Vascular endothelial growth factor D is a biomarker of fluid overload in haemodialysis patients

Growth Differentiation Factor 15 and Risk of Death in Haemodialysis Patients

Aim

Noninvasive identification of haemodialysis patients at high risk of cardiovascular events and death might improve their outcome. Growth differentiation factor 15 is a prognostic biomarker in multiple disease entities, including cardiovascular disease. The aim of this study was to assess the association between plasma GDF-15 and mortality in a cohort of haemodialysis patients.

Methods

Circulating GDF-15 was measured in 30 patients after a regular haemodialysis session, followed by a clinical follow-up for all-cause death. Measurements were performed using the Proseek Multiplex Cardiovascular disease panels (Olink Proteomics AB) and validated using the Elecsys GDF-15 electrochemiluminescence immunoassay on a Cobas E801 analyzer (Roche Diagnostics).

Results

During a median of 38 months, 9 patients (30%) died. Seven deaths occurred in the group of patients with a circulating GDF-15 above the median and two in the group with lower GDF-15. Mortality was significantly higher in patients with circulating GDF-15 levels above the median, log-rankP = 0.044. The performance of circulating GDF-15 to predict long-term mortality has an area under the ROC curve of 0.76, P = 0.028. Prevalence of most relevant comorbidities and the Charlson comorbidity index were similar across the two groups. A high agreement with a correlation among both diagnostic methods was observed (Spearman's rho = 0.83, P < 0.001).

Conclusion

Plasma GDF-15 displays promising prognostic properties for the prediction of long-term survival beyond clinical parameters in patients on maintenance haemodialysis.

The effect of SARS-Co-V2 infection on prothrombotic and anticoagulant factors in dialysis patients

BACKGROUND

Patients with COVID-19 infection are at increased risk of thrombosis. We wished to determine whether this was is due to an increase in prothrombotic or reduction in anticoagulant factors, and whether heparin would be an appropriate anticoagulant.

METHODS

We measured routine coagulation and prothrombtic factors in dialysis patients after a positive COVID-19 test between March 2020 -April 2021.

RESULTS

Routine coagulation tests were measured in 227 dialysis patients, 148 males (65.2%), median age 67.5 (53.8-77.0) years. The international normalised ratio was prolonged in 11.5%, activated partial thromboplastin time in 48.5%, thrombin time in 57%. Factor VIII was increased in 59.1%, fibrinogen in 73.8%, and D-dimer 95.5%. Protein C was reduced in 15.3%, protein S in 28%, and antithrombin (AT) in 12.1%. Two patients were Lupus anticoagulant positive , and two Factor V_Leiden positive. Factor VIII levels increased with clinical disease; outpatients 159 (136-179) IU/dL, hospitalised but not ventilated 228 (167-311) IU, ventilated 432 (368-488) IU/dL (p<0.01). Overall 75% had an AT level ≥ 88 IU/dL (reference range 79-106), but only 11.7% of non-hospitalised patientscompared to 45% of those who died, p<0.01, Fibrinogen,D-dimers, proteins S or C did not differ with clinical disease severity, whether patients required hospital admission or not and between survivors and those who died.

CONCLUSION

COVID-19 dialysis patients have increased levels of fibrinogen and D-Dimers, but only factor VIII levels in the clotting profile increased with clinical disease severity increasing systemic hypercoagulability. AT concentrations are maintained and as such should not compromise anticoagulation with heparins.

Acute heart failure

Acute heart failure (AHF) is a syndrome defined as the new onset (de novo heart failure (HF)) or worsening (acutely decompensated heart failure (ADHF)) of symptoms and signs of HF, mostly related to systemic congestion. In the presence of an underlying structural or functional cardiac dysfunction (whether chronic in ADHF or undiagnosed in de novo HF), one or more precipitating factors can induce AHF, although sometimes de novo HF can result directly from the onset of a new cardiac dysfunction, most frequently an acute coronary syndrome. Despite leading to similar clinical presentations, the underlying cardiac disease and precipitating factors may vary greatly and, therefore, the pathophysiology of AHF is highly heterogeneous. Left ventricular diastolic or systolic dysfunction results in increased preload and afterload, which in turn lead to pulmonary congestion. Fluid retention and redistribution result in systemic congestion, eventually causing organ dysfunction due to hypoperfusion. Current treatment of AHF is mostly symptomatic, centred on decongestive drugs, at best tailored according to the initial haemodynamic status with little regard to the underlying pathophysiological particularities. As a consequence, AHF is still associated with high mortality and hospital readmission rates. There is an unmet need for increased individualization of in-hospital management, including treatments targeting the causative factors, and continuation of treatment after hospital discharge to improve long-term outcomes.