseases favor the occurrence of cardiovascular diseases, it is not always realized that cardiovascular diseases induce or aggravate renal dysfunctions, in this way further deteriorating cardiac function and creating a vicious circle. In the same clinical field, the role of venous congestion in the pathogenesis of renal dysfunction is at times overlooked. This review carefully quantifies the prevalence of chronic and acute kidney abnormalities in cardiovascular diseases, mainly heart failure, regardless of ejection fraction, and the consequences of renal abnormalities on both organs, making cardiovascular diseases a major risk factor for kidney diseases. In addition, with regard to pathophysiological aspects, we attempt to substantiate the major role of fluid overload and venous congestion, including renal venous hypertension, in the pathogenesis of acute and chronic renal dysfunction occurring in heart failure. Furthermore, we describe therapeutic principles to counteract the major pathophysiological abnormalities in heart failure complicated by renal dysfunction. Finally, we underline that the mild transient worsening of renal function after decongestive therapy is not usually associated with adverse prognosis. Accordingly, the coexistence of cardiovascular and renal diseases inevitably means mediating between preserving renal function and improving cardiac activity to reach a better outcome.
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Affiliation(s)
- Giacomo Deferrari
- Department of Cardionephrology, Istituto Clinico Ligure Di Alta Specialità (ICLAS), GVM Care and Research, Via Mario Puchoz 25, 16035, Rapallo, GE, Italy.
- Department of Internal Medicine (DiMi), University of Genoa, Genoa, Italy.
| | - Adriano Cipriani
- Grown-Up Congentital Heart Disease Center (GUCH Center), Istituto Clinico Ligure Di Alta Specialità (ICLAS), GVM Care and Research, Rapallo, GE, Italy
| | - Edoardo La Porta
- Department of Cardionephrology, Istituto Clinico Ligure Di Alta Specialità (ICLAS), GVM Care and Research, Via Mario Puchoz 25, 16035, Rapallo, GE, Italy
- Department of Internal Medicine (DiMi), University of Genoa, Genoa, Italy
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50
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Jensen J, Omar M, Kistorp C, Tuxen C, Gustafsson I, Køber L, Gustafsson F, Faber J, Malik ME, Fosbøl EL, Bruun NE, Forman JL, Jensen LT, Møller JE, Schou M. Effects of empagliflozin on estimated extracellular volume, estimated plasma volume, and measured glomerular filtration rate in patients with heart failure (Empire HF Renal): a prespecified substudy of a double-blind, randomised, placebo-controlled trial. Lancet Diabetes Endocrinol 2021; 9:106-116. [PMID: 33357505 DOI: 10.1016/s2213-8587(20)30382-x] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/22/2020] [Accepted: 11/03/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND SGLT2 inhibitors are a promising treatment option in patients with heart failure and reduced ejection fraction. We aimed to investigate the effects of empagliflozin on estimated extracellular volume, estimated plasma volume, and measured glomerular filtration rate (GFR) in patients with heart failure and reduced ejection fraction. METHODS Empire HF Renal was a prespecified substudy of the investigator-initiated, double-blind, randomised, placebo-controlled Empire HF trial. The study was done at Herlev and Gentofte University Hospital (Herlev, Denmark), with patients recruited from four Danish heart failure outpatient clinics. Patients with New York Heart Association class I-III symptoms, with a left ventricular ejection fraction of 40% or lower, and on guideline-directed heart failure therapy were randomly assigned (1:1) to receive either oral empagliflozin 10 mg or matched placebo once daily for 12 weeks. The allocation sequence was computer-generated. Patients and study investigators were masked to treatment allocation. The coprimary prespecified renal outcomes were the between-group difference in the changes in estimated extracellular volume, estimated plasma volume, and measured GFR from baseline to 12 weeks. All analyses were done in the intention-to-treat population (apart from safety analyses, which were done in patients who received at least one dose of study drug), with no interim analyses done during the trial. The Empire HF trial is registered with ClinicalTrials.gov, NCT03198585, and EudraCT, 2017-001341-27. FINDINGS Between June 29, 2017, and July 15, 2019, we assessed 391 patients for eligibility, of whom 120 (31%) were randomly assigned to empagliflozin or placebo, including 105 (88%) without diabetes. In intention-to-treat analyses, 60 (100%) patients in the empagliflozin group and 59 (98%) patients in the placebo group were included for estimated extracellular volume and estimated plasma volume, and 59 (98%) patients in the empagliflozin group and 58 (97%) patients in the placebo group were included for measured GFR. Empagliflozin treatment resulted in reductions in estimated extracellular volume (adjusted mean difference -0·12 L, 95% CI -0·18 to -0·05; p=0·00056), estimated plasma volume (-7·3%, -10·3 to -4·3; p<0·0001), and measured GFR (-7·5 mL/min, -11·2 to -3·8; p=0·00010) compared with placebo. Five (8%) of 60 patients in the empagliflozin group and three (5%) of 60 patients in the placebo group had one or more serious adverse events. INTERPRETATION In patients with heart failure and reduced ejection fraction, empagliflozin reduced estimated extracellular volume, estimated plasma volume, and measured GFR after 12 weeks. Fluid volume changes might be an important mechanism underlying the beneficial clinical effects of SGLT2 inhibitors. FUNDING Research Council at Herlev and Gentofte University Hospital, Research and Innovation Foundation of the Department of Cardiology at Herlev and Gentofte University Hospital, Capital Region of Denmark, Danish Heart Foundation, and AP Møller Foundation for the Advancement of Medical Science.
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Affiliation(s)
- Jesper Jensen
- Department of Cardiology, Herlev and Gentofte University Hospital, Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Massar Omar
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Steno Diabetes Center Odense, Odense, Denmark; Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Caroline Kistorp
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Tuxen
- Department of Cardiology, Bispebjerg and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Ida Gustafsson
- Department of Cardiology, Bispebjerg and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jens Faber
- Department of Internal Medicine, Center of Endocrinology and Metabolism, Herlev and Gentofte University Hospital, Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Niels Eske Bruun
- Department of Cardiology, Zealand University Hospital, Roskilde, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Julie Lyng Forman
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Lars Thorbjørn Jensen
- Department of Clinical Physiology and Nuclear Medicine, Herlev and Gentofte University Hospital, Herlev, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Department of Cardiology, Rigshospitalet, Copenhagen, Denmark; Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte University Hospital, Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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