Chronic kidney disease in patients with cardiac disease: A review of evidence-based treatment

Prognostic impact of diabetes mellitus on in-hospital mortality in patients with acute myocardial infarction complicating renal dysfunction according to age and sex

BACKGROUND

Patients with acute myocardial infarction (AMI) complicating renal dysfunction (RD) are recognized as being at high risk. Although diabetes mellitus (DM) is a major cause of RD, the prognostic impact of coexisting DM on mortality in patients with AMI complicating RD is ill-defined. This study compared the prognostic impact of coexisting DM in patients with AMI complicating RD according to both age and sex.

METHODS

A multicenter retrospective study was conducted on 2988 consecutive patients with AMI complicating RD (estimated glomerular filtration rate <60 mL/min per 1.73 m2). Multivariable Cox regression analysis was performed to investigate the effects of DM on in-hospital mortality.

RESULTS

Statistically significant interactions between age and DM and between sex and DM for in-hospital mortality were revealed in the entire cohort. Coexisting DM was identified as an independent risk factor for in-hospital mortality (hazard ratio [HR], 2.543) in young (aged <65 years), but not old (aged ≥65 years), patients. DM was identified as an independent risk factor (HR, 1.469) in male, but not female, patients. Kaplan-Meier survival curves showed that DM correlated with significantly low survival rates in patients that were young or male as compared to those who were old or female.

CONCLUSIONS

There were significant differences in the prognostic impact of DM on in-hospital mortality between young and old as well as male and female patients with AMI complicating RD. These results have implications for future research and the management of patients with DM, RD, and AMI comorbidities.

[Clinical characteristics and quality assessment of the treatment of patients with chronic heart failure with diabetes mellitus]

AIM

A study of the clinical and instrumental characteristics and quality of treatment of patients with chronic heart failure (CHF) with diabetes mellitus.

MATERIALS AND METHODS

The study was conducted by using the CHF register method, which is a computer program with remote access, which allows on-line data collection on patients who have been examined and treated in primary care and in hospitals. The study included 8272 patients with CHF IIIV FC (functional class) (New York Heart Association NYHA); among them 62% of patients were treated in hospital.

RESULTS

The study showed that the frequency of diabetes was 21%. The main causes of CHF in diabetic patients are coronary artery disease, myocardial infarction (in anamnesis) and hypertension. These patients are more often diagnosed with III and IV CHF FC according to (NYHA) and retained LV (left ventricular) ejection fraction. The reduced ejection fraction was observed in 6.8% of cases, and the frequency of the intermediate LV was significantly higher than among patients with CHF and with diabetes and accounted for 18.9%. At patients with CHF with diabetes in comparison with patients with CHF without diabetes, atherosclerosis of the peripheral arteries, stroke (in anamnesis) and chronic kidney disease of stage III and IV were significantly more common.

CONCLUSION

Under the treatment, patients with CHF with diabetes have higher levels of SBP (systolic blood pressure), lipids and glucose in the blood plasma, indicating a lack of quality of treatment and, accordingly, the doctors are not optimally performing the clinical guidelines on treating this category of patients.

Benefits of peritoneal ultrafiltration in HFpEF and HFrEF patients

Background

Peritoneal ultrafiltration (pUF) in refractory heart failure (HF) reduces the incidence of decompensation episodes, which is of particular significance as each episode incrementally adds to mortality. Nevertheless, there are insufficient data about which patient cohort benefits the most. The objective of this study was to compare pUF in HFrEF and HFpEF, focusing on functional status, hospitalizations, surrogate endpoints and mortality.

Methods

This study involves 143 patients, who could be classified as either HFpEF (n = 37, 25.9%) or HFrEF (n = 106, 74.1%) and who received pUF due to refractory HF.

Results

Baseline eGFR was similar in HFrEF (23.1 ± 10.6 mg/dl) and HFpEF (27.8 ± 13.2 mg/dl). Significant improvements in NYHA class were found in HFpEF (3.19 ± 0.61 to 2.72 ± 0.58, P <  0.001) and HFrEF (3.45 ± 0.52 to 2.71 ± 0.72, P <  0.001). CRP decreased in HFrEF (19.4 ± 17.6 mg/l to 13.7 ± 21.4 mg/l, P = 0.018) and HFpEF (33.7 ± 52.6 mg/l to 17.1 ± 26.3 mg/l, P = 0.004). Body weight was significantly reduced in HFrEF (81.1 ± 14.6 kg to 77.2 ± 15.6 kg, P = 0.003) and HFpEF (86.9 ± 15.8 kg to 83.1 ± 15.9 kg, P = 0.005). LVEF improved only in HFrEF (25.9 ± 6.82% to 30.4 ± 12.2%, P = 0.046). BCR decreased significantly in HFrEF and HFpEF (55.7 ± 21.9 to 34.3 ± 17.9 P > 0.001 and 50.5 ± 68.9 to 37.6 ± 21.9, P = 0.006). Number of hospitalization episodes as well as number of hospitalization days decreased significantly only in HFpEF (total number 2.88 ± 1.62 to 1.25 ± 1.45, P <  0.001, days 40.4 ± 31.7 to 18.3 ± 22.5 days, P = 0.005).

Conclusions

pUF offers various benefits in HFpEF and HFrEF, but there are also substantial differences. In particular, hospitalization rates were found to be significantly reduced in HFpEF patients, indicating a greater medical and economical advantage. However, LVEF was only found to be improved in HFrEF patients. While pUF can now be regarded as an option to supplement classical HF therapy, further studies are desirable to obtain specifications about pUF in HFpEF, HFmEF and HFrEF patients.

Peritoneal dialysis as therapeutic option in heart failure patients

Aims

Each episode of acute decompensated heart failure (HF) incrementally adds to mortality. Peritoneal dialysis (PD) offers an alternative therapeutic option in refractory HF and reduces the incidence of decompensation episodes. The objective of this study was to determine the efficacy of PD, in terms of functional status, surrogate endpoints, rate of hospitalizations, and mortality.

Methods and results

This study is based on the registry of the German Society of Nephrology, involving 159 patients receiving PD treatment due to refractory HF between January 2010 and December 2014. Body weight was reduced by PD (82.2 ± 14.9 to 78.4 ± 14.8 kg, P < 0.001), and significant improvements in New York Heart Association functional class (3.38 ± 0.55 to 2.85 ± 0.49, P < 0.001) were found already after 3 months. Left ventricular ejection fraction did not change (31.5 ± 13.8 to 34.0 ± 15.7%, P = 0.175). C‐reactive protein improved with PD treatment (33.7 ± 52.6 to 17.1 ± 26.3 mg/L, P = 0.004). Blood urea nitrogen/creatinine ratio decreased significantly (148.7 ± 68.3 to 106.7 ± 44.8 mg/dL, P < 0.001). Hospitalization rates decreased significantly (total number 2.86 ± 1.88 to 1.90 ± 1.78, P = 0.001, and 39.2 ± 30.7 to 27.1 ± 25.2 days, P = 0.004). One year mortality was 39.6% in end‐stage HF patients treated with PD.

Conclusions

Peritoneal dialysis offers an additional therapeutic option in end‐stage HF and is associated with improved New York Heart Association classification and reduced hospitalization. Although PD treatment was associated with various benefits, further studies are necessary to identify which patients benefit the most from PD.

Heart failure with anemia: novel findings on the roles of renal disease, interleukins, and specific left ventricular remodeling processes

BACKGROUND

Anemia is a highly prevalent and strong independent prognostic marker in heart failure (HF), yet this association is not completely understood. Whether anemia is simply a marker of disease severity and concomitant chronic kidney disease or represents the activation of other detrimental pathways remains uncertain. We sought to determine which pathophysiological pathways are exacerbated in patients with HF, reduced ejection fraction (HFrEF) and anemia in comparison with those without anemia.

METHODS AND RESULTS

In a prospective study involving 151 patients, selected biomarkers were analyzed, each representing proposed contributive mechanisms in the pathophysiology of anemia in HF. We compared clinical, echocardiographic, and circulating biomarkers profiles among patients with HFrEF and anemia (group 1), HFrEF without anemia (group 2), and chronic kidney disease with preserved EF, without established HF (chronic kidney disease control group 3). We demonstrate here that many processes other than those related to chronic kidney disease are involved in the anemia-HF relationship. These are linked to the pathophysiological mechanisms pertaining to left ventricular systolic dysfunction and remodeling, systemic inflammation and volume overload. We found that levels of interleukin-6 and interleukin-10, specific markers of cardiac remodeling (procollagen type III N-terminal peptide, matrix metalloproteinase-2, tissue inhibitor of matrix metalloproteinase 1, left atrial volume), myocardial stretch (NT-proBNP [N-terminal probrain natriuretic peptide]), and myocyte death (troponin T) are related to anemia in HFrEF.

CONCLUSIONS

Anemia is strongly associated not only with markers of more advanced and active heart disease but also with the level of renal dysfunction in HFrEF. Increased myocardial remodeling, inflammation, and volume overload are the hallmarks of patients with anemia and HF.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT00834691.

Herbal Therapy Is Associated With the Risk of CKD in Adults Not Using Analgesics in Taiwan

BACKGROUND

Taiwan has the greatest incidence rate of end-stage renal disease in the world. Several cases of Chinese herb nephropathy were reported in Taiwan. Therefore, we studied the association between herbal therapy and chronic kidney disease (CKD) in Taiwan.

STUDY DESIGN

Cross-sectional survey.

SETTING & PARTICIPANTS

1,740 adults in the Nutrition and Health Survey in Taiwan (1993 to 1996).

PREDICTOR

Herbal and analgesic therapy.

OUTCOMES & MEASUREMENTS

CKD after adjustment for potential confounding variables.

RESULTS

Among medication users, prevalences of herbal therapy and analgesic use were 21.6% and 13.2%, respectively. The prevalence of CKD was 9.9%. Participants with CKD were older and had more analgesic use, diabetes, hypertension, and cardiovascular disease. Analgesic use was associated independently and positively with CKD (odds ratio, 2.2; 95% confidence interval, 1.4 to 3.5; P = 0.003) and CKD stage (odds ratio, 2.3; 95% confidence interval, 1.4 to 3.6; P = 0.003). Conversely, herbal therapy was associated independently and positively with CKD (odds ratio, 1.39; 95% confidence interval, 1.2 to 1.7; P = 0.002) and CKD stage (odds ratio, 1.38; 95% confidence interval, 1.1 to 1.7; P = 0.004) only in participants who did not use analgesics.

LIMITATIONS

Because this was a cross-sectional study, cause and effect could not be ascertained.

CONCLUSIONS

Herbal therapy was associated with CKD in adults in Taiwan who did not use analgesics.

Anaemia and renal function in heart failure due to idiopathic dilated cardiomyopathy

BACKGROUND

Anaemia and renal dysfunction are common in patients with heart failure (HF). Most studies involve western cohorts with ischaemic aetiology receiving treatment likely to impair renal function.

AIMS

To investigate the frequency of anaemia and renal dysfunction and the relationship between the two within a cohort of 163 newly diagnosed Black African idiopathic cardiomyopathy patients prior to commencing HF treatments and compare those findings to those of western HF cohorts.

METHODS

Single-centre retrospective analysis. Anaemia defined as haemoglobin concentration<13.0 g/dL for males (n=85) and <12 g/dL for females (n=78). Probable renal dysfunction defined as an estimated glomerular filtration rate of <60 mL/min/1.73 m2, using serum creatinine concentrations.

RESULTS

The mean age was 48+/-11 years, 52% were male. Overall, 13.5% of patients were anaemic and 11.8% had evidence of renal dysfunction, while 1.2% had both. Renal dysfunction was significantly more common in older patients (mean age 58+/-13 vs. 47+/-10 years: p<0.001).

CONCLUSION

The frequency of anaemia and renal dysfunction in this cohort was lower than that reported in western HF cohorts. These data infer a more limited relationship between HF, anaemia and renal dysfunction in patients without atherothrombotic disease; hence extrapolation of HF data from the western world to other populations should be interpreted cautiously.