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Mayer CC, Sarafidis PA, Matschkal J, Theodorakopoulou M, Lorenz G, Karagiannidis A, Angermann S, Iatridi F, Braunisch MC, Karpetas A, Baumann M, Pella E, Heemann U, Wassertheurer S, Schmaderer C. Measures of wave intensity as a non-invasive surrogate for cardiac function predicts mortality in haemodialysis patients. Clin Kidney J 2024; 17:sfae172. [PMID: 39056069 PMCID: PMC11270016 DOI: 10.1093/ckj/sfae172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Indexed: 07/28/2024] Open
Abstract
Background Risk prediction in haemodialysis (HD) patients is challenging due to the impact of the dialysis regime on the patient's volume status and the complex interplay with cardiac function, comorbidities and hypertension. Cardiac function as a key predictor of cardiovascular (CV) mortality in HD patients is challenging to assess in daily routine. Thus the aim of this study was to investigate the association of a novel, non-invasive relative index of systolic function with mortality and to assess its interplay with volume removal. Methods A total of 558 (373 male/185 female) HD patients with a median age of 66 years were included in this analysis. They underwent 24-hour ambulatory blood pressure monitoring, including wave intensity analysis [i.e. S:D ratio (SDR)]. All-cause and CV mortality served as endpoints and multivariate proportional hazards models were used for risk prediction. Intradialytic changes were analysed in tertiles according to ultrafiltration volume. During a follow-up of 37.8 months, 193 patients died (92 due to CV reasons). Results The SDR was significantly associated with all-cause {univariate hazard ratio [HR] 1.36 [95% confidence interval (CI) 1.20-1.54], P < .001} and CV [univariate HR 1.41 (95% CI 1.20-1.67), P < .001] mortality. The associations remained significant in multivariate analysis accounting for possible confounders. Changes in the SDR from pre-/early- to post-dialytic averages were significantly different for the three ultrafiltration volume groups. Conclusion This study provides well-powered evidence for the independent association of a novel index of systolic function with mortality. Furthermore, it revealed a significant association between intradialytic changes of the measure and intradialytic volume removal.
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Affiliation(s)
- Christopher C Mayer
- AIT Austrian Institute of Technology, Center for Health & Bioresources, Medical Signal Analysis, Vienna, Austria
- TU Wien, Institute for Analysis and Scientific Computing, Vienna, Austria
| | - Pantelis A Sarafidis
- Aristotle University of Thessaloniki, Department of Nephrology, Hippokration Hospital, Thessaloniki, Greece
| | - Julia Matschkal
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Nephrology, Munich, Germany
| | - Marieta Theodorakopoulou
- Aristotle University of Thessaloniki, Department of Nephrology, Hippokration Hospital, Thessaloniki, Greece
| | - Georg Lorenz
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Nephrology, Munich, Germany
| | - Artemios Karagiannidis
- Aristotle University of Thessaloniki, Department of Nephrology, Hippokration Hospital, Thessaloniki, Greece
| | - Susanne Angermann
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Nephrology, Munich, Germany
| | - Fotini Iatridi
- Aristotle University of Thessaloniki, Department of Nephrology, Hippokration Hospital, Thessaloniki, Greece
| | - Matthias C Braunisch
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Nephrology, Munich, Germany
| | | | - Marcus Baumann
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Nephrology, Munich, Germany
| | - Eva Pella
- Aristotle University of Thessaloniki, Department of Nephrology, Hippokration Hospital, Thessaloniki, Greece
| | - Uwe Heemann
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Nephrology, Munich, Germany
| | - Siegfried Wassertheurer
- AIT Austrian Institute of Technology, Center for Health & Bioresources, Medical Signal Analysis, Vienna, Austria
- TU Wien, Institute for Analysis and Scientific Computing, Vienna, Austria
| | - Christoph Schmaderer
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Nephrology, Munich, Germany
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Günthner R, Lorenz G, Braunisch MC, Angermann S, Matschkal J, Hausinger R, Kuchler T, Glaser P, Schicktanz F, Haller B, Heemann U, Streese L, Hanssen H, Kotliar K, Schmaderer C. Endothelial dysfunction in retinal vessels of hemodialysis patients compared to healthy controls. Sci Rep 2024; 14:13948. [PMID: 38886448 PMCID: PMC11183144 DOI: 10.1038/s41598-024-64581-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 06/11/2024] [Indexed: 06/20/2024] Open
Abstract
Endothelial dysfunction is a key factor promoting atherosclerosis and cardiovascular complications. Hemodialysis patients typically show various cardiovascular complications and impaired retinal venular dilation has been described as a risk factor for mortality. Non-invasive retinal vessel analysis provides insight into the microvasculature and endothelial function. Static retinal vessel analysis determines arteriolar and venular vessel diameters and dynamic retinal vessel analysis measures microvascular function by flicker-light induced stimulation, which results in physiological dilation of retinal vessels. We measured 220 healthy individuals and compared them to our preexisting cohort of hemodialysis patients (275 for static and 214 for dynamic analysis). Regarding static vessel diameters, hemodialysis patients and healthy individuals did not significantly differ between vessel diameters. Dynamic retinal vessel analysis showed attenuated dilation of the arteriole of hemodialysis patients with 1.6% vs 2.3% in healthy individuals (p = 0.009). Case-control matching for age (mean 65.4 years) did not relevantly diminish the difference. Hemodialysis patients also exhibited reduced venular dilation after matching for age (3.2% vs 3.8%, p = 0.019). Hemodialysis patients showed microvascular dysfunction compared to healthy individuals when using dynamic retinal vessel analysis. Further studies should focus on dynamic retinal vessel analysis which can add insights into the microvascular function and risk factors in multimorbid patients.
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Affiliation(s)
- Roman Günthner
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Georg Lorenz
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Matthias Christoph Braunisch
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Susanne Angermann
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Julia Matschkal
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Renate Hausinger
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Timon Kuchler
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Patrizia Glaser
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Felix Schicktanz
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bernhard Haller
- School of Medicine, Klinikum Rechts der Isar, Institute of AI and Informatics in Medicine, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Uwe Heemann
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Lukas Streese
- Preventive Sports Medicine and Systems Physiology, Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
- Faculty of Health Care, Niederrhein University of Applied Sciences, Krefeld, Germany
| | - Henner Hanssen
- Preventive Sports Medicine and Systems Physiology, Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Konstantin Kotliar
- Aachen University of Applied Sciences, Heinrich-Mussmann-Str. 1, 52428, Jülich, Germany
| | - Christoph Schmaderer
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
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3
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Letz T, Hörandtner C, Braunisch MC, Gundel P, Matschkal J, Bachler M, Lorenz G, Körner A, Schaller C, Lattermann M, Holzinger A, Heemann U, Wassertheurer S, Schmaderer C, Mayer CC. Automatic ECG-based detection of left ventricular hypertrophy and its predictive value in haemodialysis patients. Physiol Meas 2023; 44:075002. [PMID: 37336235 DOI: 10.1088/1361-6579/acdfb3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 06/19/2023] [Indexed: 06/21/2023]
Abstract
Objective.Left ventricular hypertrophy (LVH) is one of the most severe risk factors in patients with end-stage kidney disease (ESKD) regarding all-cause and cardiovascular mortality. It contributes to the risk of sudden cardiac death which accounts for approximately 25% of deaths in ESKD patients. Electrocardiography (ECG) is the least expensive way to assess whether a patient has LVH, but manual annotation is cumbersome. Thus, an automated approach has been developed to derive ECG-based LVH parameters. The aim of the current study is to compare automatic to manual measurements and to investigate their predictive value for cardiovascular and all-cause mortality.Approach.From the 12-lead 24 h ECG measurements of 301 ESKD patients undergoing haemodialysis, three different LVH parameters were calculated. Peguero-Lo Presti voltage, Cornell voltage, and Sokolow-Lyon voltage were automatically derived and compared to the manual annotations. To determine the agreement between manual and automatic measurements and their predictive value, Bland-Altman plots were created and Cox regression analysis for cardiovascular and all-cause mortality was performed.Main results.The median values for the automatic assessment were: Peguero-Lo Presti voltage 1.76 mV (IQR 1.29-2.55), Cornell voltage 1.14 mV (IQR 0.721-1.66), and Sokolow-Lyon voltage 1.66 mV (IQR 1.08-2.23). The mean differences when compared to the manual measurements were -0.027 mV (0.21 SD), 0.027 mV (0.13 SD) and -0.025 mV (0.24 SD) for Peguero-Lo Presti, Cornell, and Sokolow-Lyon voltage, respectively. The categorial LVH detection based on pre-defined thresholds differed in only 13 cases for all indices between manual and automatic assessment. Proportional hazard ratios only differed slightly in categorial LVH detection between manually and automatically determined LVH parameters; no differences could be found for continuous parameters.Significance.This study provides evidence that automatic algorithms can be as reliable in LVH parameter assessment and risk prediction as manual measurements in ESKD patients undergoing haemodialysis.
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Affiliation(s)
- Theresa Letz
- AIT Austrian Institute of Technology GmbH, Center for Health and Bioresources, Medical Signal Analysis, Giefinggasse 4, A-1210 Vienna, Austria
- TU Wien, Institute of Analysis and Scientific Computing, Wiedner Hauptstr. 8, A-1040 Vienna, Austria
| | - Carina Hörandtner
- AIT Austrian Institute of Technology GmbH, Center for Health and Bioresources, Medical Signal Analysis, Giefinggasse 4, A-1210 Vienna, Austria
- TU Wien, Institute of Analysis and Scientific Computing, Wiedner Hauptstr. 8, A-1040 Vienna, Austria
| | - Matthias C Braunisch
- Technical University of Munich, Klinikum rechts der Isar, Department of Nephrology, Ismaninger Strasse 22, D-81675 Munich, Germany
| | - Peter Gundel
- Technical University of Munich, Klinikum rechts der Isar, Department of Nephrology, Ismaninger Strasse 22, D-81675 Munich, Germany
| | - Julia Matschkal
- Technical University of Munich, Klinikum rechts der Isar, Department of Nephrology, Ismaninger Strasse 22, D-81675 Munich, Germany
| | - Martin Bachler
- AIT Austrian Institute of Technology GmbH, Center for Health and Bioresources, Medical Signal Analysis, Giefinggasse 4, A-1210 Vienna, Austria
| | - Georg Lorenz
- Technical University of Munich, Klinikum rechts der Isar, Department of Nephrology, Ismaninger Strasse 22, D-81675 Munich, Germany
| | - Andreas Körner
- TU Wien, Institute of Analysis and Scientific Computing, Wiedner Hauptstr. 8, A-1040 Vienna, Austria
| | - Carolin Schaller
- Technical University of Munich, Klinikum rechts der Isar, Department of Nephrology, Ismaninger Strasse 22, D-81675 Munich, Germany
| | - Moritz Lattermann
- Technical University of Munich, Klinikum rechts der Isar, Department of Nephrology, Ismaninger Strasse 22, D-81675 Munich, Germany
| | - Andreas Holzinger
- University of Natural Resources and Life Sciences Vienna; Peter-Jordan Straße 82, A-1190 Vienna, Austria
| | - Uwe Heemann
- Technical University of Munich, Klinikum rechts der Isar, Department of Nephrology, Ismaninger Strasse 22, D-81675 Munich, Germany
| | - Siegfried Wassertheurer
- AIT Austrian Institute of Technology GmbH, Center for Health and Bioresources, Medical Signal Analysis, Giefinggasse 4, A-1210 Vienna, Austria
| | - Christoph Schmaderer
- Technical University of Munich, Klinikum rechts der Isar, Department of Nephrology, Ismaninger Strasse 22, D-81675 Munich, Germany
| | - Christopher C Mayer
- AIT Austrian Institute of Technology GmbH, Center for Health and Bioresources, Medical Signal Analysis, Giefinggasse 4, A-1210 Vienna, Austria
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Günthner R, Streese L, Angermann S, Lorenz G, Braunisch MC, Matschkal J, Hausinger R, Stadler D, Haller B, Heemann U, Kotliar K, Hanssen H, Schmaderer C. Mortality prediction of retinal vessel diameters and function in a long-term follow-up of haemodialysis patients. Cardiovasc Res 2022; 118:3239-3249. [PMID: 35576475 DOI: 10.1093/cvr/cvac073] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 04/07/2022] [Accepted: 04/20/2022] [Indexed: 01/25/2023] Open
Abstract
AIM Retinal vessel diameters are candidate biomarkers of mortality prediction in large population-based studies. We aimed to investigate the predictive value of retinal vessel diameters and flicker-induced retinal arteriolar and venular dilation on all-cause mortality in long-term follow-up of haemodialysis patients. METHODS AND RESULTS Retinal vessel diameters as well as maximum arteriolar (aMax) and venular dilation (vMax) were investigated in 275 and 214 haemodialysis patients, respectively. Patients were observed in a long-term follow-up for a median period of 73 months. About 36% (76/214) and 41% (113/275) of patients died. Arteriolar and venular diameters were 175 ± 19 and 208 ± 20 µm, respectively. Median aMax and vMax were 1.6 (0.3-3.3) and 3.2 (2.0-5.1)%. Patients within the lowest tertile of vMax showed lower 5-year survival rates compared with the highest tertile (50.6 vs. 82.1%) and also exhibited a higher incidence of infection-related deaths (21.7 vs. 4.0%). Univariate hazard ratio (HR) per standard deviation increase of vMax for all-cause mortality was 0.69 (0.54-0.88) and was even more pronounced for infection-related mortality [HR 0.53 (0.33-0.83)]. Regarding all-cause mortality, multivariate adjustment for eight non-retinal mortality predictors including interleukin-6 did not attenuate the HR relevantly [0.73 (0.54-0.98)]. Arteriolar and venular diameters did not predict all-cause nor cardiovascular and infection-related mortality. CONCLUSIONS Long-term follow-up of patients on haemodialysis demonstrated the potential of retinal venular dilation capacity for mortality prediction, which was most pronounced for infection-related mortality. In the same cohort, retinal arteriolar and venular diameters showed no predictive value for hard endpoints. Retinal venular dilation but not arteriolar and venular diameters is a valuable diagnostic biomarker for risk prediction in patients with end-stage renal disease and should be considered for monitoring of critically ill patients.
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Affiliation(s)
- Roman Günthner
- Department of Nephrology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Lukas Streese
- Division Sports and Exercise Medicine, Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Susanne Angermann
- Department of Nephrology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Georg Lorenz
- Department of Nephrology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Matthias C Braunisch
- Department of Nephrology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Julia Matschkal
- Department of Nephrology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Renate Hausinger
- Department of Nephrology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - David Stadler
- Department of Nephrology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Bernhard Haller
- Institute for AI and Informatics in Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Uwe Heemann
- Department of Nephrology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Konstantin Kotliar
- Department of Medical Engineering and Technomathematics, Aachen University of Applied Sciences, Jülich, Germany
| | - Henner Hanssen
- Division Sports and Exercise Medicine, Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Christoph Schmaderer
- Department of Nephrology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
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Angermann S, Günthner R, Hanssen H, Lorenz G, Braunisch MC, Steubl D, Matschkal J, Kemmner S, Hausinger R, Block Z, Haller B, Heemann U, Kotliar K, Grimmer T, Schmaderer C. Cognitive impairment and microvascular function in end-stage renal disease. Int J Methods Psychiatr Res 2022; 31:e1909. [PMID: 35290686 PMCID: PMC9159686 DOI: 10.1002/mpr.1909] [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: 10/13/2021] [Accepted: 03/01/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Hemodialysis patients show an approximately threefold higher prevalence of cognitive impairment compared to the age-matched general population. Impaired microcirculatory function is one of the assumed causes. Dynamic retinal vessel analysis is a quantitative method for measuring neurovascular coupling and microvascular endothelial function. We hypothesize that cognitive impairment is associated with altered microcirculation of retinal vessels. METHODS 152 chronic hemodialysis patients underwent cognitive testing using the Montreal Cognitive Assessment. Retinal microcirculation was assessed by Dynamic Retinal Vessel Analysis, which carries out an examination recording retinal vessels' reaction to a flicker light stimulus under standardized conditions. RESULTS In unadjusted as well as in adjusted linear regression analyses a significant association between the visuospatial executive function domain score of the Montreal Cognitive Assessment and the maximum arteriolar dilation as response of retinal arterioles to the flicker light stimulation was obtained. CONCLUSION This is the first study determining retinal microvascular function as surrogate for cerebral microvascular function and cognition in hemodialysis patients. The relationship between impairment in executive function and reduced arteriolar reaction to flicker light stimulation supports the involvement of cerebral small vessel disease as contributing factor for the development of cognitive impairment in this patient population and might be a target for noninvasive disease monitoring and therapeutic intervention.
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Affiliation(s)
- Susanne Angermann
- Department of NephrologyTechnical University of MunichSchool of Medicine, Klinikum rechts der IsarMunchenGermany
| | - Roman Günthner
- Department of NephrologyTechnical University of MunichSchool of Medicine, Klinikum rechts der IsarMunchenGermany
| | - Henner Hanssen
- Department of Sport, Exercise and HealthUniversity of BaselBaselSwitzerland
| | - Georg Lorenz
- Department of NephrologyTechnical University of MunichSchool of Medicine, Klinikum rechts der IsarMunchenGermany
| | - Matthias C. Braunisch
- Department of NephrologyTechnical University of MunichSchool of Medicine, Klinikum rechts der IsarMunchenGermany
| | - Dominik Steubl
- Department of NephrologyTechnical University of MunichSchool of Medicine, Klinikum rechts der IsarMunchenGermany
| | - Julia Matschkal
- Department of NephrologyTechnical University of MunichSchool of Medicine, Klinikum rechts der IsarMunchenGermany
| | - Stephan Kemmner
- Department of NephrologyTechnical University of MunichSchool of Medicine, Klinikum rechts der IsarMunchenGermany
- Transplant CenterUniversity Hospital MunichLudwig‐Maximilians‐University (LMU)MunichGermany
| | - Renate Hausinger
- Department of NephrologyTechnical University of MunichSchool of Medicine, Klinikum rechts der IsarMunchenGermany
| | - Zenonas Block
- Department of NephrologyTechnical University of MunichSchool of Medicine, Klinikum rechts der IsarMunchenGermany
| | - Bernhard Haller
- Institute of Medical Informatics, Statistics and EpidemiologyTechnical University of MunichSchool of Medicine, Klinikum rechts der IsarMunchenGermany
| | - Uwe Heemann
- Department of NephrologyTechnical University of MunichSchool of Medicine, Klinikum rechts der IsarMunchenGermany
| | - Konstantin Kotliar
- Department of Medical Engineering and TechnomathematicsFH Aachen University of Applied SciencesCampus JülichJülichGermany
| | - Timo Grimmer
- Department of Psychiatry and PsychotherapyKlinikum rechts der IsarTechnische Universität MünchenMunichGermany
| | - Christoph Schmaderer
- Department of NephrologyTechnical University of MunichSchool of Medicine, Klinikum rechts der IsarMunchenGermany
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6
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Braunisch MC, Gundel P, Werfel S, Mayer CC, Bauer A, Haller B, Günthner R, Lorenz G, Angermann S, Matschkal J, Schaller C, Holzmann-Littig C, Kemmner S, Mann J, Krieter A, Renders L, Wassertheurer S, Schmidt G, Heemann U, Malik M, Schmaderer C. Electrocardiographic parameters of left ventricular hypertrophy and prediction of mortality in hemodialysis patients. J Nephrol 2022; 35:233-244. [PMID: 34014512 PMCID: PMC8803820 DOI: 10.1007/s40620-021-01068-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/09/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND In hemodialysis patients, left ventricular hypertrophy (LVH) contributes to high cardiovascular mortality. We examined cardiovascular mortality prediction by the recently proposed Peguero-Lo Presti voltage since it identifies more patients with electrocardiographic (ECG) LVH than Cornell or Sokolow-Lyon voltages. METHODS A total of 308 patients on hemodialysis underwent 24 h ECG recordings. LVH parameters were measured before and after dialysis. The primary endpoint of cardiovascular mortality was recorded during a median 3-year follow up. Risk prediction was assessed by Cox regression, both unadjusted and adjusted for the Charlson Comorbidity Index and the Cardiovascular Mortality Risk Score. RESULTS The Peguero-Lo Presti voltage identified with 21% the most patients with positive LVH criteria. All voltages significantly increased during dialysis. Factors such as ultrafiltration rate, Kt/V, body mass index, sex, and phosphate were the most relevant for these changes. During follow-up, 26 cardiovascular deaths occurred. Post-dialysis Peguero-Lo Presti cut-off as well as the Peguero-Lo Presti and Cornell voltages were independently associated with cardiovascular mortality in unadjusted and adjusted analysis. The Sokolow-Lyon voltage was not significantly associated with mortality. An optimal cut-off for the prediction of cardiovascular mortality was estimated at 1.38 mV for the Peguero-Lo Presti. CONCLUSIONS The post-dialysis Peguero-Lo Presti cut-off as well as the Peguero-Lo Presti and Cornell voltages allowed independent risk prediction of cardiovascular mortality in hemodialysis patients. Measuring the ECG LVH parameters after dialysis might allow a standardized interpretation as dialysis-specific factors influence the voltages.
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Affiliation(s)
- Matthias C Braunisch
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Peter Gundel
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- Klinik für Innere Medizin 4, Schwerpunkt Nephrologie und Hypertensiologie, Klinikum Nürnberg, Nuremberg, Germany
| | - Stanislas Werfel
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christopher C Mayer
- Center for Health and Bioresources, Biomedical Systems, AIT Austrian Institute of Technology GmbH, Vienna, Austria
| | - Axel Bauer
- University Hospital for Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
- Department of Cardiology, Munich University Clinic, DZHK (German Centre for Cardiovascular Research), Ludwig-Maximilians University, Munich, Germany
| | - Bernhard Haller
- Institute of Medical Informatics, Statistics and Epidemiology (IMedIS), School of Medicine, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Roman Günthner
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Georg Lorenz
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Susanne Angermann
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Julia Matschkal
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Carolin Schaller
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christopher Holzmann-Littig
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- TUM Medical Education Center, School of Medicine, Technical University of Munich, Munich, Germany
| | - Stephan Kemmner
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- Transplant Center, University Hospital Munich, Ludwig-Maximillians University (LMU), Munich, Germany
| | - Johannes Mann
- Department of Nephrology, University of Erlangen-Nürnberg, Erlangen, Germany
- KfH Kidney Center Munich, Isoldenstraße 15, Munich, Germany
| | - Axel Krieter
- Nephrocare München-Ost, Rosenkavalierplatz 5, Munich, Germany
| | - Lutz Renders
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Siegfried Wassertheurer
- Center for Health and Bioresources, Biomedical Systems, AIT Austrian Institute of Technology GmbH, Vienna, Austria
| | - Georg Schmidt
- School of Medicine, Klinik für Innere Medizin I, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Uwe Heemann
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Marek Malik
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Christoph Schmaderer
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.
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7
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Braunisch MC, Mayer CC, Werfel S, Bauer A, Haller B, Lorenz G, Günthner R, Matschkal J, Bachmann Q, Thunich S, Schlegl M, Ludwig M, Holzmann-Littig C, Assali T, Pachmann M, Küchle C, Renders L, Wassertheurer S, Müller A, Schmidt G, Heemann U, Malik M, Schmaderer C. U-Shaped Association of the Heart Rate Variability Triangular Index and Mortality in Hemodialysis Patients With Atrial Fibrillation. Front Cardiovasc Med 2021; 8:751052. [PMID: 34912859 PMCID: PMC8667023 DOI: 10.3389/fcvm.2021.751052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 10/31/2021] [Indexed: 12/04/2022] Open
Abstract
Background: Atrial fibrillation (AF) is common in hemodialysis patients and contributes to increased mortality. We aimed to examine heart rate variability triangular index (HRVI) in hemodialysis patients with AF as it has recently been reported to predict mortality in AF patients without kidney disease. Methods: A total of 88 patients on hemodialysis with a medical history of AF or newly diagnosed AF underwent 24-h electrocardiography recordings. The primary endpoint of cardiovascular mortality was recorded during a median follow up of 3.0 years. Risk prediction was assessed by Cox regression, both unadjusted and adjusted for the Charlson Comorbidity Index and the Cardiovascular Mortality Risk Score. Results: Median age was 76 years, median dialysis vintage was 27 months. Altogether, 22 and 44 patients died due to cardiovascular and non-cardiovascular causes. In 55% of patients AF was present during the recording. Kaplan-Meier plots of HRVI quartiles suggested a non-linear association between HRVI, cardiovascular, and all-cause mortality which was confirmed in non-linear Cox regression analysis. Adjusted linear Cox regression revealed a hazard ratio of 6.2 (95% CI: 2.1-17.7, p = 0.001) and 2.2 (95% CI: 1.3-3.8, p = 0.002) for the outer quartiles (combined first and fourth quartile) for cardiovascular and all-cause mortality, respectively. Patients in the first quartile were more likely to have sinus rhythm whereas patients in the fourth quartile were more likely to have AF. Conclusions: We found a U-shaped association between HRVI and mortality in hemodialysis AF patients. The results might contribute to risk stratification independent of known risk scores in hemodialysis AF patients.
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Affiliation(s)
- Matthias C. Braunisch
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christopher C. Mayer
- Center for Health and Bioresources, Biomedical Systems, AIT Austrian Institute of Technology GmbH, Vienna, Austria
| | - Stanislas Werfel
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Axel Bauer
- University Hospital for Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
- Department of Cardiology, Munich University Clinic, DZHK (German Centre for Cardiovascular Research), Ludwig-Maximilians University, Munich, Germany
| | - Bernhard Haller
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- School of Medicine, Klinikum Rechts der Isar, Institute of Medical Informatics, Statistics and Epidemiology (IMedIS), Technical University of Munich, Munich, Germany
| | - Georg Lorenz
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Roman Günthner
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Julia Matschkal
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Quirin Bachmann
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Stephan Thunich
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- School of Medicine, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Michaela Schlegl
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Maximilian Ludwig
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christopher Holzmann-Littig
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Tarek Assali
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | | | - Claudius Küchle
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Lutz Renders
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Siegfried Wassertheurer
- Center for Health and Bioresources, Biomedical Systems, AIT Austrian Institute of Technology GmbH, Vienna, Austria
| | - Alexander Müller
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- School of Medicine, Klinik für Innere Medizin I, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Georg Schmidt
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- School of Medicine, Klinik für Innere Medizin I, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Uwe Heemann
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Marek Malik
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Christoph Schmaderer
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
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8
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Werfel S, Lorenz G, Haller B, Günthner R, Matschkal J, Braunisch MC, Schaller C, Gundel P, Kemmner S, Hayek SS, Nusshag C, Reiser J, Moog P, Heemann U, Schmaderer C. Application of regularized regression to identify novel predictors of mortality in a cohort of hemodialysis patients. Sci Rep 2021; 11:9287. [PMID: 33927289 PMCID: PMC8085040 DOI: 10.1038/s41598-021-88655-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 04/09/2021] [Indexed: 02/02/2023] Open
Abstract
Cohort studies often provide a large array of data on study participants. The techniques of statistical learning can allow an efficient way to analyze large datasets in order to uncover previously unknown, clinically relevant predictors of morbidity or mortality. We applied a combination of elastic net penalized Cox regression and stability selection with the aim of identifying novel predictors of mortality in a cohort of prevalent hemodialysis patients. In our analysis we included 475 patients from the "rISk strAtification in end-stage Renal disease" (ISAR) study, who we split into derivation and confirmation cohorts. A wide array of examinations was available for study participants, resulting in over a hundred potential predictors. In the selection approach many of the well established predictors were retrieved in the derivation cohort. Additionally, the serum levels of IL-12p70 and AST were selected as mortality predictors and confirmed in the withheld subgroup. High IL-12p70 levels were specifically prognostic of infection-related mortality. In summary, we demonstrate an approach how statistical learning can be applied to a cohort study to derive novel hypotheses in a data-driven way. Our results suggest a novel role of IL-12p70 in infection-related mortality, while AST is a promising additional biomarker in patients undergoing hemodialysis.
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Affiliation(s)
- Stanislas Werfel
- grid.6936.a0000000123222966Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Georg Lorenz
- grid.6936.a0000000123222966Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Bernhard Haller
- grid.6936.a0000000123222966Institute of Medical Informatics, Statistics and Epidemiology, Technical University Munich, Munich, Germany
| | - Roman Günthner
- grid.6936.a0000000123222966Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Julia Matschkal
- grid.6936.a0000000123222966Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Matthias C. Braunisch
- grid.6936.a0000000123222966Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Carolin Schaller
- grid.6936.a0000000123222966Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Peter Gundel
- grid.6936.a0000000123222966Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Stephan Kemmner
- grid.6936.a0000000123222966Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany ,grid.5252.00000 0004 1936 973XTransplant Center, University Hospital Munich, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Salim S. Hayek
- grid.214458.e0000000086837370Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, MI USA
| | - Christian Nusshag
- grid.240684.c0000 0001 0705 3621Department of Medicine, Rush University Medical Center, Chicago, IL USA ,grid.5253.10000 0001 0328 4908Departement of Nephrology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jochen Reiser
- grid.240684.c0000 0001 0705 3621Department of Medicine, Rush University Medical Center, Chicago, IL USA
| | - Philipp Moog
- grid.6936.a0000000123222966Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Uwe Heemann
- grid.6936.a0000000123222966Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Christoph Schmaderer
- grid.6936.a0000000123222966Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
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9
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Werfel S, Günthner R, Hapfelmeier A, Hanssen H, Kotliar K, Heemann U, Schmaderer C. Identification of cardiovascular high risk groups from dynamic retinal vessel signals using untargeted machine learning. Cardiovasc Res 2021; 118:612-621. [PMID: 33576412 DOI: 10.1093/cvr/cvab040] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 02/09/2021] [Indexed: 12/11/2022] Open
Abstract
AIMS Dynamic retinal vessel analysis (DVA) provides a noninvasive way to asses microvascular function in patients and potentially to improve predictions of individual cardiovascular (CV) risk. The aim of our study was to use untargeted machine learning on DVA in order to improve CV mortality prediction and to identify corresponding response alterations. METHODS AND RESULTS We adopted a workflow consisting of noise reduction and extraction of independent components within DVA signals. Predictor performance was assessed in survival random forest models. Applying our technique to the prediction of all-cause mortality in a cohort of 214 hemodialysis patients resulted in the selection of a component which was highly correlated to maximal venous dilation following flicker stimulation (vMax), a previously identified predictor, confirming the validity of our approach. When fitting for CV mortality as the outcome of interest, a combination of three components derived from the arterial signal resulted in a marked improvement in predictive performance. Clustering analysis suggested that these independent components identified groups of patients with substantially higher CV mortality. CONCLUSIONS Our results provide a machine learning workflow to improve the predictive performance of DVA and identify groups of hemodialysis patients at high risk of CV mortality. Our approach may also prove to be promising for DVA signal analysis in other CV disease states. TRANSLATIONAL PERSPECTIVE DVA is a noninvasive technique which can help to assess microvascular dysfunction, one of the driving factors of CV disease. This study demonstrates a machine learning method which improves DVA interpretation for the estimation of CV risk in hemodialysis patients. Similar techniques can help doctors to identify high risk patients for timely therapeutic interventions and to monitor the effects of these interventions.
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Affiliation(s)
- Stanislas Werfel
- Department of Nephrology, Klinikum Rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675 Munich, Germany
| | - Roman Günthner
- Department of Nephrology, Klinikum Rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675 Munich, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Informatics, Statistics and Epidemiology, School of Medicine, Technical University Munich, Munich, Germany
- Institute of General Practice and Health Services Research, School of Medicine, Technical University Munich, Munich, Germany
| | - Henner Hanssen
- Division of Sports Medicine, Institute of Exercise and Health Sciences (ISSW), University of Basel, Basel, Switzerland
| | - Konstantin Kotliar
- Department of Biomedical Engineering and Technomathematics, Aachen University of Applied Sciences, Juelich, Germany
| | - Uwe Heemann
- Department of Nephrology, Klinikum Rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675 Munich, Germany
| | - Christoph Schmaderer
- Department of Nephrology, Klinikum Rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675 Munich, Germany
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10
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Schüttler D, Schönermarck U, Wenner F, Toepfer M, Rizas KD, Bauer A, Brunner S, Hamm W. Large potassium shifts during dialysis enhance cardiac repolarization instability. J Nephrol 2020; 34:1301-1305. [PMID: 33058038 PMCID: PMC8357640 DOI: 10.1007/s40620-020-00880-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 09/27/2020] [Indexed: 12/01/2022]
Abstract
Background Patients with end-stage kidney disease are at high risk for the development of arrhythmias and sudden cardiac death (SCD). This has been especially attributed to large potassium shifts during hemodialysis (HD), and malignant arrhythmias are closely linked to dysfunction of the autonomic nervous system. Nevertheless, there is still a lack of methods for risk stratification in these patients. Methods In the present pilot study we investigated changes of the novel ECG-based biomarker periodic repolarization dynamics (PRD) mirroring the effect of efferent sympathetic nervous activity on the ventricular myocardium in 18 patients undergoing routine hemodialysis. High-resolution ECGs were recorded throughout the dialysis and PRD values were calculated out of 30 min intervals at the start and the end of dialysis. Results We detected a clear correlation between the intradialytic potassium shift and the increase in PRD levels (Spearman correlation coefficient R = 0.62, p = 0.006). Patients with a potassium shift > 1 mmol/l showed significantly increased levels of PRD at the end of dialysis when compared to patients with potassium shifts ≤ 1.0 mmol/l [delta PRD 2.82 (IQR 2.13) vs. − 2.08 (IQR 3.60), p = 0.006]. Spearman analysis showed no significant correlation between PRD changes and fluid removal (R = − 0.23, p = 0.36). Conclusions We provide evidence that large potassium shifts during HD enhance sympathetic activity-associated repolarization instability. This could facilitate the occurrence of malignant arrhythmias, and PRD measurements might serve as a non-invasive monitoring tool in HD patients in future.
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Affiliation(s)
- Dominik Schüttler
- Medizinische Klinik Und Poliklinik I, Campus Grosshadern and Innenstadt, University Hospital Munich, Ludwig-Maximilians University Munich (LMU), Marchioninistraße 15, 81377, Munich, Germany. .,DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance (MHA), Partner Site Munich, Munich, Germany. .,Walter Brendel Centre of Experimental Medicine, Ludwig-Maximilians University Munich (LMU), Munich, Germany.
| | - Ulf Schönermarck
- Nephrology Division, Medizinische Klinik Und Poliklinik IV, Klinikum der Universität München - Campus Großhadern, Munich, Germany
| | - Felix Wenner
- Medizinische Klinik Und Poliklinik I, Campus Grosshadern and Innenstadt, University Hospital Munich, Ludwig-Maximilians University Munich (LMU), Marchioninistraße 15, 81377, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance (MHA), Partner Site Munich, Munich, Germany
| | | | - Konstantinos D Rizas
- Medizinische Klinik Und Poliklinik I, Campus Grosshadern and Innenstadt, University Hospital Munich, Ludwig-Maximilians University Munich (LMU), Marchioninistraße 15, 81377, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance (MHA), Partner Site Munich, Munich, Germany
| | - Axel Bauer
- DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance (MHA), Partner Site Munich, Munich, Germany.,University Hospital for Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Stefan Brunner
- Medizinische Klinik Und Poliklinik I, Campus Grosshadern and Innenstadt, University Hospital Munich, Ludwig-Maximilians University Munich (LMU), Marchioninistraße 15, 81377, Munich, Germany
| | - Wolfgang Hamm
- Medizinische Klinik Und Poliklinik I, Campus Grosshadern and Innenstadt, University Hospital Munich, Ludwig-Maximilians University Munich (LMU), Marchioninistraße 15, 81377, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance (MHA), Partner Site Munich, Munich, Germany
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11
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Mayer CC, Schmaderer C, Loutradis C, Matschkal J, Theodorakopoulou M, Lorenz G, Karpetas A, Angermann S, Bikos A, Braunisch MC, Raptis V, Baumann M, Papagianni A, Heemann U, Wassertheurer S, Sarafidis PA. Heart Failure and Atrial Fibrillation Modify the Associations of Nocturnal Blood Pressure Dipping Pattern With Mortality in Hemodialysis Patients. Hypertension 2020; 76:1231-1239. [PMID: 32862707 DOI: 10.1161/hypertensionaha.120.15420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Heart failure (HF), hypertension, and abnormal nocturnal blood pressure dipping are highly prevalent in hemodialysis patients. Atrial fibrillation (AF) and HF might be important mediators for the association of abnormal dipping patterns with worse prognosis. Thus, the aim of this study is to investigate the association of dipping with mortality in hemodialysis patients and to assess the influence of AF and HF. In total, 525 hemodialysis patients underwent 24-hour ambulatory blood pressure monitoring. All-cause and cardiovascular mortality served as end points. Patients were categorized according to their systolic dipping pattern (dipper, nondipper, and reverse dipper). Cox regression analysis was performed to determine the association between dipping pattern and study end points with dipping as reference. Subgroup analysis was performed for patients with and without AF or HF. In total, 185 patients with AF or HF and 340 patients without AF or HF were included. During a median follow-up of 37.8 months, 177 patients died; 81 from cardiovascular causes. Nondipping and reverse dipping were significantly associated with all-cause mortality in the whole cohort (nondipper: hazard ratio, 1.95 [1.22-3.14]; P=0.006; reverse dipper: hazard ratio, 2.31 [1.42-3.76]; P<0.001) and in patients without AF or HF (nondipper: hazard ratio, 2.78 [1.16-6.66]; P=0.02; reverse dipper: hazard ratio, 4.48 [1.87-10.71]; P<0.001) but not in patients with AF or HF. For cardiovascular mortality, associations were again significant in patients without AF or HF and in the whole cohort. The observed associations remained significant after adjustment for possible confounders. This study provides well-powered evidence for the association between abnormal dipping patterns and mortality in hemodialysis patients and suggests that HF or AF modifies this association.
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Affiliation(s)
- Christopher C Mayer
- From the AIT Austrian Institute of Technology GmbH, Center for Health and Bioresources, Biomedical Systems, Vienna, Austria (C.C.M., S.W.).,Vienna University of Technology, Institute for Analysis and Scientific Computing, Vienna, Austria (C.C.M., S.W.)
| | - Christoph Schmaderer
- Department of Nephrology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany (C.S., J.M., G.L., S.A., M.C.B., M.B., U.H.)
| | - Charalampos Loutradis
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece (C.L., M.T., A.B., A.P., P.A.S.)
| | - Julia Matschkal
- Department of Nephrology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany (C.S., J.M., G.L., S.A., M.C.B., M.B., U.H.)
| | - Marrieta Theodorakopoulou
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece (C.L., M.T., A.B., A.P., P.A.S.)
| | - Georg Lorenz
- Department of Nephrology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany (C.S., J.M., G.L., S.A., M.C.B., M.B., U.H.)
| | | | - Susanne Angermann
- Department of Nephrology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany (C.S., J.M., G.L., S.A., M.C.B., M.B., U.H.)
| | - Athanasios Bikos
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece (C.L., M.T., A.B., A.P., P.A.S.).,Protypo Hemodialysis Unit, Thessaloniki, Greece (A.B.)
| | - Matthias C Braunisch
- Department of Nephrology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany (C.S., J.M., G.L., S.A., M.C.B., M.B., U.H.)
| | - Vasilios Raptis
- From the AIT Austrian Institute of Technology GmbH, Center for Health and Bioresources, Biomedical Systems, Vienna, Austria (C.C.M., S.W.)
| | - Marcus Baumann
- Department of Nephrology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany (C.S., J.M., G.L., S.A., M.C.B., M.B., U.H.)
| | - Aikaterini Papagianni
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece (C.L., M.T., A.B., A.P., P.A.S.)
| | - Uwe Heemann
- Department of Nephrology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany (C.S., J.M., G.L., S.A., M.C.B., M.B., U.H.)
| | - Siegfried Wassertheurer
- From the AIT Austrian Institute of Technology GmbH, Center for Health and Bioresources, Biomedical Systems, Vienna, Austria (C.C.M., S.W.).,Vienna University of Technology, Institute for Analysis and Scientific Computing, Vienna, Austria (C.C.M., S.W.)
| | - Pantelis A Sarafidis
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece (C.L., M.T., A.B., A.P., P.A.S.)
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12
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Braunisch MC, Mayer CC, Bauer A, Lorenz G, Haller B, Rizas KD, Hagmair S, von Stülpnagel L, Hamm W, Günthner R, Angermann S, Matschkal J, Kemmner S, Hasenau AL, Zöllinger I, Steubl D, Mann JF, Lehnert T, Scherf J, Braun JR, Moog P, Küchle C, Renders L, Malik M, Schmidt G, Wassertheurer S, Heemann U, Schmaderer C. Cardiovascular Mortality Can Be Predicted by Heart Rate Turbulence in Hemodialysis Patients. Front Physiol 2020; 11:77. [PMID: 32116784 PMCID: PMC7027389 DOI: 10.3389/fphys.2020.00077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 01/23/2020] [Indexed: 12/12/2022] Open
Abstract
Background Excess mortality in hemodialysis patients is mostly of cardiovascular origin. We examined the association of heart rate turbulence (HRT), a marker of baroreflex sensitivity, with cardiovascular mortality in hemodialysis patients. Methods A population of 290 prevalent hemodialysis patients was followed up for a median of 3 years. HRT categories 0 (both turbulence onset [TO] and slope [TS] normal), 1 (TO or TS abnormal), and 2 (both TO and TS abnormal) were obtained from 24 h Holter recordings. The primary end-point was cardiovascular mortality. Associations of HRT categories with the endpoints were analyzed by multivariable Cox regression models including HRT, age, albumin, and the improved Charlson Comorbidity Index for hemodialysis patients. Multivariable linear regression analysis identified factors associated with TO and TS. Results During the follow-up period, 20 patients died from cardiovascular causes. In patients with HRT categories 0, 1 and 2, cardiovascular mortality was 1, 10, and 22%, respectively. HRT category 2 showed the strongest independent association with cardiovascular mortality with a hazard ratio of 19.3 (95% confidence interval: 3.69-92.03; P < 0.001). Age, calcium phosphate product, and smoking status were associated with TO and TS. Diabetes mellitus and diastolic blood pressure were only associated with TS. Conclusion Independent of known risk factors, HRT assessment allows identification of hemodialysis patients with low, intermediate, and high risk of cardiovascular mortality. Future prospective studies are needed to translate risk prediction into risk reduction in hemodialysis patients.
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Affiliation(s)
- Matthias C Braunisch
- Abteilung für Nephrologie, Klinikum Rechts der Isar, Fakultät für Medizin, Technische Universität München, Munich, Germany
| | - Christopher C Mayer
- Center for Health & Bioresources, Biomedical Systems, AIT Austrian Institute of Technology GmbH, Vienna, Austria
| | - Axel Bauer
- Department of Cardiology, Munich University Clinic, German Centre for Cardiovascular Research, Ludwig Maximilian University of Munich, Munich, Germany.,University Hospital for Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Georg Lorenz
- Abteilung für Nephrologie, Klinikum Rechts der Isar, Fakultät für Medizin, Technische Universität München, Munich, Germany
| | - Bernhard Haller
- Institut für Medizinische Informatik, Statistik und Epidemiologie, Klinikum Rechts der Isar, Fakultät für Medizin, Technische Universität München, Munich, Germany
| | - Konstantinos D Rizas
- Department of Cardiology, Munich University Clinic, German Centre for Cardiovascular Research, Ludwig Maximilian University of Munich, Munich, Germany
| | - Stefan Hagmair
- Center for Health & Bioresources, Biomedical Systems, AIT Austrian Institute of Technology GmbH, Vienna, Austria
| | - Lukas von Stülpnagel
- Department of Cardiology, Munich University Clinic, German Centre for Cardiovascular Research, Ludwig Maximilian University of Munich, Munich, Germany.,University Hospital for Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Wolfgang Hamm
- Department of Cardiology, Munich University Clinic, German Centre for Cardiovascular Research, Ludwig Maximilian University of Munich, Munich, Germany
| | - Roman Günthner
- Abteilung für Nephrologie, Klinikum Rechts der Isar, Fakultät für Medizin, Technische Universität München, Munich, Germany
| | - Susanne Angermann
- Abteilung für Nephrologie, Klinikum Rechts der Isar, Fakultät für Medizin, Technische Universität München, Munich, Germany
| | - Julia Matschkal
- Abteilung für Nephrologie, Klinikum Rechts der Isar, Fakultät für Medizin, Technische Universität München, Munich, Germany
| | - Stephan Kemmner
- Abteilung für Nephrologie, Klinikum Rechts der Isar, Fakultät für Medizin, Technische Universität München, Munich, Germany
| | - Anna-Lena Hasenau
- Abteilung für Nephrologie, Klinikum Rechts der Isar, Fakultät für Medizin, Technische Universität München, Munich, Germany
| | - Isabel Zöllinger
- Abteilung für Nephrologie, Klinikum Rechts der Isar, Fakultät für Medizin, Technische Universität München, Munich, Germany
| | - Dominik Steubl
- Abteilung für Nephrologie, Klinikum Rechts der Isar, Fakultät für Medizin, Technische Universität München, Munich, Germany
| | - Johannes F Mann
- Department of Nephrology, University of Erlangen-Nuremberg, Erlangen, Germany.,KfH Kidney Center, Munich, Germany
| | | | | | | | - Philipp Moog
- Abteilung für Nephrologie, Klinikum Rechts der Isar, Fakultät für Medizin, Technische Universität München, Munich, Germany
| | - Claudius Küchle
- Abteilung für Nephrologie, Klinikum Rechts der Isar, Fakultät für Medizin, Technische Universität München, Munich, Germany
| | - Lutz Renders
- Abteilung für Nephrologie, Klinikum Rechts der Isar, Fakultät für Medizin, Technische Universität München, Munich, Germany
| | - Marek Malik
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Georg Schmidt
- Klinik für Innere Medizin I, Klinikum Rechts der Isar, Fakultät für Medizin, Technische Universität München, Munich, Germany
| | - Siegfried Wassertheurer
- Center for Health & Bioresources, Biomedical Systems, AIT Austrian Institute of Technology GmbH, Vienna, Austria
| | - Uwe Heemann
- Abteilung für Nephrologie, Klinikum Rechts der Isar, Fakultät für Medizin, Technische Universität München, Munich, Germany
| | - Christoph Schmaderer
- Abteilung für Nephrologie, Klinikum Rechts der Isar, Fakultät für Medizin, Technische Universität München, Munich, Germany
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13
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Angermann S, Schier J, Baumann M, Steubl D, Hauser C, Lorenz G, Günthner R, Braunisch MC, Kemmner S, Satanovskij R, Haller B, Heemann U, Lehnert T, Bieber R, Pachmann M, Braun J, Scherf J, Schätzle G, Fischereder M, Grimmer T, Schmaderer C. Cognitive Impairment is Associated with Mortality in Hemodialysis Patients. J Alzheimers Dis 2019; 66:1529-1537. [PMID: 30412499 DOI: 10.3233/jad-180767] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND The prevalence of cognitive impairment in hemodialysis patients is notably high. In previous studises performed in the general population, cognitive impairment has been associated with increased mortality. OBJECTIVE We evaluated the relationship between global cognitive function tested by a short screening instrument and mortality in hemodialysis patients. METHODS Cognitive testing was performed in 242 maintenance hemodialysis patients under standardized conditions at baseline using the Montreal Cognitive Assessment (MoCA).Cognitive impairment was defined as a MoCA test score ≤24 points, as published previously. All-cause mortality was monitored during a median follow-up of 3.54 years. Kaplan-Meier plot and Cox regression model adjusted for known risk factors for mortality in hemodialysis patients were used to examine a possible association between global cognitive function and all-cause mortality. RESULTS A MoCA test score ≤24 points resulted in a significant almost 3-fold higher hazard for all-cause mortality (unadjusted hazard ratio [HR]: 2.812; 95% confidence interval [95% CI]: 1.683-4.698; p < 0.001). After adjustment, this association was attenuated but remained significant (adjusted HR: 1.749; 95% CI: 1.007-3.038; p = 0.047). CONCLUSION Impairment of global cognitive function measured by a short screening instrument was identified for the first time as an independent predictor of all-cause mortality in hemodialysis patients. Thus, implementing the MoCA test in clinical routine could contribute to a better risk stratification of this patient population.
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Affiliation(s)
- Susanne Angermann
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Johannes Schier
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Marcus Baumann
- Department of Nephrology, Klinikum Ansbach, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen-Nuremberg, Germany
| | - Dominik Steubl
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Christine Hauser
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Georg Lorenz
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Roman Günthner
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Matthias C Braunisch
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Stephan Kemmner
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Robin Satanovskij
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Bernhard Haller
- Institute for Medical Statistics and Epidemiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | | | | | | | | | - Julia Scherf
- KfH-Nierenzentrum München-Giesing, Munich, Germany
| | | | - Michael Fischereder
- Department of Nephrology, Klinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany
| | - Timo Grimmer
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Christoph Schmaderer
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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14
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Günthner R, Hanssen H, Hauser C, Angermann S, Lorenz G, Kemmner S, Matschkal J, Braunisch MC, Kuechle C, Renders L, Moog P, Wassertheurer S, Baumann M, Hammes HP, Mayer CC, Haller B, Stryeck S, Madl T, Carbajo-Lozoya J, Heemann U, Kotliar K, Schmaderer C. Impaired Retinal Vessel Dilation Predicts Mortality in End-Stage Renal Disease. Circ Res 2019; 124:1796-1807. [PMID: 30929571 DOI: 10.1161/circresaha.118.314318] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
RATIONALE Patients with end-stage renal disease (ESRD) are characterized by increased cardiovascular (CV) and all-cause mortality due to advanced remodeling of the macro- and microvascular beds. OBJECTIVE The aim of this study was to determine whether retinal microvascular function can predict all-cause and CV mortality in patients with ESRD. METHODS AND RESULTS In the multicenter prospective observational ISAR (Risk Stratification in End-Stage Renal Disease) study, data on dynamic retinal vessel analysis (DVA) was available in a sub-cohort of 214 dialysis patients (mean age 62.6{plus minus}15.0; 32% female). Microvascular dysfunction was quantified by measuring maximum arteriolar (aMax) and venular dilation (vMax) of retinal vessels in response to flicker light stimulation. During a mean follow-up of 44 months, 55 patients died, including 25 CV and 30 non-CV fatal events. vMax emerged as a strong independent predictor for all-cause mortality. In the Kaplan-Meier analysis, individuals within the lowest tertile of vMax showed significantly shorter three-year survival rates than those within the highest tertile (66.9{plus minus}5.8% vs 92.4{plus minus}3.3%). Uni- and multivariate hazard ratios for all-cause mortality per SD increase of vMax were 0.62 [0.47;0.82] and 0.65[0.47;0.91], respectively. aMax and vMax were able to significantly predict nonfatal and fatal CV events (HR 0.74[0.57;0.97] and 0.78[0.61;0.99], respectively). CONCLUSIONS Our results provide the first evidence that impaired retinal venular dilation is a strong and independent predictor of all-cause mortality in hemodialyzed ESRD patients. DVA provides added value for prediction of all-cause mortality and may be a novel diagnostic tool to optimize CV risk stratification in ESRD and other high-risk CV cohorts. CLINICAL TRIAL REGISTRATION NCT01152892.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Christopher C Mayer
- Center for Health and Bioresources, Biomedical Systems, AIT Austrian Institute of Technology GmbH, AUSTRIA
| | - Bernhard Haller
- Institute for Medical Statistics and Epidemiology, Technical University of Munich
| | - Sarah Stryeck
- Gottfried Schatz Research Center for Cell Signaling, Metabolism and Aging, Medical University of Graz
| | - Tobias Madl
- Gottfried Schatz Research Center for Cell Signaling, Metabolism and Aging, Medical University of Graz
| | | | | | - Konstantin Kotliar
- Medical Engineering and Technomathematics, FH Aachen University of Applied Sciences
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15
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Mayer CC, Matschkal J, Sarafidis PA, Hagmair S, Lorenz G, Angermann S, Braunisch MC, Baumann M, Heemann U, Wassertheurer S, Schmaderer C. Association of Ambulatory Blood Pressure with All-Cause and Cardiovascular Mortality in Hemodialysis Patients: Effects of Heart Failure and Atrial Fibrillation. J Am Soc Nephrol 2018; 29:2409-2417. [PMID: 30045925 DOI: 10.1681/asn.2018010086] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 07/03/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Evidence on the utility of ambulatory BP monitoring for risk prediction has been scarce and inconclusive in patients on hemodialysis. In addition, in cardiac diseases such as heart failure and atrial fibrillation (common among patients on hemodialysis), studies have found that parameters such as systolic BP (SBP) and pulse pressure (PP) have inverse or nonlinear (U-shaped) associations with mortality. METHODS In total, 344 patients on hemodialysis (105 with atrial fibrillation, heart failure, or both) underwent ambulatory BP monitoring for 24 hours, starting before a dialysis session. The primary end point was all-cause mortality; the prespecified secondary end point was cardiovascular mortality. We performed linear and nonlinear Cox regression analyses for risk prediction to determine the associations between BP and study end points. RESULTS During the mean 37.6-month follow-up, 115 patients died (47 from a cardiovascular cause). SBP and PP showed a U-shaped association with all-cause and cardiovascular mortality in the cohort. In linear subgroup analysis, SBP and PP were independent risk predictors and showed a significant inverse relationship to all-cause and cardiovascular mortality in patients with atrial fibrillation or heart failure. In patients without these conditions, these associations were in the opposite direction. SBP and PP were significant independent risk predictors for cardiovascular mortality; PP was a significant independent risk predictor for all-cause mortality. CONCLUSIONS This study provides evidence for the U-shaped association between peripheral ambulatory SBP or PP and mortality in patients on hemodialysis. Furthermore, it suggests that underlying cardiac disease can explain the opposite direction of associations.
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Affiliation(s)
- Christopher C Mayer
- Center for Health and Bioresources, Biomedical Systems, AIT Austrian Institute of Technology GmbH, Vienna, Austria; .,Institute for Analysis and Scientific Computing, Vienna University of Technology, Vienna, Austria
| | - Julia Matschkal
- Department of Nephrology, Technical University of Munich, Klinkum rechts der Isar, Munich, Germany
| | - Pantelis A Sarafidis
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece; and
| | - Stefan Hagmair
- Center for Health and Bioresources, Biomedical Systems, AIT Austrian Institute of Technology GmbH, Vienna, Austria.,Institute for Analysis and Scientific Computing, Vienna University of Technology, Vienna, Austria
| | - Georg Lorenz
- Department of Nephrology, Technical University of Munich, Klinkum rechts der Isar, Munich, Germany
| | - Susanne Angermann
- Department of Nephrology, Technical University of Munich, Klinkum rechts der Isar, Munich, Germany
| | - Matthias C Braunisch
- Department of Nephrology, Technical University of Munich, Klinkum rechts der Isar, Munich, Germany
| | - Marcus Baumann
- Internistische Fachklinik Dr. Steger, Nuremberg, Germany
| | - Uwe Heemann
- Department of Nephrology, Technical University of Munich, Klinkum rechts der Isar, Munich, Germany
| | - Siegfried Wassertheurer
- Center for Health and Bioresources, Biomedical Systems, AIT Austrian Institute of Technology GmbH, Vienna, Austria.,Institute for Analysis and Scientific Computing, Vienna University of Technology, Vienna, Austria
| | - Christoph Schmaderer
- Department of Nephrology, Technical University of Munich, Klinkum rechts der Isar, Munich, Germany;
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16
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Lorenz G, Steubl D, Kemmner S, Pasch A, Koch-Sembdner W, Pham D, Haller B, Bachmann Q, Mayer CC, Wassertheurer S, Angermann S, Lech M, Moog P, Bauer A, Heemann U, Schmaderer C. Worsening calcification propensity precedes all-cause and cardiovascular mortality in haemodialyzed patients. Sci Rep 2017; 7:13368. [PMID: 29042624 PMCID: PMC5645333 DOI: 10.1038/s41598-017-12859-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 09/14/2017] [Indexed: 12/17/2022] Open
Abstract
A novel in-vitro test (T50-test) assesses ex-vivo serum calcification propensity which predicts mortality in HD patients. The association of longitudinal changes of T50 with all-cause and cardiovascular mortality has not been investigated. We assessed T50 in paired sera collected at baseline and at 24 months in 188 prevalent European HD patients from the ISAR cohort, most of whom were Caucasians. Patients were followed for another 19 [interquartile range: 11–37] months. Serum T50 exhibited a significant decline between baseline and 24 months (246 ± 64 to 190 ± 68 minutes; p < 0.001). With serum Δ-phosphate showing the strongest independent association with declining T50 (r = −0.39; p < 0.001) in multivariable linear regression. The rate of decline of T50 over 24 months was a significant predictor of all-cause (HR = 1.51 per 1SD decline, 95% CI: 1.04 to 2.2; p = 0.03) and cardiovascular mortality (HR = 2.15; 95% CI: 1.15 to 3.97; p = 0.02) in Kaplan Meier and multivariable Cox-regression analysis, while cross-sectional T50 at inclusion and 24 months were not. Worsening serum calcification propensity was an independent predictor of mortality in this small cohort of prevalent HD patients. Prospective larger scaled studies are needed to assess the value of calcification propensity as a longitudinal parameter for risk stratification and monitoring of therapeutic interventions.
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Affiliation(s)
- Georg Lorenz
- Department of nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.
| | - Dominik Steubl
- Department of nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Stephan Kemmner
- Department of nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | | | - Wilhelm Koch-Sembdner
- Department of nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Dang Pham
- Department of nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Bernhard Haller
- Institute of Medical Statistics and Epidemiology, Technical University Munich, Munich, Germany
| | - Quirin Bachmann
- Department of nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Christopher C Mayer
- AIT Austrian Institute of Technology, Center for Health & Bioresources, Biomedical Systems, Vienna, Austria
| | - Siegfried Wassertheurer
- AIT Austrian Institute of Technology, Center for Health & Bioresources, Biomedical Systems, Vienna, Austria
| | - Susanne Angermann
- Department of nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Maciej Lech
- Department of nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Philipp Moog
- Department of nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Axel Bauer
- Department of cardiology Ludwig-Maximilian University, Munich, Germany
| | - Uwe Heemann
- Department of nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Christoph Schmaderer
- Department of nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.
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17
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Angermann S, Baumann M, Steubl D, Lorenz G, Hauser C, Suttmann Y, Reichelt AL, Satanovskij R, Sonntag F, Heemann U, Grimmer T, Schmaderer C. Cognitive impairment in hemodialysis patients: Implementation of cut-off values for the Montreal Cognitive Assessment (MoCA)-test for feasible screening. PLoS One 2017; 12:e0184589. [PMID: 29016605 PMCID: PMC5634551 DOI: 10.1371/journal.pone.0184589] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 08/26/2017] [Indexed: 11/18/2022] Open
Abstract
Objective Reliable identification of cognitive impairment in hemodialysis patients is of utmost importance, as it is associated with poor outcomes including dialysis withdrawal and death. High prevalence of cognitive impairment has been demonstrated in several studies using brief screening instruments or neuropsychological test batteries. However, the relevance of cognitive impairment as well as the accuracy of screening procedures have never been studied in this patient population. Methods 151 chronic hemodialysis patients (mean age 65.78 ± 14.88 years, 73,5% male) underwent cognitive testing under standardized conditions by the Montreal Cognitive Assessment (MoCA) and, in a second step, the Clinical Dementia Rating scale (CDR), an international standard to measure the severity of dementia. For calculating MoCA cut-off values on the basis of the CDR global score, receiver operator characteristics (ROC) analysis and c-statistic were applied. Results 49.0% of patients were categorized as 0.5 in the CDR global with memory being the predominantly affected domain (47.7% of patients scored ≥ 0.5). Youden’s Index led to a threshold of 23.5 points for the MoCA test for optimal differentiation between cognitively normal (CDR global < 0.5) and impaired patients (CDR global ≥ 0.5) based on a sensitivity of approximately 99% and a specificity of approximately 74%. Conclusion Interference of cognitive impairment with patients’ independence and daily life was shown using the CDR for the first time in hemodialysis patients. A MoCA score of 23.5 points turned out as optimal threshold to differentiate between patients with and without functional impairment in the CDR, thereby paving the way for implementation of the MoCA test as a quick and thus highly feasible screening instrument for periodic testing in clinical routine.
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Affiliation(s)
- Susanne Angermann
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Bavaria, Germany
| | - Marcus Baumann
- Department of Nephrology, Klinikum Ansbach, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen-Nuremberg, Bavaria, Germany
| | - Dominik Steubl
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Bavaria, Germany
| | - Georg Lorenz
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Bavaria, Germany
| | - Christine Hauser
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Bavaria, Germany
| | - Yana Suttmann
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Bavaria, Germany
| | - Anna-Lena Reichelt
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Bavaria, Germany
| | - Robin Satanovskij
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Bavaria, Germany
| | - Franziska Sonntag
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Bavaria, Germany
| | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Bavaria, Germany
| | - Timo Grimmer
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Technische Universität München, Munich, Bavaria, Germany
| | - Christoph Schmaderer
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Bavaria, Germany
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18
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Lorenz G, Schmalenberg M, Kemmner S, Haller B, Steubl D, Pham D, Schreiegg A, Bachmann Q, Schmidt A, Haderer S, Huber M, Angermann S, Günthner R, Braunisch M, Hauser C, Reichelt AL, Matschkal J, Suttmann Y, Moog P, Stock K, Küchle C, Thürmel K, Renders L, Bauer A, Baumann M, Heemann U, Luppa PB, Schmaderer C. Mortality prediction in stable hemodialysis patients is refined by YKL-40, a 40-kDa glycoprotein associated with inflammation. Kidney Int 2017; 93:221-230. [PMID: 28941940 DOI: 10.1016/j.kint.2017.07.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 07/01/2017] [Accepted: 07/13/2017] [Indexed: 12/21/2022]
Abstract
Chronic inflammation contributes to increased mortality in hemodialysis (HD) patients. YKL-40 is a novel marker of inflammation, tissue remodeling, and highly expressed in macrophages inside vascular lesions. Elevated levels of YKL-40 have been reported for HD patients but how it integrates into the proinflammatory mediator network as a predictor of mortality remains elusive. We studied serum YKL-40, Interleukin-6 (IL-6), high-sensitivity C-reactive protein, monocyte chemotactic protein-1 (MCP-1), and interferon-gamma induced protein-10 (IP-10) in 475 chronic hemodialysis patients. Patients were followed for mortality for a median of 37 [interquartile range: 25-49] months and checked for interrelation of the measured mediators. To plot cumulative incidence functions, patients were stratified into terciles per YKL-40, IL-6, MCP-1, and IP-10 levels. Multivariable Cox regression models were built to examine associations of YKL-40, IP-10, and MCP-1 with all-cause and cause-specific mortality. Net reclassification improvement was calculated for the final models containing YKL-40 and IL-6. Increased YKL-40 was independently associated with age, IP-10, and IL-6 serum levels. After adjustment for demographic and laboratory parameters, comorbidities, and IL-6, only YKL-40 significantly improved risk prediction for all-cause (hazard ratio 1.4; 95% confidence interval 1.1-1.8) and cardiovascular mortality (hazard ratio 1.5; 95% confidence interval 1.03-2.2). Thus, in contrast to other biomarkers of aberrant macrophage activation, YKL-40 reflects inflammatory activity, which is not covered by IL-6. Mechanistic and prospective studies are needed to test for causal involvement of YKL-40 and whether it might qualify as a therapeutic target.
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Affiliation(s)
- Georg Lorenz
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.
| | - Michael Schmalenberg
- Department of Clinical Chemistry, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Stephan Kemmner
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Bernhard Haller
- Department of Medical Statistics and Epidemiology, Technical University Munich, Munich, Germany
| | - Dominik Steubl
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Dang Pham
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Anita Schreiegg
- Department of Clinical Chemistry, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Quirin Bachmann
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Alina Schmidt
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Sandra Haderer
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Monika Huber
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Susanne Angermann
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Roman Günthner
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Matthias Braunisch
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Christine Hauser
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Anna-Lena Reichelt
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Julia Matschkal
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Yana Suttmann
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Philipp Moog
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Konrad Stock
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Claudius Küchle
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Klaus Thürmel
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Lutz Renders
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Axel Bauer
- Department of Cardiology, Ludwig-Maximilian University, Munich, Germany
| | - Marcus Baumann
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Peter B Luppa
- Department of Clinical Chemistry, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Christoph Schmaderer
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.
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19
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Pulse wave velocity is associated with cognitive impairment in hemodialysis patients. Clin Sci (Lond) 2017; 131:1483-1493. [PMID: 28495909 DOI: 10.1042/cs20170087] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 04/27/2017] [Accepted: 05/10/2017] [Indexed: 11/17/2022]
Abstract
Cognitive impairment in hemodialysis patients is common and associated with adverse outcomes. So far, the underlying pathogenesis remains unclear. Therefore, we examined the potential relationship between cognitive impairment and three different categories of risk factors with particular focus on arterial stiffness measured by pulse wave velocity (PWV). A total of 201 chronic hemodialysis patients underwent cognitive testing under standardized conditions using the Montreal Cognitive Assessment (MoCA). Demographic data including cardiovascular risk factors, dialysis-associated factors as well as factors related to chronic kidney disease (CKD) were analyzed. To account for arterial stiffness, PWV was measured by ambulatory blood pressure monitoried with an oscillometric device that records brachial blood pressure along with pulse waves. In our cohort, 60.2% of patients showed pathological MoCA test results indicating cognitive impairment. PWV was significantly associated with cognitive impairment apart from age, educational level, diabetes, and hypercholesterolemia. High prevalence of cognitive impairment in hemodialysis patients was confirmed. For the first time, an association between cognitive impairment and arterial stiffness was detected in a larger cohort of hemodialysis patients. Concerning the underlying pathogenesis of cognitive impairment, current results revealed a potential involvement of arterial stiffness, which has to be further evaluated in future studies.
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20
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Hagmair S, Braunisch MC, Bachler M, Schmaderer C, Hasenau AL, Bauer A, Rizas KD, Wassertheurer S, Mayer CC. Implementation and verification of an enhanced algorithm for the automatic computation of RR-interval series derived from 24 h 12-lead ECGs. Physiol Meas 2016; 38:1-14. [PMID: 27941217 DOI: 10.1088/1361-6579/38/1/1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
An important tool in early diagnosis of cardiac dysfunctions is the analysis of electrocardiograms (ECGs) obtained from ambulatory long-term recordings. Heart rate variability (HRV) analysis became a significant tool for assessing the cardiac health. The usefulness of HRV assessment for the prediction of cardiovascular events in end-stage renal disease patients was previously reported. The aim of this work is to verify an enhanced algorithm to obtain an RR-interval time series in a fully automated manner. The multi-lead corrected R-peaks of each ECG lead are used for RR-series computation and the algorithm is verified by a comparison with manually reviewed reference RR-time series. Twenty-four hour 12-lead ECG recordings of 339 end-stage renal disease patients from the ISAR (rISk strAtification in end-stage Renal disease) study were used. Seven universal indicators were calculated to allow for a generalization of the comparison results. The median score of the indicator of synchronization, i.e. intraclass correlation coefficient, was 96.4% and the median of the root mean square error of the difference time series was 7.5 ms. The negligible error and high synchronization rate indicate high similarity and verified the agreement between the fully automated RR-interval series calculated with the AIT Multi-Lead ECGsolver and the reference time series. As a future perspective, HRV parameters calculated on this RR-time series can be evaluated in longitudinal studies to ensure clinical benefit.
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Affiliation(s)
- Stefan Hagmair
- Health & Environment Department, AIT Austrian Institute of Technology GmbH, Vienna, Austria
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