1
|
Juarez-Villa JD, Zepeda-Quiroz I, Toledo-Ramírez S, Gomez-Johnson VH, Pérez-Allende F, Garibay-Vega BR, Rodríguez Castellanos FE, Moguel-González B, Garcia-Cruz E, Lopez-Gil S. Exploring kidney biopsy findings in congenital heart diseases: Insights beyond cyanotic nephropathy. World J Nephrol 2024; 13:88972. [PMID: 38596269 PMCID: PMC11000040 DOI: 10.5527/wjn.v13.i1.88972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/20/2023] [Accepted: 01/15/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND The association between congenital heart disease and chronic kidney disease is well known. Various mechanisms of kidney damage associated with congenital heart disease have been established. The etiology of kidneydisease has commonly been considered to be secondary to focal segmental glomerulosclerosis (FSGS), however, this has only been demonstrated in case reports and not in observational or clinical trials. AIM To identify baseline and clinical characteristics, as well as the findings in kidney biopsies of patients with congenital heart disease in our hospital. METHODS This is a retrospective observational study conducted at the Nephrology Department of the National Institute of Cardiology "Ignacio Chávez". All patients over 16 years old who underwent percutaneous kidney biopsy from January 2000 to January 2023 with congenital heart disease were included in the study. RESULTS Ten patients with congenital heart disease and kidney biopsy were found. The average age was 29.00 years ± 15.87 years with pre-biopsy proteinuria of 6193 mg/24 h ± 6165 mg/24 h. The most common congenital heart disease was Fallot's tetralogy with 2 cases (20%) and ventricular septal defect with 2 (20%) cases. Among the 10 cases, one case of IgA nephropathy and one case of membranoproliferative glomerulonephritis associated with immune complexes were found, receiving specific treatment after histopathological diagnosis, delaying the initiation of kidney replacement therapy. Among remaining 8 cases (80%), one case of FSGS with perihilar variety was found, while the other 7 cases were non-specific FSGS. CONCLUSION Determining the cause of chronic kidney disease can help in delaying the need for kidney replacement therapy. In 2 out of 10 patients in our study, interventions were performed, and initiation of kidney replacement therapy was delayed. Prospective studies are needed to determine the usefulness of kidney biopsy in patients with congenital heart disease.
Collapse
Affiliation(s)
- Jose Daniel Juarez-Villa
- Department of Nephrology, Instituto Nacional de Cardiología Ignacio Chavez, Mexico City 14080, Mexico
| | - Iván Zepeda-Quiroz
- Department of Nephrology, Instituto Nacional de Cardiología Ignacio Chavez, Mexico City 14080, Mexico
| | - Sebastián Toledo-Ramírez
- Department of Nephrology, Instituto Nacional de Cardiología Ignacio Chavez, Mexico City 14080, Mexico
| | - Victor Hugo Gomez-Johnson
- Department of Nephrology, Instituto Nacional de Cardiología Ignacio Chavez, Mexico City 14080, Mexico
| | - Francisco Pérez-Allende
- Department of Nephrology, Instituto Nacional de Cardiología Ignacio Chavez, Mexico City 14080, Mexico
| | | | | | - Bernardo Moguel-González
- Department of Nephrology, Instituto Nacional de Cardiología Ignacio Chavez, Mexico City 14080, Mexico
| | - Edgar Garcia-Cruz
- Congenital Heart Disease, Instituto Nacional de Cardiología Ignacio Chavez, Mexico City 14080, Mexico
| | - Salvador Lopez-Gil
- Department of Nephrology, Instituto Nacional de Cardiología Ignacio Chavez, Mexico City 14080, Mexico
| |
Collapse
|
2
|
Muraoka M, Nagata H, Yamamura K, Sakamoto I, Ishikita A, Nishizaki A, Eguchi Y, Fukuoka S, Uike K, Nagatomo Y, Hirata Y, Nishiyama K, Tsutsui H, Ohga S. Long-Term Renal Involvement in Association with Fontan Circulation. Pediatr Cardiol 2024; 45:340-350. [PMID: 37966520 DOI: 10.1007/s00246-023-03334-3] [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: 07/23/2023] [Accepted: 10/19/2023] [Indexed: 11/16/2023]
Abstract
Multiorgan dysfunction is a concern of Fontan patients. To clarify the pathophysiology of Fontan nephropathy, we characterize renal disease in the long-term observational study. Medical records of 128 consecutive Fontan patients [median age: 22 (range 15-37) years old] treated between 2009 and 2018 were reviewed to investigate the incidence of nephropathy and its association with other clinical variables. Thirty-seven patients (29%) showed proteinuria (n = 34) or < 90 mL/min/1.73 m2 of estimated glomerular filtration rate (eGFR) (n = 7), including 4 overlapping cases. Ninety-six patients (75%) had liver dysfunction (Forns index > 4.21). Patients with proteinuria received the Fontan procedure at an older age [78 (26-194) vs. 56 (8-292) months old, p = 0.02] and had a higher cardiac index [3.11 (1.49-6.35) vs. 2.71 (1.40-4.95) L/min/m2, p = 0.02], central venous pressure [12 (7-19) vs. 9 (5-19) mmHg, p < 0.001], and proportion with > 4.21 of Forns index (88% vs. 70%, p = 0.04) than those without proteinuria. The mean renal perfusion pressure was lower in patients with a reduced eGFR than those without it [55 (44-65) vs. 65 (45-102) mmHg, p = 0.03], but no other variables differed significantly. A multivariable analysis revealed that proteinuria was associated with an increased cardiac index (unit odds ratio 2.02, 95% confidence interval 1.12-3.65, p = 0.02). Seven patients with severe proteinuria had a lower oxygen saturation than those with no or mild proteinuria (p = 0.01, 0.03). Proteinuria or a decreased eGFR differentially occurred in approximately 30% of Fontan patients. Suboptimal Fontan circulation may contribute to the development of proteinuria and reduced eGFR.
Collapse
Affiliation(s)
- Mamoru Muraoka
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Hazumu Nagata
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan.
| | - Kenichiro Yamamura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Ichiro Sakamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ayako Ishikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akiko Nishizaki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshimi Eguchi
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Shoji Fukuoka
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Kiyoshi Uike
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Yusaku Nagatomo
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Yuichiro Hirata
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Kei Nishiyama
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| |
Collapse
|
3
|
Goldberg DJ, Hu C, Lubert AM, Rathod RH, Penny DJ, Petit CJ, Schumacher KR, Ginde S, Williams RV, Yoon JK, Kim GB, Nowlen TT, DiMaria MV, Frischhertz BP, Wagner JB, McHugh KE, McCrindle BW, Cartoski MJ, Detterich JA, Yetman AT, John AS, Richmond ME, Yung D, Payne RM, Mackie AS, Davis CK, Shahanavaz S, Hill KD, Almaguer M, Zak V, McBride MG, Goldstein BH, Pearson GD, Paridon SM. The Fontan Udenafil Exercise Longitudinal Trial: Subgroup Analysis. Pediatr Cardiol 2023; 44:1691-1701. [PMID: 37382636 DOI: 10.1007/s00246-023-03204-y] [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: 03/01/2023] [Accepted: 05/31/2023] [Indexed: 06/30/2023]
Abstract
The Pediatric Heart Network's Fontan Udenafil Exercise Longitudinal (FUEL) Trial (Mezzion Pharma Co. Ltd., NCT02741115) demonstrated improvements in some measures of exercise capacity and in the myocardial performance index following 6 months of treatment with udenafil (87.5 mg twice daily). In this post hoc analysis, we evaluate whether subgroups within the population experienced a differential effect on exercise performance in response to treatment. The effect of udenafil on exercise was evaluated within subgroups defined by baseline characteristics, including peak oxygen consumption (VO2), serum brain-type natriuretic peptide level, weight, race, gender, and ventricular morphology. Differences among subgroups were evaluated using ANCOVA modeling with fixed factors for treatment arm and subgroup and the interaction between treatment arm and subgroup. Within-subgroup analyses demonstrated trends toward quantitative improvements in peak VO2, work rate at the ventilatory anaerobic threshold (VAT), VO2 at VAT, and ventilatory efficiency (VE/VCO2) for those randomized to udenafil compared to placebo in nearly all subgroups. There was no identified differential response to udenafil based on baseline peak VO2, baseline BNP level, weight, race and ethnicity, gender, or ventricular morphology, although participants in the lowest tertile of baseline peak VO2 trended toward larger improvements. The absence of a differential response across subgroups in response to treatment with udenafil suggests that the treatment benefit may not be restricted to specific sub-populations. Further work is warranted to confirm the potential benefit of udenafil and to evaluate the long-term tolerability and safety of treatment and to determine the impact of udenafil on the development of other morbidities related to the Fontan circulation.Trial Registration NCT0274115.
Collapse
Affiliation(s)
- David J Goldberg
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, 34th Street and Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | | | - Adam M Lubert
- Cincinnati Children's Hospital and Medical Center, Heart Institute, Cincinnati, OH, 45229, USA
| | - Rahul H Rathod
- Department of Cardiology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Daniel J Penny
- Division of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Christopher J Petit
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, 10032, USA
| | - Kurt R Schumacher
- Division of Cardiology, C.S. Mott Children's Hospital, Ann Arbor, MI, 48109, USA
| | - Salil Ginde
- Division of Cardiology, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, 53226, USA
| | - Richard V Williams
- Division of Pediatric Cardiology, University of Utah, Primary Children's Hospital, Salt Lake City, UT, 84132, USA
| | - J K Yoon
- Department of Pediatrics, Sejong General Hospital, Bucheon, South Korea
| | - Gi Beom Kim
- Seoul National University School of Medicine, Seoul National University Children's Hospital, Seoul, South Korea
| | - Todd T Nowlen
- Heart Center, Phoenix Children's Hospital, Phoenix, AZ, 85016, USA
| | - Michael V DiMaria
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Benjamin P Frischhertz
- Division of Cardiology, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Jonathan B Wagner
- Divisions of Cardiology and Clinical Pharmacology, Children's Mercy Kansas City, Kansas City, MO, 64108, USA
| | - Kimberly E McHugh
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Brian W McCrindle
- Department of Pediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - Mark J Cartoski
- Nemours Cardiac Center, Nemours / Alfred I. DuPont Hospital for Children, Wilmington, DE, 19803, USA
| | - Jon A Detterich
- Division of Cardiology, Children's Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, CA, 90027, USA
| | - Anji T Yetman
- Children's Hospital and Medical Center, University of Nebraska, Omaha, NE, 68114, USA
| | - Anitha S John
- Division of Cardiology, Children's National Hospital, Washington, DC, 20010, USA
| | - Marc E Richmond
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, 10032, USA
| | - Delphine Yung
- Division of Pediatric Cardiology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, 98105, USA
| | - R Mark Payne
- Division of Cardiology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Andrew S Mackie
- Division of Cardiology, Stollery Children's Hospital, Edmonton, AB, T6G 2B7, Canada
| | - Christopher K Davis
- Division of Cardiology, Rady Children's Hospital San Diego, University of California San Diego, San Diego, CA, 92123, USA
| | - Shabana Shahanavaz
- Division of Cardiology, St. Louis Children's Hospital, St. Louis, MO, 63110, USA
| | - Kevin D Hill
- Duke Children's Pediatric and Congenital Heart Center, Durham, NC, 27705, USA
| | - Marisa Almaguer
- Cincinnati Children's Hospital and Medical Center, Heart Institute, Cincinnati, OH, 45229, USA
| | | | - Michael G McBride
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, 34th Street and Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Bryan H Goldstein
- Division of Cardiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, 15224, USA
| | - Gail D Pearson
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD, 20892, USA
| | - Stephen M Paridon
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, 34th Street and Civic Center Blvd, Philadelphia, PA, 19104, USA
| |
Collapse
|
4
|
Ishida H, Maeda J, Uchida K, Yamagishi H. Unique Pulmonary Hypertensive Vascular Diseases Associated with Heart and Lung Developmental Defects. J Cardiovasc Dev Dis 2023; 10:333. [PMID: 37623346 PMCID: PMC10455332 DOI: 10.3390/jcdd10080333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/10/2023] [Accepted: 08/01/2023] [Indexed: 08/26/2023] Open
Abstract
Although pediatric pulmonary hypertension (PH) shares features and mechanisms with adult PH, there are also some significant differences between the two conditions. Segmental PH is a unique pediatric subtype of PH with unclear and/or multifactorial pathophysiological mechanisms, and is often associated with complex congenital heart disease (CHD), pulmonary atresia with ventricular septal defect, and aortopulmonary collateral arteries. Some cases of complex CHD, associated with a single ventricle after Fontan operation, show pathological changes in the small peripheral pulmonary arteries and pulmonary vascular resistance similar to those observed in pulmonary arterial hypertension (PAH). This condition is termed as the pediatric pulmonary hypertensive vascular disease (PPHVD). Recent advances in genetics have identified the genes responsible for PAH associated with developmental defects of the heart and lungs, such as TBX4 and SOX17. Targeted therapies for PAH have been developed; however, their effects on PH associated with developmental heart and lung defects remain to be established. Real-world data analyses on the anatomy, pathophysiology, genetics, and molecular biology of unique PPHVD cases associated with developmental defects of the heart and lungs, using nationwide and/or international registries, should be conducted in order to improve the treatments and prognosis of patients with these types of pediatric PH.
Collapse
Affiliation(s)
- Hidekazu Ishida
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita 565-0871, Osaka, Japan;
| | - Jun Maeda
- Department of Cardiology, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu 183-8561, Tokyo, Japan;
| | - Keiko Uchida
- Department of Pediatrics, Keio University of Medicine, 35 Shinanomachi, Shinjuku-ku 160-8582, Tokyo, Japan;
- Keio University Health Center, 4-1-1 Hiyoshi, Kohoku-ku, Yokohama 223-8521, Kanagawa, Japan
| | - Hiroyuki Yamagishi
- Department of Pediatrics, Keio University of Medicine, 35 Shinanomachi, Shinjuku-ku 160-8582, Tokyo, Japan;
| |
Collapse
|
5
|
Utility of urinary liver-type fatty acid-binding protein as a prognostic marker in adult congenital heart patients hospitalized for acute heart failure. Heart Vessels 2023; 38:371-380. [PMID: 36169710 DOI: 10.1007/s00380-022-02174-0] [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: 05/11/2022] [Accepted: 09/14/2022] [Indexed: 02/07/2023]
Abstract
Progression to acute kidney injury (AKI) under treatment in adult congenital heart disease (ACHD) patients with heart failure is associated with poor prognosis, early detection and interventions are necessary. We aimed to explore the utility of urinary liver-type fatty acid binding protein (L-FABP) in ACHD patients hospitalized for acute decompensated heart failure (ADHF). We prospectively evaluated hemodynamic, biochemical data, and urinary biomarkers including urinary L-FABP in ACHD patients hospitalized in our institution from June 2019 to March 2022. The primary outcomes were the development of AKI and death. AKI was defined as serum creatinine level increased by 0.3 mg/dl or more within 5 days after hospitalization. A total of 104 ADHF patients aged 31 (36-51) years were enrolled. 26 cases (25% of ADHF patients) developed AKI during hospitalization and 4 died after hospital discharge. Serum creatinine (sCr), serum total bilirubin, brain natriuretic peptide (BNP), and urinary L-FABP in AKI patients were significantly higher than in non-AKI patients, whereas systemic oxygen saturation of the peripheral artery (SpO2) and estimated glomerular filtration ratio in AKI patients were lower than non-AKI patients. There was no difference in the intravenous diuretic dose on admission and during hospitalization between the two groups. In the receiver operating characteristic (ROC) analysis, the maximum area under the curve (AUC) of urinary biomarkers in AKI patients was urinary L-FABP (AUC = 0.769, p < 0.001) with a cutoff value of 4.86 µg/gCr. Urinary L-FABP level on admission was associated with a predictor for AKI development during hospitalization after adjusting for sCr, BNP and SpO2. Urinary L-FABP was a useful predictor for the development of AKI in ACHD patients hospitalized for ADHF. Monitoring of urinary L-FABP allows us to detect a high-risk patient earlier than the conventional biomarkers.
Collapse
|
6
|
Ohuchi H, Kawata M, Uemura H, Akagi T, Yao A, Senzaki H, Kasahara S, Ichikawa H, Motoki H, Syoda M, Sugiyama H, Tsutsui H, Inai K, Suzuki T, Sakamoto K, Tatebe S, Ishizu T, Shiina Y, Tateno S, Miyazaki A, Toh N, Sakamoto I, Izumi C, Mizuno Y, Kato A, Sagawa K, Ochiai R, Ichida F, Kimura T, Matsuda H, Niwa K. JCS 2022 Guideline on Management and Re-Interventional Therapy in Patients With Congenital Heart Disease Long-Term After Initial Repair. Circ J 2022; 86:1591-1690. [DOI: 10.1253/circj.cj-22-0134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology and Adult Congenital Heart Disease, National Cerebral and Cardiovascular Center
| | - Masaaki Kawata
- Division of Pediatric and Congenital Cardiovascular Surgery, Jichi Children’s Medical Center Tochigi
| | - Hideki Uemura
- Congenital Heart Disease Center, Nara Medical University
| | - Teiji Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Atsushi Yao
- Division for Health Service Promotion, University of Tokyo
| | - Hideaki Senzaki
- Department of Pediatrics, International University of Health and Welfare
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Hirohiko Motoki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Morio Syoda
- Department of Cardiology, Tokyo Women’s Medical University
| | - Hisashi Sugiyama
- Department of Pediatric Cardiology, Seirei Hamamatsu General Hospital
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Kei Inai
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women’s Medical University
| | - Takaaki Suzuki
- Department of Pediatric Cardiac Surgery, Saitama Medical University
| | | | - Syunsuke Tatebe
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Tomoko Ishizu
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba
| | - Yumi Shiina
- Cardiovascular Center, St. Luke’s International Hospital
| | - Shigeru Tateno
- Department of Pediatrics, Chiba Kaihin Municipal Hospital
| | - Aya Miyazaki
- Division of Congenital Heart Disease, Department of Transition Medicine, Shizuoka General Hospital
| | - Norihisa Toh
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Ichiro Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yoshiko Mizuno
- Faculty of Nursing, Tokyo University of Information Sciences
| | - Atsuko Kato
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Koichi Sagawa
- Department of Pediatric Cardiology, Fukuoka Children’s Hospital
| | - Ryota Ochiai
- Department of Adult Nursing, Yokohama City University
| | - Fukiko Ichida
- Department of Pediatrics, International University of Health and Welfare
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | | - Koichiro Niwa
- Department of Cardiology, St. Luke’s International Hospital
| | | |
Collapse
|
7
|
Blissett S, Kheiwa A, Mahadevan VS. Extracardiac manifestations of the Fontan circulation in adults: Beyond the liver. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
|
8
|
Abstract
The Patient Registry for Adolescents and Adults with Stable Fontan Circulation aims to describe a contemporary cohort of Fontan patients who could be eligible for a clinical trial investigating macitentan, an endothelin receptor antagonist. This international, non-interventional, multicentre, cross-sectional, observational registry enrolled patients with "stable" Fontan circulation ≥10 years following extra-cardiac conduit or lateral tunnel procedure. Main exclusion criteria were NYHA functional class IV, reoperation of Fontan circulation, or signs of disease worsening. Patient characteristics at enrolment are described; available data were collected during a single registration visit. Of the 266 screened patients, 254 were included in this analysis. At enrolment, median (interquartile range) age was 24 (20;30) years, 37%/63% of patients were from the USA/Europe, 54% were male, 54%/47% had undergone extra-cardiac conduit/lateral tunnel procedures, and 95% were in NYHA functional class I or II. History of arrhythmia was more common in older patients and patients with lateral tunnel; overall prevalence was 19%. Most laboratory values were within the normal range but mean creatinine clearance was abnormally low (87.7 ml/min). Angiotensin-converting enzyme inhibitors were used by 48% of patients and their use was associated with creatinine clearance <90 ml/min (p = 0.007), as was Fontan completion at an older age (p = 0.007). 53.4% of patients had clinical characteristics that could potentially meet an endothelin receptor antagonist trial's eligibility criteria. The PREpArE-Fontan registry describes a cohort of patients who could potentially participate in an endothelin receptor antagonist trial and identified early subtle signs of Fontan failure, even in "stable" patients.
Collapse
|
9
|
Ritmeester E, Veger VA, van der Ven JPG, van Tussenbroek GMJW, van Capelle CI, Udink ten Cate FEA, Helbing WA. Fontan Circulation Associated Organ Abnormalities Beyond the Heart, Lungs, Liver, and Gut: A Systematic Review. Front Cardiovasc Med 2022; 9:826096. [PMID: 35391839 PMCID: PMC8981209 DOI: 10.3389/fcvm.2022.826096] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/17/2022] [Indexed: 12/22/2022] Open
Abstract
Introduction Patients with a Fontan circulation are at risk for sequelae of Fontan physiology during follow-up. Fontan physiology affects all organ systems and an overview of end-organ damage is needed. Methods We performed a systematic review of abnormalities in multiple organ systems for patients with a longstanding Fontan circulation. We searched online databases for articles describing abnormalities in multiple organ systems. Cardio-pulmonary abnormalities, protein losing enteropathy, and Fontan associated liver disease have already extensively been described and were excluded from this systematic review. Results Our search returned 5,704 unique articles. After screening, we found 111 articles relating to multiple organ systems. We found abnormalities in, among others, the nervous system, pituitary, kidneys, and musculoskeletal system. Pituitary edema—relating to the unique pituitary vasculature- may affect the thyroid axis. Renal dysfunction is common. Creatinine based renal function estimates may be inappropriate due to myopenia. Both lean muscle mass and bone mineral density are decreased. These abnormalities in multiple organ systems may be related to Fontan physiology, cyanosis, iatrogenic factors, or lifestyle. Conclusions Health care providers should be vigilant for hypothyroidism, visual or hearing deficits, and sleep disordered breathing in Fontan patients. We recommend including cystatin C for assessment of renal function. This review may aid health care providers and guide future research. Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021232461, PROSPERO, identifier: CRD42021232461.
Collapse
Affiliation(s)
- Evi Ritmeester
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - Veerle A. Veger
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - Jelle P. G. van der Ven
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
- Netherlands Heart Institute, Utrecht, Netherlands
| | | | - Carine I. van Capelle
- Department of Pediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - Floris E. A. Udink ten Cate
- Department of Pediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Willem A. Helbing
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
- Department of Pediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
- *Correspondence: Willem A. Helbing
| |
Collapse
|
10
|
Chowdhury SM, Graham EM, Taylor CL, Savage A, McHugh KE, Gaydos S, Nutting AC, Zile MR, Atz AM. Diastolic Dysfunction With Preserved Ejection Fraction After the Fontan Procedure. J Am Heart Assoc 2022; 11:e024095. [PMID: 35023347 PMCID: PMC9238510 DOI: 10.1161/jaha.121.024095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/16/2021] [Indexed: 01/08/2023]
Abstract
Background Heart failure phenotyping in single-ventricle Fontan patients is challenging, particularly in patients with normal ejection fraction (EF). The objective of this study was to identify Fontan patients with abnormal diastolic function, who are high risk for heart failure with preserved ejection fraction (HFpEF), and characterize their cardiac mechanics, exercise function, and functional health status. Methods and Results Data were obtained from the Pediatric Heart Network Fontan Cross-sectional Study database. EF was considered abnormal if <50%. Diastolic function was defined as abnormal if the diastolic pressure:volume quotient (lateral E:e'/end-diastolic volume) was >90th percentile (≥0.26 mL-1). Patients were divided into: controls=normal EF and diastolic function; systolic dysfunction (SD) = abnormal EF with normal diastolic function; diastolic dysfunction (DD) = normal EF with abnormal diastolic pressure:volume quotient. Exercise function was quantified as percent predicted peak VO2. Physical Functioning Summary Score (FSS) was reported from the Child Health Questionnaire. A total of 239 patients were included, 177 (74%) control, 36 (15%) SD, and 26 (11%) DD. Median age was 12.2 (5.4) years. Arterial elastance, a measure of arterial stiffness, was higher in DD (3.6±1.1 mm Hg/mL) compared with controls (2.5±0.8 mm Hg/mL), P<0.01. DD patients had lower predicted peak VO2 compared with controls (52% [20] versus 67% [23], P<0.01). Physical FSS was lower in DD (45±13) and SD (44±13) compared with controls (50±7), P<0.01. Conclusions Fontan patients with abnormal diastolic function and normal EF have decreased exercise tolerance, decreased functional health status, and elevated arterial stiffness. Identification of patients at high risk for HFpEF is feasible and should be considered when evaluating Fontan patients.
Collapse
Affiliation(s)
- Shahryar M. Chowdhury
- Division of CardiologyDepartment of PediatricsMedical University of South CarolinaCharlestonSC
| | - Eric M. Graham
- Division of CardiologyDepartment of PediatricsMedical University of South CarolinaCharlestonSC
| | - Carolyn L. Taylor
- Division of CardiologyDepartment of PediatricsMedical University of South CarolinaCharlestonSC
| | - Andrew Savage
- Division of CardiologyDepartment of PediatricsMedical University of South CarolinaCharlestonSC
| | - Kimberly E. McHugh
- Division of CardiologyDepartment of PediatricsMedical University of South CarolinaCharlestonSC
| | - Stephanie Gaydos
- Division of CardiologyDepartment of MedicineMedical University of South CarolinaCharlestonSC
| | - Arni C. Nutting
- Division of CardiologyDepartment of PediatricsMedical University of South CarolinaCharlestonSC
| | - Michael R. Zile
- Division of CardiologyDepartment of MedicineMedical University of South CarolinaCharlestonSC
| | - Andrew M. Atz
- Division of CardiologyDepartment of PediatricsMedical University of South CarolinaCharlestonSC
| |
Collapse
|
11
|
Katz DA, Lubert AM, Gao Z, Powell AW, Szugye C, Woodly S, Goldstein SL, Alsaied T, Opotowsky AR. Comparison of creatinine and cystatin C estimation of glomerular filtration rate in the Fontan circulation. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
|
12
|
Houlihan TH, Lopez S, Dodds K, Goldberg D, Wernovsky G, Baluarte HJ, Meyer K, Rychik J. Living-Related Donor Kidney Transplant in a Patient With Single Ventricle and Fontan Circulation. World J Pediatr Congenit Heart Surg 2021; 12:673-675. [PMID: 33899567 DOI: 10.1177/2150135120978959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The hemodynamic profile of the Fontan circulation presents challenges that raise questions about candidacy for organ transplantation. We report a case of a 24-year-old male with double-inlet right ventricle and aortic atresia, who suffered bilateral renal cortical necrosis due to neonatal cardiovascular shock, received a live-donor kidney transplant from his mother at age 17, and has diminished yet stable renal function seven years posttransplant.
Collapse
Affiliation(s)
- Taylor H Houlihan
- Division of Cardiology, The Cardiac Center at The Children's Hospital of Philadelphia, PA, USA
| | - Sonya Lopez
- Division of Nephrology, The Children's Hospital of Philadelphia, PA, USA
| | - Kathryn Dodds
- Division of Cardiology, The Cardiac Center at The Children's Hospital of Philadelphia, PA, USA
| | - David Goldberg
- Division of Cardiology, The Cardiac Center at The Children's Hospital of Philadelphia, PA, USA
| | - Gil Wernovsky
- Division of Cardiac Critical Care, Children's National Medical Center, Washington, DC, USA
| | - H Jorge Baluarte
- Division of Nephrology, The Children's Hospital of Philadelphia, PA, USA
| | - Kevin Meyer
- Division of Nephrology, The Children's Hospital of Philadelphia, PA, USA
| | - Jack Rychik
- Division of Cardiology, The Cardiac Center at The Children's Hospital of Philadelphia, PA, USA
| |
Collapse
|
13
|
Amdani S, Simpson KE, Thrush P, Shih R, Simmonds J, Knecht K, Mogul DB, Hurley K, Koehl D, Cantor R, Naftel D, Kirklin JK, Daly KP. Hepatorenal dysfunction assessment with the Model for End-Stage Liver Disease Excluding INR score predicts worse survival after heart transplant in pediatric Fontan patients. J Thorac Cardiovasc Surg 2021; 163:1462-1473.e12. [PMID: 33745714 DOI: 10.1016/j.jtcvs.2021.02.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 02/01/2021] [Accepted: 02/03/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Fontan physiology results in multiorgan dysfunction, most notably affecting the liver and kidney. We evaluated the utility of Model for End-Stage Liver Disease Excluding INR (MELD-XI) score, a score evaluating the function of both liver and kidney to identify Fontan patients at increased risk for morbidity and mortality post-heart transplant. METHODS The Pediatric Heart Transplant Society database was queried to identify Fontan patients listed for heart transplant between January 2005 and December 2018. MELD-XI scores were calculated at listing and heart transplant. A multivariable analysis was conducted to identify risk factors for post-heart transplant mortality. Demographic, clinical characteristics, and survival differences were evaluated and compared between the high and low MELD-XI score cohorts. The impact of changing MELD-XI scores during the waitlist period on post-heart transplant outcomes was also evaluated. RESULTS Of 565 Fontan patients who underwent transplantation, 524 (93%) had calculable MELD-XI scores at the time of heart transplant: 421 calculable at listing and 392 calculable at listing and at heart transplant. On multivariable analysis, only MELD-XI score (squared) (hazard ratio, 1.007), history of protein-losing enteropathy (hazard ratio, 2.1), and ventricular assist device use at transplant (hazard ratio, 3.4) were risk factors for early phase post-heart transplant mortality. Patients with high MELD-XI scores at heart transplant had inferior survival post-heart transplant (P = .02); those in the high MELD-XI score cohort at wait listing and heart transplant tend to have the worst post-heart transplant survival; however, this was not significant (P = .42). CONCLUSIONS The MELD-XI, an easily calculated score, serves as a valuable aid in identifying pediatric Fontan patients at increased risk for post-heart transplant mortality.
Collapse
Affiliation(s)
- Shahnawaz Amdani
- Department of Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio.
| | - Kathleen E Simpson
- Division of Cardiology, Department of Pediatrics, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colo
| | - Phil Thrush
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Renata Shih
- Congenital Heart Center, University of Florida, Gainesville, Fla
| | - Jacob Simmonds
- Great Ormond Street Hospital for Children Foundation Trust, London, United Kingdom
| | - Ken Knecht
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Ark
| | - Douglas B Mogul
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Kathleen Hurley
- St Louis Children's Hospital, Washington University School of Medicine, St Louis, Mo
| | - Devin Koehl
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Ala
| | - Ryan Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Ala
| | - David Naftel
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Ala
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Ala
| | - Kevin P Daly
- Harvard Medical School and Boston Children's Hospital, Boston, Mass
| |
Collapse
|
14
|
Patel S, Anne P, Langman CB, Zilberman MV. Author Response to "Letter to the Editor" "Inferior Vena Cava Diameter and Fontan-Related Nephropathy: Considerations About Clinical Usefulness and Physiology" (PEDC-D-20-00743). Pediatr Cardiol 2021; 42:219-220. [PMID: 33464373 DOI: 10.1007/s00246-020-02517-6] [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: 10/31/2020] [Accepted: 12/01/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Sheetal Patel
- Division of Pediatric Cardiology, Ann & Robert H Lurie Children's Hospital of Chicago, 225 E Chicago Ave; Box 21, Chicago, IL, 60611, USA.
| | - Premchand Anne
- Division of Pediatric Cardiology, Ascension St. John Children's Hospital, Detroit, MI, USA
| | - Craig B Langman
- Division of Kidney Disease, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Mark V Zilberman
- Division of Pediatric Cardiology, Tufts Medical Center, Boston, MA, USA
| |
Collapse
|
15
|
Bojan M, Pieroni L, Mirabile C, Froissart M, Bonnet D. Chronic Kidney Disease in Adolescents after Surgery for Congenital Heart Disease. Cardiorenal Med 2020; 10:353-361. [PMID: 32721971 DOI: 10.1159/000508177] [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: 01/14/2020] [Accepted: 04/20/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The onset of chronic kidney disease (CKD) is an important prognostic factor in young adults with congenital heart disease (CHD). Although it is likely that CKD is manifest early in CHD patients, the prevalence among adolescents is still unknown. The National Kidney Foundation's Kidney Disease Improving Global Outcomes guidelines 2012 recommend new equations for the estimated glomerular filtration rate (eGFR) and highlight the importance of albuminuria for CKD screening. The objective of the present study was to estimate the prevalence of CKD in CHD adolescents. METHODS This observational cross-sectional study included 115 patients aged 10-18 years attending the cardiologic outpatient clinic at our institution as a follow-up after cardiac surgery in infancy related to various CHDs. CKD assessment used the CKD criteria 2012, including eGFR equations based on serum creatinine and cystatin C, and measurement of albuminuria. RESULTS No patient had an eGFR <60 mL min-1 1.73 m-2. However, 28.7% of all patients (95% CI 20.7-37.9) had eGFRbetween 60 and 89 mL min-1 1.73 m-2 when estimated by the bedside Schwartz creatinine-based equation,and 17.4% (95% CI 11.2-24.1) had eGFRbetween 60 and 89 mL min-1 1.73 m-2 when estimated by the Zappitelli equation, combining creatinine and cystatin C. Of all patients, 20.0% (95% CI 12.1-26.7) had orthostatic proteinuria, and none had persistent albuminuria. CONCLUSIONS There was no evidence of CKD in the present population aged 10-18 years. The significance of an eGFR between 60 and 90 mL min-1 1.73 m-2 is not concordant for this age range and requires further investigations.
Collapse
Affiliation(s)
- Mirela Bojan
- Department of Anesthesiology, Congenital Cardiac Unit, Marie Lannelongue Hospital, Le Plessis-Robinson, France,
| | - Laurence Pieroni
- Department of Biochemistry, Lapeyronie Hospital, Montpellier, France
| | - Cristian Mirabile
- Department of Critical Care, Congenital Cardiac Unit, Marie Lannelongue Hospital, Le Plessis-Robinson, France
| | - Marc Froissart
- Clinical Research Center, Lausanne University Hospital, Lausanne, Switzerland.,University of Lausanne, Lausanne, Switzerland
| | - Damien Bonnet
- Pediatric Cardiology, Necker-Enfants Malades Hospital, Paris, France.,Paris Descartes University, Paris, France
| |
Collapse
|
16
|
Zafar F, Lubert AM, Katz DA, Hill GD, Opotowsky AR, Alten JA, Goldstein SL, Alsaied T. Long-Term Kidney Function After the Fontan Operation. J Am Coll Cardiol 2020; 76:334-341. [DOI: 10.1016/j.jacc.2020.05.042] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/07/2020] [Accepted: 05/10/2020] [Indexed: 01/28/2023]
|
17
|
Primack W, Kleeman S, Boineau F, Jernigan S. Are My Pediatric Patients at Increased Risk of Developing Chronic Kidney Disease? Clin Pediatr (Phila) 2020; 59:801-808. [PMID: 32400181 DOI: 10.1177/0009922820920015] [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] [Indexed: 11/17/2022]
Abstract
Chronic kidney disease (CKD) is an underrecognized and often undiagnosed cause of morbidity and mortality. Many children and adolescents are at increased risk of developing CKD as they mature and age, secondary to conditions commonly cared for by pediatric health professionals. Prematurity, diabetes mellitus, hypertension, congenital heart disease, sickle cell disease and trait, severe obesity, cancer chemotherapy, other drug toxicities, and systemic situations that may cause acute kidney injury such as sepsis or extracorporeal membrane oxygenation therapy predispose to potential CKD. Clinicians should be aware of these conditions in order to screen for CKD, choose non-nephrotoxic treatments for these children whenever possible, and treat or refer those who have early signs of CKD.
Collapse
|
18
|
Binotto MA. Renal function and Fontan patients: What is the real impact in the long-term outcomes? Int J Cardiol 2020; 306:86-87. [PMID: 32145936 DOI: 10.1016/j.ijcard.2020.02.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 02/26/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Maria Angélica Binotto
- Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Avenida Higienopolis, 1048/86, CEP 01238/000 Sao Paulo, SP, Brazil.
| |
Collapse
|
19
|
Patel S, Anne P, Somerfield-Ronek J, Du W, Zilberman MV. Inferior Vena Cava Diameter Predicts Nephropathy in Patients Late After Fontan Palliation. Pediatr Cardiol 2020; 41:789-794. [PMID: 32016581 DOI: 10.1007/s00246-020-02313-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/24/2020] [Indexed: 11/28/2022]
Abstract
Single ventricle congenital heart defect patients have improved survival with Fontan palliation. However, they remain at risk for nephropathy, as indicated by pathologic microalbuminuria. We sought to investigate whether echocardiographic measures of the inferior vena cava diameter (a surrogate for elevated CVP) indexed to the body surface area (iIVC) or cardiac index (CI) can predict the presence of nephropathy in Fontan patients. We performed a single-center case-control study, including 39 asymptomatic Fontan (age 14.8 ± 7.9 years) and 29 healthy controls (age 12.7 ± 2.7 years). The primary outcome was abnormal microalbumin-creatinine ratio (MCR) from the first-morning void urine in Fontan patients. Measurements of iIVC and CI were derived using transthoracic echocardiography by two investigators with a high intra-class correlation coefficient (ICC = 0.97). Group comparison between Fontan and controls as well as between Fontan with normal and abnormal MCR was performed using Fisher's exact and t tests. Pearson and Spearman's correlations and multivariate regressions were performed to analyze the relations between the MCR, iIVC, and CI. Abnormal MCR was noted in 13/39(33%) of Fontan patients. The mean iIVC was larger in the Fontan compared to controls (p < 0.0001) and in Fontan with abnormal MCR compared to those with normal MCR (p = 0.0006). A positive correlation (r = 0.62; p < 0.001) was noted between MCR and iIVC. All patients with abnormal MCR had the iIVC > 1 cm/m2. There were no significant relations between the CI and MCR. Significant prevalence of nephropathy late after Fontan palliation warrents screening. Echocardiographic measurement of iIVC could serve as one of the screening measures. The finding of the iIVC diameter > 1 cm/m2 should prompt further renal evaluation.
Collapse
Affiliation(s)
- Sheetal Patel
- Division of Pediatric Cardiology, Ann & Robert H Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Box 21, Chicago, IL, 60611, USA.
| | - Premchand Anne
- Division of Pediatric Cardiology, Ascension St. John Children's Hospital, Detroit, MI, USA
| | | | - Wei Du
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA
| | - Mark V Zilberman
- Floating Hospital for Children at Tufts Medical Center, Boston, MA, USA
| |
Collapse
|
20
|
Broda CR, Downing TE, John AS. Diagnosis and management of the adult patient with a failing Fontan circulation. Heart Fail Rev 2020; 25:633-646. [DOI: 10.1007/s10741-020-09932-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
21
|
Khuong JN, Wilson TG, Grigg LE, Bullock A, Celermajer D, Disney P, Wijesekera VA, Hornung T, Zannino D, Iyengar AJ, d'Udekem Y. Fontan-associated nephropathy: Predictors and outcomes. Int J Cardiol 2020; 306:73-77. [PMID: 31955974 DOI: 10.1016/j.ijcard.2020.01.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 01/08/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Nephropathy is a known complication of the Fontan circulation, but its determinants have not been identified and patient outcomes are also still unknown. METHODS The Australia and New Zealand Fontan Registry was used to identify those who underwent Fontan operation before and survived beyond 16-years-old with an intact Fontan circulation. Serum creatinine values were collected for each patient between 16 and 25 years and at recent follow-up. The Modification of Diet in Renal Disease (MDRD) equation was used to calculate eGFR. Patient outcomes were obtained from the Registry. Fontan failure was defined as death, transplantation, plastic bronchitis, protein losing enteropathy, Fontan takedown and NYHA class III-IV. RESULTS Serum creatinine measurements were available for 328 patients. Renal dysfunction was defined as eGFR <90 mL/min/1.72m2. Renal dysfunction was present in 67/328 (20%) and 3/328 (1%) patients had an eGFR <60 mL/min/1.72m2. The 10-year survival and 10-year freedom from death and transplantation were the same, 96% (95% CI: 0.9-1) for those with renal dysfunction, and 89% (0.83-0.95; p = 0.1) and 87% (95% CI: 0.81-0.94; p = 0.05) for patients without dysfunction. The 10-year freedom from failure were also similar, 83% (95% CI: 0.70-0.97) for those without renal dysfunction vs 80% (95% CI: 0.74-0.89; p = 0.84). There was no change in mean eGFR for the renal dysfunction group over a mean of 8 ± 5.5 years. CONCLUSION By the time they reach adulthood, 20% of patients with a Fontan circulation have renal dysfunction by eGFR calculation. Over the course of one decade, Fontan-associated nephropathy appears well tolerated.
Collapse
Affiliation(s)
- Jacqueline Nguyen Khuong
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Melbourne, Australia
| | - Thomas G Wilson
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Melbourne, Australia
| | - Leeanne E Grigg
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Andrew Bullock
- Children's Cardiac Centre, Princess Margaret Hospital for Children, Perth, Australia
| | - David Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Patrick Disney
- Department of Cardiology, Women's and Children's Hospital, Adelaide, Australia
| | | | - Tim Hornung
- Green Lane Paediatric and Congenital Cardiac Service, Auckland District Health Board, Auckland, New Zealand
| | - Diana Zannino
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia
| | - Ajay J Iyengar
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Melbourne, Australia; Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia
| | - Yves d'Udekem
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Melbourne, Australia; Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia.
| |
Collapse
|
22
|
Zentner D, Celermajer DS, Gentles T, d’Udekem Y, Ayer J, Blue GM, Bridgman C, Burchill L, Cheung M, Cordina R, Culnane E, Davis A, du Plessis K, Eagleson K, Finucane K, Frank B, Greenway S, Grigg L, Hardikar W, Hornung T, Hynson J, Iyengar AJ, James P, Justo R, Kalman J, Kasparian N, Le B, Marshall K, Mathew J, McGiffin D, McGuire M, Monagle P, Moore B, Neilsen J, O’Connor B, O’Donnell C, Pflaumer A, Rice K, Sholler G, Skinner JR, Sood S, Ward J, Weintraub R, Wilson T, Wilson W, Winlaw D, Wood A. Management of People With a Fontan Circulation: a Cardiac Society of Australia and New Zealand Position statement. Heart Lung Circ 2020; 29:5-39. [DOI: 10.1016/j.hlc.2019.09.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/16/2019] [Indexed: 02/07/2023]
|
23
|
CT and MR imaging findings of the livers in adults with Fontan palliation: an observational study. Abdom Radiol (NY) 2020; 45:188-202. [PMID: 31471707 DOI: 10.1007/s00261-019-02119-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To describe liver imaging findings and complications on computed tomography (CT) or magnetic resonance imaging (MRI) in adults with Fontan palliation and investigate whether imaging features show correlations with clinical and physiological parameters. METHODS Our Institutional Review Board approved this retrospective study. Two blinded abdominal radiologists reviewed abdominal CT (n = 21) and MRI (n = 16) images between September 2011 and October 2017 in 37 adults (median age 27 years, interquartile range 21-36 years, 14 males [38%]) with a Fontan palliation (median post-Fontan duration 22 years, interquartile range 19-28 years). Correlation between CT/MRI findings and clinical parameters including laboratory results within 6 months of CT/MRI examinations was assessed by Spearman's rank correlation coefficient. RESULTS Lobulated hepatic surface and blunt hepatic edge were seen in 92% (34/37) and 95% (35/37) of patients, respectively. Surface nodularity was noted in 32% (12/37). In 7 patients, there were 11 hepatic nodules which showed arterial-phase hyperenhancement and washout. Among them, 2 were biopsy-proven hepatocellular carcinomas (HCCs), and the remaining 9 were focal nodular hyperplasia (FNH)-like nodules. Suprahepatic inferior vena cava (IVC) diameter showed positive correlations with post-Fontan duration (p < 0.01), serum gamma-glutamyl transferase (p < 0.01), and total bilirubin (p < 0.01). CONCLUSION The livers in post-Fontan adults show a unique morphology of blunt edge and lobulating surface with occasional nodularity. There is a diagnostic challenge in distinguishing HCCs from FNH-like nodules in post-Fontan population due to overlapping imaging findings. Suprahepatic IVC diameter is a potentially useful imaging marker that reflects hepatic dysfunction in Fontan palliation.
Collapse
|
24
|
Abstract
Half a century has passed since the original Fontan palliation. In the interim, surgical and medical advancements have allowed more single ventricle patients to reach Fontan and long-term survival for Fontan patients to improve significantly. However, the risk for Fontan failure and need for heart transplantation remains. In this article we discuss mechanisms of Fontan failure, risk factors and special considerations for Fontan patients in both medical and surgical management around heart transplantation and provide an updated review of survival for Fontan patients after heart transplantation.
Collapse
Affiliation(s)
- Amanda D McCormick
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| |
Collapse
|
25
|
Finkelstein DM, Goldberg DJ. After planned surgeries, there is still work to be done: Medical therapies. PROGRESS IN PEDIATRIC CARDIOLOGY 2019. [DOI: 10.1016/j.ppedcard.2019.101133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
26
|
Challenges, opportunities and solutions in hypoplastic left heart syndrome: Surveillance strategies for the patient with HLHS and a Fontan circulation. PROGRESS IN PEDIATRIC CARDIOLOGY 2019. [DOI: 10.1016/j.ppedcard.2019.101144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
27
|
Rychik J, Atz AM, Celermajer DS, Deal BJ, Gatzoulis MA, Gewillig MH, Hsia TY, Hsu DT, Kovacs AH, McCrindle BW, Newburger JW, Pike NA, Rodefeld M, Rosenthal DN, Schumacher KR, Marino BS, Stout K, Veldtman G, Younoszai AK, d'Udekem Y. Evaluation and Management of the Child and Adult With Fontan Circulation: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e234-e284. [PMID: 31256636 DOI: 10.1161/cir.0000000000000696] [Citation(s) in RCA: 407] [Impact Index Per Article: 81.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
It has been 50 years since Francis Fontan pioneered the operation that today bears his name. Initially designed for patients with tricuspid atresia, this procedure is now offered for a vast array of congenital cardiac lesions when a circulation with 2 ventricles cannot be achieved. As a result of technical advances and improvements in patient selection and perioperative management, survival has steadily increased, and it is estimated that patients operated on today may hope for a 30-year survival of >80%. Up to 70 000 patients may be alive worldwide today with Fontan circulation, and this population is expected to double in the next 20 years. In the absence of a subpulmonary ventricle, Fontan circulation is characterized by chronically elevated systemic venous pressures and decreased cardiac output. The addition of this acquired abnormal circulation to innate abnormalities associated with single-ventricle congenital heart disease exposes these patients to a variety of complications. Circulatory failure, ventricular dysfunction, atrioventricular valve regurgitation, arrhythmia, protein-losing enteropathy, and plastic bronchitis are potential complications of the Fontan circulation. Abnormalities in body composition, bone structure, and growth have been detected. Liver fibrosis and renal dysfunction are common and may progress over time. Cognitive, neuropsychological, and behavioral deficits are highly prevalent. As a testimony to the success of the current strategy of care, the proportion of adults with Fontan circulation is increasing. Healthcare providers are ill-prepared to tackle these challenges, as well as specific needs such as contraception and pregnancy in female patients. The role of therapies such as cardiovascular drugs to prevent and treat complications, heart transplantation, and mechanical circulatory support remains undetermined. There is a clear need for consensus on how best to follow up patients with Fontan circulation and to treat their complications. This American Heart Association statement summarizes the current state of knowledge on the Fontan circulation and its consequences. A proposed surveillance testing toolkit provides recommendations for a range of acceptable approaches to follow-up care for the patient with Fontan circulation. Gaps in knowledge and areas for future focus of investigation are highlighted, with the objective of laying the groundwork for creating a normal quality and duration of life for these unique individuals.
Collapse
|
28
|
Opotowsky AR, Carazo M, Singh MN, Dimopoulos K, Cardona-Estrada DA, Elantably A, Waikar SS, Mc Causland FR, Veldtman G, Grewal J, Gray C, Loukas BN, Rajpal S. Creatinine versus cystatin C to estimate glomerular filtration rate in adults with congenital heart disease: Results of the Boston Adult Congenital Heart Disease Biobank. Am Heart J 2019; 214:142-155. [PMID: 31203159 DOI: 10.1016/j.ahj.2019.04.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 04/26/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Glomerular filtration rate is a key physiologic variable with a central role in clinical decision making and a strong association with prognosis in diverse populations. Reduced estimated glomerular filtration rate (eGFR) is common among adults with congenital heart disease (ACHD). METHODS We conducted a prospective cohort study of outpatient ACHD ≥18 years old seen in 2012-2017. Creatinine and cystatin C were measured; eGFR was calculated using either the creatinine or cystatin C Chronic Kidney Disease-Epidemiology Collaboration equation (CKD-EPICr and CKD-EPICysC, respectively). Survival analysis was performed to define the relationship between eGFR and both all-cause mortality and a composite outcome of death or nonelective cardiovascular hospitalization. RESULTS Our cohort included 911 ACHD (39 ± 14 years old, 49% female). Mean CKD-EPICr and CKD-EPICysC were similar (101 ± 20 vs 100 ± 23 mL/min/1.73 m2), but CKD-EPICr estimates were higher for patients with a Fontan circulation (n = 131, +10 ± 19 mL/min/1.73 m2). After mean follow-up of 659 days, 128 patients (14.1%) experienced the composite outcome and 31 (3.4%) died. CKD-EPICysC more strongly predicted all-cause mortality (eGFR <60 vs >90 mL/min/1.73 m2: CKD-EPICysC unadjusted HR = 20.2 [95% CI 7.6-53.1], C-statistic = 0.797; CKD-EPICr unadjusted HR = 4.6 [1.7-12.7], C-statistic = 0.620). CKD-EPICysC independently predicted the composite outcome, whereas CKD-EPICr did not (CKD-EPICysC adjusted HR = 3.0 [1.7-5.3]; CKD-EPICr adjusted HR = 1.5 [0.8-3.1]). Patients reclassified to a lower eGFR category by CKD-EPICysC, compared with CKD-EPICr, were at increased risk for the composite outcome (HR = 2.9 [2.0-4.3], P < .0001); those reclassified to a higher eGFR class were at lower risk (HR = 0.5 [0.3-0.9], P = .03). CONCLUSIONS Cystatin C-based eGFR more strongly predicts clinical events than creatinine-based eGFR in ACHD. Creatinine-based methods appear particularly questionable in the Fontan circulation.
Collapse
Affiliation(s)
- Alexander R Opotowsky
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Matthew Carazo
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael N Singh
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College of Science and Medicine, London, United Kingdom
| | | | - Ahmed Elantably
- Department of Medicine, North Shore Medical Center, Salem, MA, USA
| | - Sushrut S Waikar
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Gruschen Veldtman
- Adolescent and Adult Congenital Heart Disease Program, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jasmine Grewal
- Pacific Adult Congenital Heart Disease Clinic, Division of Cardiology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Catherine Gray
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States
| | - Brittani N Loukas
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States
| | - Saurabh Rajpal
- Ohio State University Division of Cardiovascular Medicine and Nationwide Children's Hospital Heart Center, Columbus, OH, USA
| |
Collapse
|
29
|
Kirelik D, Fisher M, DiMaria M, Soranno DE, Gist KM. Comparison of creatinine and cystatin C for estimation of glomerular filtration rate in pediatric patients after Fontan operation. CONGENIT HEART DIS 2019; 14:760-764. [PMID: 30993817 DOI: 10.1111/chd.12776] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/11/2019] [Accepted: 04/03/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND There are several limitations when using creatinine to estimate glomerular filtration rate, especially in children with chronic medical conditions who are at high risk of kidney dysfunction. Cystatin C has been the recent focus of research as a replacement biomarker for creatinine. Our objective was to compare the 2 biomarkers in pediatric single-ventricle heart disease patients who have undergone the Fontan operation. We hypothesized that there would be poor correlation and agreement between the 2 estimates of renal function. METHODS This was a single center retrospective chart review of 20 patients who had previously undergone Fontan operation. Demographic and clinical data were collected from medical records. Blood samples were collected as part of routine clinical care and simultaneously measured for serum creatinine and cystatin C. Glomerular filtration rate was calculated using the creatinine-based bedside Schwartz formula and cystatin C-based Zapatelli equation. Spearman correlation and Bland-Altman analysis were used to assess correlation and agreement. RESULTS The median Schwartz-derived estimated glomerular filtration rate was 98.94 mL/min/1.73 m2 while the median Zappitelli-derived estimated glomerular filtration rate was 84.76 mL/min/1.73 m2 . The mean difference was -19.27 suggesting poor agreement. There was weak to moderate correlation between the Schwartz and cystatin C estimated glomerular filtration rate. CONCLUSION The bedside Schwartz formula may be an overestimate of glomerular filtration rate in pediatric single-ventricle heart disease patients who have undergone the Fontan operation. While larger studies are necessary, cystatin C is a promising biomarker to replace creatinine and better estimate kidney function in this population.
Collapse
Affiliation(s)
- Danielle Kirelik
- George Washington University School of Medicine, Washington, DC.,Section of Pediatric Cardiology, Department of Pediatrics, University of Colorado, Children's Hospital Colorado, Aurora, Colorado
| | - Mark Fisher
- Section of Pediatric Cardiology, Department of Pediatrics, University of Colorado, Children's Hospital Colorado, Aurora, Colorado
| | - Michael DiMaria
- Section of Pediatric Cardiology, Department of Pediatrics, University of Colorado, Children's Hospital Colorado, Aurora, Colorado
| | - Danielle E Soranno
- Section of Pediatric Nephrology, Department of Pediatrics, University of Colorado, Children's Hospital Colorado, Aurora, Colorado
| | - Katja M Gist
- Section of Pediatric Cardiology, Department of Pediatrics, University of Colorado, Children's Hospital Colorado, Aurora, Colorado
| |
Collapse
|
30
|
Michel M, Zlamy M, Entenmann A, Pichler K, Scholl-Bürgi S, Karall D, Geiger R, Salvador C, Niederwanger C, Ohuchi H. Impact of the Fontan Operation on Organ Systems. Cardiovasc Hematol Disord Drug Targets 2019; 19:205-214. [PMID: 30747084 DOI: 10.2174/1871529x19666190211165124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 01/09/2019] [Accepted: 01/29/2019] [Indexed: 02/06/2023]
Abstract
In patients having undergone the Fontan operation, besides the well discussed changes in the cardiac, pulmonary and gastrointestinal system, alterations of further organ systems including the hematologic, immunologic, endocrinological and metabolic are reported. As a medical adjunct to Fontan surgery, the systematic study of the central role of the liver as a metabolizing and synthesizing organ should allow for a better understanding of the pathomechanism underlying the typical problems in Fontan patients, and in this context, the profiling of endocrinological and metabolic patterns might offer a tool for the optimization of Fontan follow-up, targeted monitoring and specific adjunct treatment.
Collapse
Affiliation(s)
- Miriam Michel
- Department of Pediatrics III, Division of Cardiology, Pulmology, Allergology, and Cystic Fibrosis, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Manuela Zlamy
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Andreas Entenmann
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Karin Pichler
- Department of Pediatrics, Vienna Medical University, Währinger Gürtel 16, 1090 Vienna, Austria
| | - Sabine Scholl-Bürgi
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Daniela Karall
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Ralf Geiger
- Department of Pediatrics III, Division of Cardiology, Pulmology, Allergology, and Cystic Fibrosis, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Christina Salvador
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Christian Niederwanger
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Hideo Ohuchi
- Department for Pediatric Cardiology, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka 565-8565, Japan
| |
Collapse
|
31
|
Wilson TG, d'Udekem Y, Winlaw DS, Cordina RL, Ayer J, Gentles TL, Weintraub RG, Grigg LE, Cheung M, Cain TM, Rao P, Verrall C, Plessis KD, Rice K, Iyengar AJ. Creatinine-based estimation of glomerular filtration rate in patients with a Fontan circulation. CONGENIT HEART DIS 2019; 14:454-463. [PMID: 30664330 DOI: 10.1111/chd.12746] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/17/2018] [Accepted: 01/03/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients with a Fontan circulation are at risk of renal dysfunction. We analyzed cross-sectional data in pediatric and adult Fontan patients in order to assess the accuracy of commonly used serum creatinine-based methods in estimating glomerular filtration rate (GFR). METHODS A total of 124 Fontan patients (58 children, 66 adults) were enrolled across three study centers. Measurement of GFR (mGFR) using in vivo 99m Tc-DTPA clearance was performed. Various serum creatinine-based equations were used to calculate estimated GFR (eGFR). RESULTS Mean mGFR was 108 ± 28 mL/min/1.73 m2 in children and 92 ± 20 mL/min/1.73 m2 in adults. Fourteen children (25%) and 28 adults (45%) had an mGFR <90 mL/min/1.73 m2 . There was no significant correlation between mGFR and eGFR (Schwartz) in children (r = 0.22, P = .1), which substantially overestimated mGFR (bias 50.8, 95%CI: 41.1-60.5 mL/min/1.73 m2 , P < .0001). The Bedside Schwartz equation also performed poorly in the children (r = 0.08, P = .5; bias 5.9, 95%CI: -2.9-14.6 mL/min/1.73 m2 , P < .0001). There was a strong correlation between mGFR and both eGFR (CKD-EPI) and eGFR (MDRD) in adults (r = 0.67, P < .0001 in both cases), however, both methods overestimated mGFR (eGFR(CKD-EPI):bias 23.8, 95%CI: 20-27.6 mL/min/1.73 m2 , P < .0001; eGFR (MDRD):bias 16.1, 95%CI: 11.8-20.4 mL/min/1.73 m2 , P < .0001). None of the children with an mGFR <90 mL/min/1.73 m2 had an eGFR (Schwartz) <90 mL/min/1.73 m2 . Sensitivity and specificity of eGFR (CKD-EPI) and eGFR (MDRD) for mGFR <90 mL/min/1.73 m2 in adults were 25% and 92% and 39% and 100%, respectively. CONCLUSIONS This study identifies the unreliability of using creatinine-based equations to estimate GFR in children with a Fontan circulation. The accuracy of formulas incorporating cystatin C should be further investigated and may aid noninvasive surveillance of renal function in this population.
Collapse
Affiliation(s)
- Thomas G Wilson
- Heart Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Yves d'Udekem
- Heart Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - David S Winlaw
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Department of Paediatrics, University of Sydney, Sydney, New South Wales, Australia
| | - Rachael L Cordina
- Department of Paediatrics, University of Sydney, Sydney, New South Wales, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Julian Ayer
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Department of Paediatrics, University of Sydney, Sydney, New South Wales, Australia
| | - Thomas L Gentles
- Greenlane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand
| | - Robert G Weintraub
- Heart Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Cardiology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Leeanne E Grigg
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Michael Cheung
- Heart Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Cardiology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Timothy M Cain
- Medical Imaging Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Padma Rao
- Medical Imaging Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Charlotte Verrall
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Karin Du Plessis
- Heart Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Kathryn Rice
- Greenlane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand
| | - Ajay J Iyengar
- Heart Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
32
|
Surveillance Testing and Preventive Care After Fontan Operation: A Multi-Institutional Survey. Pediatr Cardiol 2019; 40:110-115. [PMID: 30159585 DOI: 10.1007/s00246-018-1966-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 08/16/2018] [Indexed: 01/27/2023]
Abstract
More children with single ventricle heart disease are surviving after Fontan surgery. This circulation has pervasive effects on multiple organ systems and has unique modes of failure. Many centers have created multidisciplinary programs to care for these patients. Our aim was to survey such programs to better understand current approaches to care. We hypothesized that significant variability in surveillance testing strategy would be present. Eleven academic institutions with established Fontan care programs performing a combined estimated 300 Fontan surgeries per year, with a total population of 1500-2000 Fontan patients, were surveyed using a REDCap survey regarding surveillance testing and basic practice philosophies. Fontan care programs were structured both as consultative services (64%) and as the primary clinical team (9%). Electrocardiograms (73%) and echocardiograms (64%) were most commonly obtained annually. Serum studies, including complete blood count (73%), complete metabolic panel (73%), and Brain-type natriuretic peptide (54%), were most commonly obtained annually. Hepatic testing consisted of liver ultrasound in most centers, obtained biennially (45%) or > every 2 years (45%). Liver biopsy was not routinely recommended (54%). Neurodevelopmental outcomes were assessed at most institutions (54%), with a median frequency of every 3-4 years. There is considerable variability in the surveillance testing regimen and management strategy after a Fontan procedure at surveyed programs. There is an urgent need for surveillance guidelines to reduce variability, define quality metrics, streamline collaborative practice, and prospective research to better understand the complex adaptations of the body to Fontan physiology.
Collapse
|
33
|
Hepatic and renal end-organ damage in the Fontan circulation: A report from the Australian and New Zealand Fontan Registry. Int J Cardiol 2018; 273:100-107. [DOI: 10.1016/j.ijcard.2018.07.118] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 07/21/2018] [Accepted: 07/23/2018] [Indexed: 11/23/2022]
|
34
|
Young B, Franklin W, Lam W, Ermis P. Single-center experience of hemodialysis in patients after Fontan palliation. IJC HEART & VASCULATURE 2018; 21:94-95. [PMID: 30417073 PMCID: PMC6218632 DOI: 10.1016/j.ijcha.2018.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/13/2018] [Accepted: 10/21/2018] [Indexed: 12/04/2022]
Affiliation(s)
- Brian Young
- Department of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, United States of America
| | - Wayne Franklin
- Department of Adult Congenital Heart Disease, Baylor College of Medicine, Houston, TX, United States of America
| | - Wilson Lam
- Department of Adult Congenital Heart Disease, Baylor College of Medicine, Houston, TX, United States of America
| | - Peter Ermis
- Department of Adult Congenital Heart Disease, Baylor College of Medicine, Houston, TX, United States of America
| |
Collapse
|
35
|
Shi Y, Liu Z, Shen Y, Zhu H. A Novel Perspective Linkage Between Kidney Function and Alzheimer's Disease. Front Cell Neurosci 2018; 12:384. [PMID: 30429775 PMCID: PMC6220726 DOI: 10.3389/fncel.2018.00384] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 10/08/2018] [Indexed: 02/03/2023] Open
Abstract
It has long been believed that kidney function is linked to brain activity. Clinical studies demonstrate that patients with chronic kidney disease (CKD) are more prone to cognitive impairment and Alzheimer's disease (AD), and the degree of cognitive impairment is closely related to CKD progression and renal failure. Moreover, the fact that cognitive function in CKD patients is significantly improved after successful kidney transplantation reveals a linkage between CKD and AD. However, the mechanisms behind this linkage are unclear. The physiological function of the kidney is to maintain the stability of the internal environment, including the cerebrovascular circulation, whereas abnormal kidney function often leads to ischemia and hypoxia. Many CKD patients experience chronic hypoxia, and many urinary toxins accumulate after renal function is impaired. In this mini review, we will propose a novel perspective on the association between AD and CKD and the connection between the kidney and brain.
Collapse
Affiliation(s)
- Yan Shi
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Research Institute of Nephrology, Zhengzhou University, Zhengzhou, China
| | - Zhangsuo Liu
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Research Institute of Nephrology, Zhengzhou University, Zhengzhou, China
| | - Yong Shen
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
- Center for Advanced Therapeutic Strategies for Brain Disorders, The Roskamp Institute, Sarasota, FL, United States
| | - Hanyu Zhu
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| |
Collapse
|
36
|
Broda CR, Sriraman H, Wadhwa D, Wang Y, Tunuguntla H, Akcan-Arikan A, Ermis PR, Price JF. Renal dysfunction is associated with higher central venous pressures in patients with Fontan circulation. CONGENIT HEART DIS 2018; 13:602-607. [PMID: 30079627 DOI: 10.1111/chd.12617] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 03/07/2018] [Accepted: 04/25/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE Elevated central venous pressure (CVP) has deleterious effects on several organ systems in patients with Fontan circulation. However, the relationship between CVP and estimated glomerular filtration rate (eGFR) has not been assessed in patients with Fontan circulation. METHODS Patients with Fontan circulation whose hemodynamics were assessed by catheterization between 1987 and 2015 and had a serum creatinine measured within 72 hours prior to the procedure were included for analysis. Patients with primary kidney disease were excluded. Renal function was calculated by "bedside Schwartz" equation in children (< 18 years) and Modification of Diet in Renal Disease equation in adults. Renal dysfunction (RD) was defined by eGFR < 90mL/min/1.73m2 . Fontan patients with and without RD were compared based on demographics, co-morbidities, medication use, echocardiographic findings, hemodynamics assessed at time of catheterization, and laboratory testing values. RESULTS Sixty-seven patients with Fontan circulation met inclusion criteria and 15 patients (22%) had RD; eGFR (mL/min/1.73m2 ) was 60-89in 13 (87%), 45-59in 1 (7%), and 30-45in 1 (7%). Compared to patients with eGFR equal to or greater than 90, patients with RD had higher CVP (18.0 [15.0-21.0] mm Hg vs 13.5 [12.3-16.0] mm Hg (P = 0.001), lower pulmonary blood flow 2.2 [1.9-2.6] L/min/m2 vs 2.8 [2.3-3.7] L/min/m2 , higher ventricular end-diastolic pressure 10.5 [7.0-17.3] mm Hg vs 8.0 [6.0-10.0] mm Hg (P = 0.050), were more likely to have worse atrioventricular valve regurgitation (P = 0.02) and were more likely to be African American (P = 0.009). CONCLUSIONS In this study population, renal dysfunction in patients with Fontan circulation is associated with increased CVP and factors that affect CVP. African Americans with Fontan circulation may be at particular risk for renal dysfunction. Continued investigation of the effects of venous congestion on kidneys and other factors associated with renal dysfunction in patients with Fontan circulation is warranted.
Collapse
Affiliation(s)
- Christopher R Broda
- Department of Pediatrics, Section of Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Hamsini Sriraman
- George R. Brown School of Engineering, Rice University, Houston, Texas
| | - Devanshi Wadhwa
- George R. Brown School of Engineering, Rice University, Houston, Texas
| | - Yunfei Wang
- Department of Pediatrics, Section of Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Hari Tunuguntla
- Department of Pediatrics, Section of Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas.,Department of Pediatrics, Section of Nephrology, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Peter R Ermis
- Department of Pediatrics, Section of Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Jack F Price
- Department of Pediatrics, Section of Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| |
Collapse
|
37
|
Gerardin JF, Earing MG. Preoperative Evaluation of Adult Congenital Heart Disease Patients for Non-cardiac Surgery. Curr Cardiol Rep 2018; 20:76. [DOI: 10.1007/s11886-018-1016-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
38
|
Oka H, Nakau K, Kajihama A, Azuma H. Assessment of Potential Renal Dysfunction in Patients with Congenital Heart Disease after Biventricular Repair. Korean Circ J 2018; 48:418-426. [PMID: 29671286 PMCID: PMC5940646 DOI: 10.4070/kcj.2017.0017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 01/25/2018] [Accepted: 02/13/2018] [Indexed: 11/13/2022] Open
Abstract
Background and Objectives There are few reports on renal dysfunction in the remote period after biventricular repair, and biomarkers for early detection of renal dysfunction are not well understood. We examined whether early fluctuation of biomarkers of renal function occurs in the remote period after biventricular repair in patients with congenital heart disease (CHD). Methods Fourteen patients with CHD after biventricular repair were included. The examination values obtained by cardiac catheterization test and renal function indices based on blood and urine sampling were compared. Results The median estimated glomerular filtration rate (eGFR) of creatinine was 113 mL/min/1.73 m2, and the median eGFR of cystatin C was 117 mL/min/1.73 m2. A urine albumin-to-creatinine ratio (UACR) ≥10 mg/gCr was considered a risk factor for cardiovascular disease in 6 (43%) patients. There was a significant difference in right ventricular ejection fraction and deviation in right ventricular end-diastolic volume from the normal value between the 2 groups divided by UACR. Cyanosis before biventricular repair was noted in 2 (25%) patients with UACR <10 mg/gCr and in 4 (67%) patients with UACR ≥10 mg/gCr. Conclusions Increased UACR was noted in 43% of patients. In patients with UACR ≥10 mg/gCr, right heart system abnormality was observed, and several patients had cyanosis before radical treatment. Measurement for UACR may be able to detect renal dysfunction early in the postoperative remote period.
Collapse
Affiliation(s)
- Hideharu Oka
- Department of Pediatrics, Asahikawa Medical University, Asahikawa, Japan.
| | - Kouichi Nakau
- Department of Pediatrics, Asahikawa Medical University, Asahikawa, Japan
| | - Aya Kajihama
- Department of Pediatrics, Asahikawa Medical University, Asahikawa, Japan
| | - Hiroshi Azuma
- Department of Pediatrics, Asahikawa Medical University, Asahikawa, Japan
| |
Collapse
|
39
|
|
40
|
Windsor J, Townsley MM, Briston D, Villablanca PA, Alegria JR, Ramakrishna H. Fontan Palliation for Single-Ventricle Physiology: Perioperative Management for Noncardiac Surgery and Analysis of Outcomes. J Cardiothorac Vasc Anesth 2017; 31:2296-2303. [DOI: 10.1053/j.jvca.2017.04.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Indexed: 12/14/2022]
|
41
|
Diagnosis and Management of Noncardiac Complications in Adults With Congenital Heart Disease: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e348-e392. [DOI: 10.1161/cir.0000000000000535] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Life expectancy and quality of life for those born with congenital heart disease (CHD) have greatly improved over the past 3 decades. While representing a great advance for these patients, who have been able to move from childhood to successful adult lives in increasing numbers, this development has resulted in an epidemiological shift and a generation of patients who are at risk of developing chronic multisystem disease in adulthood. Noncardiac complications significantly contribute to the morbidity and mortality of adults with CHD. Reduced survival has been documented in patients with CHD with renal dysfunction, restrictive lung disease, anemia, and cirrhosis. Furthermore, as this population ages, atherosclerotic cardiovascular disease and its risk factors are becoming increasingly prevalent. Disorders of psychosocial and cognitive development are key factors affecting the quality of life of these individuals. It is incumbent on physicians who care for patients with CHD to be mindful of the effects that disease of organs other than the heart may have on the well-being of adults with CHD. Further research is needed to understand how these noncardiac complications may affect the long-term outcome in these patients and what modifiable factors can be targeted for preventive intervention.
Collapse
|
42
|
Ohuchi H, Negishi J, Hayama Y, Miyazaki A, Shiraishi I, Ichikawa H. Renal resistive index reflects Fontan pathophysiology and predicts mortality. Heart 2017; 103:1631-1637. [PMID: 28465331 DOI: 10.1136/heartjnl-2016-310812] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 02/09/2017] [Accepted: 03/03/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The renal resistive index (RRI) reflects non-renal pathophysiology, such as great artery stiffness, haemodynamics and even end-organ damage in patients with hypertension. This study was conducted to clarify the clinical significance of the RRI in Fontan pathophysiology. METHODS We measured the RRI in 280 consecutive Fontan patients and 36 healthy controls. RESULTS The patients exhibited a higher RRI than the controls (0.71±0.07 vs 0.60±0.04, p<0.0001). A high central venous pressure, low arterial pressure, greater pulse pressure and low arterial oxygen saturation (SaO2) independently predicted a high RRI (p<0.05-0.0001). The RRI was inversely correlated with the peak oxygen uptake (PVO2) and 24-hour creatine clearance, and was positively correlated with the plasma levels of brain natriuretic peptide (BNP) (p<0.0001 for all). The high RRI was also associated with liver dysfunction and postprandial hyperglycaemia during the oral glucose tolerance test (p<0.001). During the follow-up period, 18 patients died. Age, RRI, SaO2, BNP, use of diuretics and antiarrhythmic drugs, and PVO2 predicted mortality. When PVO2 was excluded, RRI (HR: 1.13; 95% CI: 1.04 to 1.23; p<0.01) or RRI ≥0.81 (HR: 12.0; 95% CI: 3.4 to 50; p<0.0001) independently predicted mortality. CONCLUSIONS The RRI reflected heart failure severity, hepatorenal function and glucose intolerance, and predicted all-cause mortality in Fontan patients. Therefore, the RRI may be a useful marker of Fontan-associated multiorgan pathophysiology.
Collapse
Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Jun Negishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yohsuke Hayama
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Aya Miyazaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Isao Shiraishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hajime Ichikawa
- Department of Pediatric Thoracic Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| |
Collapse
|
43
|
Creating a lesion-specific "roadmap" for ambulatory care following surgery for complex congenital cardiac disease. Cardiol Young 2017; 27:648-662. [PMID: 27373527 DOI: 10.1017/s1047951116000974] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Over the past 20 years, the successes of neonatal and infant surgery have resulted in dramatically changed demographics in ambulatory cardiology. These school-aged children and young adults have complex and, in some cases, previously unexpected cardiac and non-cardiac consequences of their surgical and/or transcatheter procedures. There is a growing need for additional cardiac and non-cardiac subspecialists, and coordination of care may be quite challenging. In contrast to hospital-based care, where inpatient care protocols are common, and perioperative expectations are more or less predictable for most children, ambulatory cardiologists have evolved strategies of care more or less independently, based on their education, training, experience, and individual styles, resulting in highly variable follow-up strategies. We have proposed a combination proactive-reactive collaborative model with a patient's primary cardiologist, primary-care provider, and subspecialists, along with the patient and their family. The goal is to help standardise data collection in the ambulatory setting, reduce patient and family anxiety, increase health literacy, measure and address the non-cardiac consequences of complex cardiac disease, and aid in the transition to self-care as an adult.
Collapse
|
44
|
Goldberg DJ, Surrey LF, Glatz AC, Dodds K, O'Byrne ML, Lin HC, Fogel M, Rome JJ, Rand EB, Russo P, Rychik J. Hepatic Fibrosis Is Universal Following Fontan Operation, and Severity is Associated With Time From Surgery: A Liver Biopsy and Hemodynamic Study. J Am Heart Assoc 2017; 6:JAHA.116.004809. [PMID: 28446492 PMCID: PMC5524062 DOI: 10.1161/jaha.116.004809] [Citation(s) in RCA: 173] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background Congestive hepatopathy is a recognized complication of Fontan physiology. Data regarding the incidence of hepatopathy and risk factors are lacking. Methods and Results Liver biopsies and cardiac catherizations were performed as part of an evaluation offered to all patients ≥10 years after Fontan. Quantitative determination of hepatic fibrosis was performed using Sirius red staining with automated calculation of collagen deposition per slide (%CD). Biopsies from included subjects were compared to stained specimens from controls without known fibrotic liver disease. Patient characteristics, echocardiographic findings, and hemodynamic measures were evaluated as potential risk factors. The cohort consisted of 67 patients (31 female) at mean age of 17.3±4.5 years and mean time from Fontan of 14.9±4.5 years. Right ventricular morphology was present in 37 subjects. Median %CD by Sirius red staining was 21.6% (range 8.7% to 49.4%) compared to 2.6% (range 2.2% to 3.0%) in controls. There was a significant correlation between time from Fontan and degree of Sirius red staining (r=0.33, P<0.01). Serum liver enzymes and platelet count did not correlate with %CD. The median inferior vena cava pressure was 13 mm Hg (range 6‐24 mm Hg) and did not correlate with %CD. There was no difference in %CD based on ventricular morphology or severity of atrioventricular valve insufficiency. Conclusions In this cohort of predominantly asymptomatic children and adolescents electively evaluated after a Fontan operation, all exhibited evidence for hepatic fibrosis as measured by collagen deposition in the liver. Time from Fontan was the only factor significantly associated with collagen deposition. These findings demonstrate that liver fibrosis is an inherent feature of Fontan physiology and that the degree of fibrosis increases over time.
Collapse
Affiliation(s)
- David J Goldberg
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lea F Surrey
- Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Andrew C Glatz
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kathryn Dodds
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Henry C Lin
- Division of Gastroenterology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mark Fogel
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jonathan J Rome
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth B Rand
- Division of Gastroenterology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Pierre Russo
- Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jack Rychik
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
45
|
Rajpal S, Alshawabkeh L, Opotowsky AR. Current Role of Blood and Urine Biomarkers in the Clinical Care of Adults with Congenital Heart Disease. Curr Cardiol Rep 2017; 19:50. [DOI: 10.1007/s11886-017-0860-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
46
|
Clift P, Celermajer D. Managing adult Fontan patients: where do we stand? Eur Respir Rev 2016; 25:438-450. [PMID: 27903666 PMCID: PMC9487559 DOI: 10.1183/16000617.0091-2016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/13/2016] [Indexed: 01/10/2023] Open
Abstract
The Fontan operation is performed as a palliative procedure to improve survival in infants born with a functionally univentricular circulation. The success of the operation is demonstrated by a growing adult Fontan population that exists with this unique physiology. Late follow-up has demonstrated expected and unexpected sequelae, and has shown multisystem effects of this circulation. This review discusses the challenges of managing the late complications in terms of understanding this unique physiology and the innovative therapeutic interventions that are being investigated. The challenge remains to maintain quality of life for adult survivors, as well as extending life expectancy. Innovative solutions are required to meet the challenges of the Fontan circulation faced in adult lifehttp://ow.ly/XTSm305oH8b
Collapse
|
47
|
Opotowsky AR, Baraona FR, Mc Causland FR, Loukas B, Landzberg E, Landzberg MJ, Sabbisetti V, Waikar SS. Estimated glomerular filtration rate and urine biomarkers in patients with single-ventricle Fontan circulation. Heart 2016; 103:434-442. [PMID: 27670967 DOI: 10.1136/heartjnl-2016-309729] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 08/19/2016] [Accepted: 08/25/2016] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES To define whether adults with a Fontan circulation, who have lifelong venous congestion and limited cardiac output, have impaired glomerular filtration rate (GFR) or elevated urinary biomarkers of kidney injury. METHODS We measured circulating cystatin C and creatinine (n=70) and urinary creatinine, albumin, kidney injury molecule-1 (KIM-1), neutrophil gelatinase-associated lipocalin (NGAL) and N-acetyl glucosaminidase (NAG) (n=59) in ambulatory adult Fontan patients and 20 age-matched and sex-matched controls. Urinary biomarkers were normalised to urine creatinine concentration. Survival free from non-elective cardiovascular hospitalisation was compared by estimated GFR and urinary biomarker levels using survival analysis. RESULTS Cystatin C GFR was lower in the Fontan group compared with controls (114.2±22.8 vs 136.3±12.8 mL/min/1.73 m2, p<0.0001); GFR<90 mL/min/1.73 m2 in 14.3% vs 0% of controls. Albumin-to-creatinine ratio (ACR), KIM-1 and NAG were elevated compared with controls; ACR=23.2 (7.6-38.3) vs 3.6 (2.5-5.7) mg/g, p<0.0001; NAG=1.8 (1.1-2.6) vs 1.1 (0.9-1.6) U/g, p=0.02; KIM-1=0.91 (0.52-1.45) vs 0.33 (0.24-0.74) ng/mg, p=0.001. Microalbuminuria, ACR>30 mg/g, was present in 33.9% of the Fontan patients but in none of the controls. Over median 707 (IQR 371-942)-day follow-up, 31.4% of patients had a clinical event. Higher KIM-1 and NAG were associated with higher risk of non-elective hospitalisation or death (HR/+1 SD=2.1, 95% CI 1.3 to 3.3, p=0.002; HR/+1 SD=1.6, 95% CI 1.05 to 2.4, p=0.03, respectively); cystatin C GFR was associated with risk of the outcome (HR/+1 SD=0.66, 95% CI 0.48 to 0.90, p=0.009) but creatinine-based GFR was not (HR/+1 SD=0.91, 95% CI 0.61 to 1.38, p=0.66). Neither ACR nor NGAL was associated with events. CONCLUSIONS The Fontan circulation is commonly associated with reduced estimated GFR and evidence for glomerular and tubular injury. Those with lower cystatin C GFR and tubular injury are at increased risk of adverse outcomes.
Collapse
Affiliation(s)
- Alexander R Opotowsky
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Fernando R Baraona
- División de Enfermedades Cardiovasculares, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Brittani Loukas
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Michael J Landzberg
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Venkata Sabbisetti
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sushrut S Waikar
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|