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Edwards CV, Ferri GM, Villegas-Galaviz J, Ghosh S, Bawa PS, Wang F, Klimtchuk E, Ajayi TB, Morgan GJ, Prokaeva T, Staron A, Ruberg FL, Sanchorawala V, Giadone RM, Murphy GJ. Abnormal global longitudinal strain and reduced serum inflammatory markers in cardiac AL amyloidosis patients without significant amyloid fibril deposition. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.03.14.584987. [PMID: 38558967 PMCID: PMC10980073 DOI: 10.1101/2024.03.14.584987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background Cardiac dysfunction in AL amyloidosis is thought to be partly related to the direct impact of AL LCs on cardiomyocyte function, with the degree of dysfunction at diagnosis as a major determinant of clinical outcomes. Nonetheless, mechanisms underlying LC-induced myocardial toxicity are not well understood. Methods We identified gene expression changes correlating with human cardiac cells exposed to a cardiomyopathy-associated κAL LC. We then sought to confirm these findings in a clinical dataset by focusing on clinical parameters associated with the pathways dysregulated at the gene expression level. Results Upon exposure to a cardiomyopathy-associated κAL LC, cardiac cells exhibited gene expression changes related to myocardial contractile function and inflammation, leading us to hypothesize that there could be clinically detectable changes in GLS on echocardiogram and serum inflammatory markers in patients. Thus, we identified 29 patients with normal IVSd but abnormal cardiac biomarkers suggestive of LC-induced cardiac dysfunction. These patients display early cardiac biomarker staging, abnormal GLS, and significantly reduced serum inflammatory markers compared to patients with clinically evident amyloid fibril deposition. Conclusion Collectively, our findings highlight early molecular and functional signatures of cardiac AL amyloidosis, with potential impact for developing improved patient biomarkers and novel therapeutics.
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Zhao Y, Zhao L, Wang Y, Zhang J, Ren H, Zhang R, Wu Y, Zou Y, Tong N, Liu F. The association of plasma NT-proBNP level and progression of diabetic kidney disease. Ren Fail 2023; 45:2158102. [PMID: 36820611 PMCID: PMC9970255 DOI: 10.1080/0886022x.2022.2158102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 12/05/2022] [Indexed: 02/24/2023] Open
Abstract
AIMS Diabetic kidney disease (DKD) is the most common cause of end-stage kidney disease (ESKD). The identification of risk factors involved in the progression of DKD to ESKD is expected to result in early detection and appropriate intervention and improve prognosis. This study aimed to explore whether plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) was associated with kidney outcomes in patients with type 2 diabetes mellitus (T2DM) and biopsy-proven DKD. METHODS Patients with biopsy-proven DKD who were followed up at West China Hospital over 12 months were enrolled. The kidney outcome was defined as progression to ESKD. The cutoff value of plasma NT-proBNP concentration was calculated by using receiver operating characteristic (ROC) curve analysis. The influence of NT-proBNP levels on kidney outcome in patients with DKD was assessed using Cox regression analysis. RESULTS A total of 30 (24.5%) patients reached ESKD during a median follow-up of 24.1 months. The baseline serum NT-proBNP level had a significant correlation with baseline proteinuria, kidney function, glomerular lesions, interstitial fibrosis tubular atrophy (IFTA), and arteriolar hyalinosis. Multivariate Cox regression analysis indicated that increased NT-proBNP level was significantly associated with a higher risk of progression to ESKD (HR 6.43; 95% CI (1.65-25.10, p = 0.007), and each 1 SD increase in LG (NT-proBNP) was also associated with a higher risk (HR 2.43; 95% CI 1.94-5.29, p = 0.047) of an adverse kidney outcome after adjusting for confounding factors. CONCLUSIONS A higher level of plasma NT-proBNP predicts kidney prognosis in patients with biopsy-proven DKD. This warrants further investigation into the potential mechanisms.
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Affiliation(s)
- Yuancheng Zhao
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, SichuanChina
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Lijun Zhao
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, SichuanChina
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yiting Wang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, SichuanChina
| | - Junlin Zhang
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Honghong Ren
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, SichuanChina
| | - Rui Zhang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, SichuanChina
| | - Yucheng Wu
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, SichuanChina
| | - Yutong Zou
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, SichuanChina
| | - Nanwei Tong
- Division of Endocrinology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Fang Liu
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, SichuanChina
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Wall JS, Martin EB, Lands R, Ramchandren R, Stuckey A, Heidel RE, Whittle B, Powell D, Richey T, Williams AD, Foster JS, Guthrie S, Kennel SJ. Cardiac Amyloid Detection by PET/CT Imaging of Iodine ( 124I) Evuzamitide ( 124I-p5+14): A Phase 1/2 Study. JACC Cardiovasc Imaging 2023; 16:1433-1448. [PMID: 37940323 DOI: 10.1016/j.jcmg.2023.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/07/2023] [Accepted: 08/21/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND The noninvasive detection of cardiac amyloid, as well as deposits in other vital organs, is critical for early diagnosis and quantitative disease monitoring. Positron emission tomography is an intrinsically quantitative imaging modality suitable for high-resolution amyloid detection. OBJECTIVES This study sought to evaluate the safety and efficacy of a novel amyloid-reactive peptide, designated p5+14, labeled with iodine-124 (124I), in patients with diverse types of systemic amyloidosis. METHODS In a single-site, open label phase 1/2 study (NCT03678259), the safety, biodistribution, and sensitivity of a single intravenous infusion of 124I-evuzamitide was assessed in patients with systemic amyloidosis (n = 50), asymptomatic transthyretin sequence variant carriers (n = 2), and healthy volunteers (n = 5). Subjects were administered 1.4 ± 0.2 mg of 124I-evuzamitide (71.5 ± 12.4 MBq) and positron emission tomography/x-ray computed tomography images acquired at 5.2 hours (Q25-Q75: 4.9-5.4 hours) postinfusion. Images were assessed visually and semi-quantitatively for positive uptake of radiotracer in the heart and other major organs. RESULTS Uptake of 124I-evuzamitide in the heart and other abdominothoracic organs was consistent with the patient's clinical presentation and the type of amyloidosis. The patient- and cardiac-associated sensitivity for imaging and clinical observations was 93.6% (95% CI: 82.8%-97.8%) and 96.2% (95% CI: 81.8%-99.8%), respectively. Semi-quantitative uptake of the radiotracer correlated significantly with serum N-terminal pro-B-type natriuretic peptide measurements in patients with light chain-associated amyloidosis. Cardiac uptake was not observed in any healthy volunteers. The agent was well tolerated, with 1 drug-related adverse event and no deaths. CONCLUSIONS 124I-evuzamitide is an amyloid-binding radiotracer capable of detecting cardiac amyloid in patients with high sensitivity.
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Affiliation(s)
- Jonathan S Wall
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA.
| | - Emily B Martin
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA
| | - Ronald Lands
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA
| | | | - Alan Stuckey
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA
| | - R Eric Heidel
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA
| | - Bryan Whittle
- Department of Radiology, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Dustin Powell
- Hendersonville Radiologic Consultants, Hendersonville, North Carolina, USA
| | - Tina Richey
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA
| | - Angela D Williams
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA
| | - James S Foster
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA
| | | | - Stephen J Kennel
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA
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Association between Intra- and Extra-Cellular Water Ratio Imbalance and Natriuretic Peptides in Patients Undergoing Hemodialysis. Nutrients 2023; 15:nu15051274. [PMID: 36904273 PMCID: PMC10005491 DOI: 10.3390/nu15051274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/24/2023] [Accepted: 03/01/2023] [Indexed: 03/08/2023] Open
Abstract
Natriuretic peptides are associated with malnutrition and volume overload. Over-hydration cannot simply be explained by excess extracellular water in patients undergoing hemodialysis. We assessed the relationship between the extracellular and intracellular water (ECW/ICW) ratio, N-terminal pro-B-type natriuretic peptide (NT-proBNP), human atrial natriuretic peptide (hANP), and echocardiographic findings. Body composition was examined by segmental multi-frequency bioelectrical impedance analysis in 368 patients undergoing maintenance dialysis (261 men and 107 women; mean age, 65 ± 12 years). Patients with higher ECW/ICW ratio quartiles tended to be older, were on dialysis longer, and had higher post-dialysis blood pressure and lower body mass index, ultrafiltration volume, serum albumin, blood urea nitrogen, and creatinine levels (p < 0.05). The ECW/ICW ratio significantly increased with decreasing ICW, but not with ECW. Patients with a higher ECW/ICW ratio and lower percent fat had significantly higher natriuretic peptide levels. After adjusting for covariates, the ECW/ICW ratio remained an independent associated factor for natriuretic peptides (β = 0.34, p < 0.001 for NT-proBNP and β = 0.40, p < 0.001 for hANP) and the left ventricular mass index (β = 0.20, p = 0.002). The ICW-ECW volume imbalance regulated by decreased cell mass may explain the reserve capacity for fluid accumulation in patients undergoing hemodialysis.
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Impact of socioeconomic and cardiovascular risk factors on the effect of genetic variants associated with NT-proBNP. Sci Rep 2022; 12:15560. [PMID: 36114409 PMCID: PMC9481588 DOI: 10.1038/s41598-022-19821-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 09/05/2022] [Indexed: 11/15/2022] Open
Abstract
N-terminal prohormone of brain natriuretic peptide (NT-proBNP) is an established biomarker for diagnosis of heart failure. The study aims to explore whether known cardiovascular risk factors, including education and income as indicators of socioeconomic position (SEP), may interact with the genetic effect of NT-proBNP-related single nucleotide polymorphisms (SNP) to influence plasma levels of NT-proBNP in a population-based study sample. Information on effect alleles of three SNPs previously reported to be related to NT-proBNP was combined individually for 4,520 participants of the Heinz Nixdorf Recall Study to calculate a genetic risk allele sum score (GRSNT-proBNP). Linear Regression models were used to examine the association of cardiovascular risk factors and GRSNT-proBNP with log-transformed NT-proBNP levels, as well as cardiovascular risk factor by GRSNT-proBNP interactions. The GRSNT-proBNP was associated with NT-proBNP showing 1.13-fold (95% CI 1.10–1.16) higher plasma levels per additional effect allele. Interaction terms included in the regression models gave some indication for interaction of the GRSNT-proBNP with the SEP indicator income as well as with C-reactive protein. In regression models stratified by income quartiles the strongest genetic effect was observed in the third income quartile showing 1.18-fold (95% CI 1.12–1.25) higher average NT-proBNP levels per additional allele compared to the lowest income quartile with 1.08-fold (95% CI 1.01–1.15) higher NT-proBNP levels. The results of the present study indicate that genetic effects of NT-proBNP increasing alleles are stronger in higher SEP groups. This may be due to a stronger influence of non-genetic cardiovascular risk on NT-proBNP in low SEP groups.
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Mayne KJ, Shemilt R, Keane DF, Lees JS, Mark PB, Herrington WG. Bioimpedance indices of fluid overload and cardiorenal outcomes in heart failure and chronic kidney disease: a systematic review. J Card Fail 2022; 28:1628-1641. [PMID: 36038013 DOI: 10.1016/j.cardfail.2022.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/23/2022] [Accepted: 08/04/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Bioimpedance-based estimates of fluid overload have been widely studied and systematically reviewed in dialysis populations, but data from heart failure or non-dialysis chronic kidney disease (CKD) populations have not. METHODS AND RESULTS We conducted a systematic review of studies using whole-body bioimpedance from heart failure and non-dialysis CKD populations which reported associations with mortality, cardiovascular outcomes and/or CKD progression. We searched MEDLINE, Embase databases and the Cochrane CENTRAL registry from inception to 14th March 2022. Thirty one eligible studies were identified: 20 heart failure and 11 CKD cohorts, with 2 studies including over 1000 participants. A wide range of different bioimpedance methods were used across the studies (heart failure: 8 parameters; CKD: 6). Studies generally reported positive associations, but between-study differences in bioimpedance methods, fluid overload exposure definitions, and modelling approaches precluded meta-analysis. The largest identified study was in non-dialysis CKD (Chronic Renal Insufficiency Cohort, 3751 participants) which reported adjusted hazard ratios (95% confidence intervals) for phase angle <5.59 versus ≥6.4 of 2.02 (1.67-2.43) for all-cause mortality; 1.80 (1.46-2.23) for heart failure events; and 1.78 (1.56-2.04) for CKD progression. CONCLUSIONS Bioimpedance indices of fluid overload are associated with risk of important cardiorenal outcomes in heart failure and CKD. Facilitation of more widespread use of bioimpedance needs consensus on the optimum device, standardized analytical methods, and larger studies including more detailed characterization of cardiac and renal phenotypes.
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Affiliation(s)
- Kaitlin J Mayne
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Institute of Cardiovascular & Medical Sciences, BHF Glasgow Cardiovascular Research Centre (GCRC), University of Glasgow, Glasgow, UK.
| | - Richard Shemilt
- Institute of Cardiovascular & Medical Sciences, BHF Glasgow Cardiovascular Research Centre (GCRC), University of Glasgow, Glasgow, UK
| | - David F Keane
- CÚRAM SFI Research Centre for Medical Devices, HRB-Clinical Research Facility Galway, National University of Ireland Galway, Ireland
| | - Jennifer S Lees
- Institute of Cardiovascular & Medical Sciences, BHF Glasgow Cardiovascular Research Centre (GCRC), University of Glasgow, Glasgow, UK
| | - Patrick B Mark
- Institute of Cardiovascular & Medical Sciences, BHF Glasgow Cardiovascular Research Centre (GCRC), University of Glasgow, Glasgow, UK
| | - William G Herrington
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK.
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Ferraro S, Biganzoli G, Calcaterra V, Zuccotti G, Biganzoli EM, Plebani M. Fibroblast growth factor 23: translating analytical improvement into clinical effectiveness for tertiary prevention in chronic kidney disease. Clin Chem Lab Med 2022; 60:1694-1705. [PMID: 36008874 DOI: 10.1515/cclm-2022-0635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 07/22/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Fibroblast growth factor 23 (FGF23) plays a key role in the pathophysiology of chronic kidney disease (CKD) and of the associated cardiovascular diseases, ranking on the crossroads of several evolving areas with a relevant impact on the health-care system (ageing, treatment of CKD and prevention from cardiovascular and renal events). In this review, we will critically appraise the overall issues concerning the clinical usefulness of FGF23 determination in CKD, focusing on the analytical performances of the methods, aiming to assess whether and how the clinical introduction of FGF23 may promote cost-effective health care policies in these patients. CONTENT Our comprehensive critical appraisal of the literature revealed that we are currently unable to establish the clinical usefulness of FGF23 measured by ELISA in CKD, as stability issues and suboptimal analytical performances are the major responsible for the release of misleading results. The meta-analytical approach has failed to report unambiguous evidence in face of the wide heterogeneity of the results from single studies. SUMMARY AND OUTLOOK Our review has largely demonstrated that the clinical usefulness depends on a thorough analytical validation of the assay. The recent introduction of chemiluminescent intact-FGF23 (iFGF23) assays licensed for clinical use, after passing a robust analytical validation, has allowed the actual assessment of preliminary risk thresholds for cardiovascular and renal events and is promising to capture the iFGF23 clinically relevant changes as a result of a therapeutic modulation. In this perspective, the analytical optimization of FGF23 determination may allow a marriage between physiology and epidemiology and a merging towards clinical outcomes.
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Affiliation(s)
- Simona Ferraro
- Endocrinology Laboratory Unit, "Luigi Sacco" University Hospital, Milan, Italy
| | - Giacomo Biganzoli
- Medical Statistics Unit, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, University of Milan, Milan, Italy
| | - Valeria Calcaterra
- Department of Internal Medicine, University of Pavia, Pavia, Italy.,Pediatric Department, "V. Buzzi" Children's Hospital, Milan, Italy
| | - Gianvincenzo Zuccotti
- Pediatric Department, "V. Buzzi" Children's Hospital, Milan, Italy.,Department of Biomedical and Clinical Science, University of Milan, Milan, Italy
| | - Elia Mario Biganzoli
- Medical Statistics Unit, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, University of Milan, Milan, Italy
| | - Mario Plebani
- Department of Medicine-DIMED, University of Padova, Padova, Italy
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Mitrosz-Gołębiewska K, Rydzewska-Rosołowska A, Kakareko K, Zbroch E, Hryszko T. Water - A life-giving toxin - A nephrological oxymoron. Health consequences of water and sodium balance disorders. A review article. Adv Med Sci 2022; 67:55-65. [PMID: 34979423 DOI: 10.1016/j.advms.2021.12.002] [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: 04/13/2021] [Revised: 08/24/2021] [Accepted: 12/15/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND This article aims to reveal misconceptions about methods of assessment of hydration status and impact of the water disorders on the progression of kidney disease or renal dysfunction. MATERIALS AND METHODS The PubMed database was searched for reviews, meta-analyses and original articles on hydration, volume depletion, fluid overload and diagnostic methods of hydration status, which were published in English. RESULTS Based on the results of available literature the relationship between the amount of fluid consumed, and the rate of progression of chronic kidney disease, autosomal dominant polycystic kidney disease, and kidney stones disease was discussed. Selected aspects of the assessment of the hydration level in clinical practice based on physical examination, laboratory tests, and imaging are presented. The subject of in-hospital fluid therapy is discussed. Based on available randomized studies, an attempt was made to assess, which fluids should be selected for intravenous treatment. CONCLUSIONS There is some evidence for the beneficial effect of increased water intake in preventing recurrent cystitis and kidney stones, but there are still no convincing data for chronic kidney disease and autosomal dominant polycystic kidney disease. Further studies are needed to clarify the aforementioned issues and establish a reliable way to assess the volemia and perform suitable fluid therapy.
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Affiliation(s)
- Katarzyna Mitrosz-Gołębiewska
- 2nd Department of Nephrology and Hypertension with Dialysis Unit, Medical University of Bialystok, Bialystok, Poland.
| | - Alicja Rydzewska-Rosołowska
- 2nd Department of Nephrology and Hypertension with Dialysis Unit, Medical University of Bialystok, Bialystok, Poland
| | - Katarzyna Kakareko
- 2nd Department of Nephrology and Hypertension with Dialysis Unit, Medical University of Bialystok, Bialystok, Poland
| | - Edyta Zbroch
- Department of Internal Medicine and Hypertension, Medical University od Bialystok, Bialystok, Poland
| | - Tomasz Hryszko
- 2nd Department of Nephrology and Hypertension with Dialysis Unit, Medical University of Bialystok, Bialystok, Poland
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Seoudy H, Eberstein M, Frank J, Thomann M, Puehler T, Lutter G, Lutz M, Bramlage P, Frey N, Saad M, Frank D. HFA‐PEFF score: prognosis in patients with preserved ejection fraction after transcatheter aortic valve implantation. ESC Heart Fail 2022; 9:1071-1079. [PMID: 35092186 PMCID: PMC8934930 DOI: 10.1002/ehf2.13774] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/31/2021] [Accepted: 12/02/2021] [Indexed: 12/19/2022] Open
Affiliation(s)
- Hatim Seoudy
- Department of Internal Medicine III, Cardiology and Angiology University Hospital Schleswig‐Holstein, Campus Kiel Arnold‐Heller‐Str.3, Haus K3 Kiel 24105 Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck Kiel Germany
| | - Mira Eberstein
- Department of Internal Medicine III, Cardiology and Angiology University Hospital Schleswig‐Holstein, Campus Kiel Arnold‐Heller‐Str.3, Haus K3 Kiel 24105 Germany
| | - Johanne Frank
- Department of Internal Medicine III, Cardiology and Angiology University Hospital Schleswig‐Holstein, Campus Kiel Arnold‐Heller‐Str.3, Haus K3 Kiel 24105 Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck Kiel Germany
| | - Maren Thomann
- Department of Internal Medicine III, Cardiology and Angiology University Hospital Schleswig‐Holstein, Campus Kiel Arnold‐Heller‐Str.3, Haus K3 Kiel 24105 Germany
| | - Thomas Puehler
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck Kiel Germany
- Department of Cardiac and Vascular Surgery University Hospital Schleswig‐Holstein, Campus Kiel Kiel Germany
| | - Georg Lutter
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck Kiel Germany
- Department of Cardiac and Vascular Surgery University Hospital Schleswig‐Holstein, Campus Kiel Kiel Germany
| | - Matthias Lutz
- Department of Internal Medicine III, Cardiology and Angiology University Hospital Schleswig‐Holstein, Campus Kiel Arnold‐Heller‐Str.3, Haus K3 Kiel 24105 Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck Kiel Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine Cloppenburg Germany
| | - Norbert Frey
- Department of Cardiology, Angiology and Pneumology Heidelberg University Hospital Heidelberg Germany
- DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim Heidelberg Germany
| | - Mohammed Saad
- Department of Internal Medicine III, Cardiology and Angiology University Hospital Schleswig‐Holstein, Campus Kiel Arnold‐Heller‐Str.3, Haus K3 Kiel 24105 Germany
| | - Derk Frank
- Department of Internal Medicine III, Cardiology and Angiology University Hospital Schleswig‐Holstein, Campus Kiel Arnold‐Heller‐Str.3, Haus K3 Kiel 24105 Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck Kiel Germany
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Chronic Kidney Disease and Heart Failure-Everyday Diagnostic Challenges. Diagnostics (Basel) 2021; 11:diagnostics11112164. [PMID: 34829511 PMCID: PMC8624132 DOI: 10.3390/diagnostics11112164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/18/2021] [Accepted: 11/19/2021] [Indexed: 01/10/2023] Open
Abstract
Is advanced chronic kidney disease (CKD) a cardiac “no man’s land”? Chronic heart failure (HF) is widely believed to be one of the most serious medical challenges of the 21st century. Moreover, the number of patients with CKD is increasing. To date, patients with estimated glomerular filtration rates <30 mL/min/1.73 m2 have frequently been excluded from large, randomized clinical trials. Although this situation is slowly changing, in everyday practice we continue to struggle with problems that are not clearly addressed in the guidelines. This literature review was conducted by an interdisciplinary group, which comprised a nephrologist, internal medicine specialists, and cardiologist. In this review, we discuss the difficulties in ruling out HF for patients with advanced CKD and issues regarding the cardiotoxicity of dialysis fistulas and the occurrence of pulmonary hypertension in patients with CKD. Due to the recent publication of the new HF guidelines by the European Society of Cardiology, this is a good time to address these difficult issues. Contrary to appearances, these are not niche issues, but problems that affect many patients.
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Bauer S, Strack C, Ücer E, Wallner S, Hubauer U, Luchner A, Maier LS, Jungbauer C. Evaluation of a multimarker panel in chronic heart failure: a 10-year follow-up. Biomark Med 2021; 15:1709-1719. [PMID: 34783584 DOI: 10.2217/bmm-2020-0722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: We assessed the 10-year prognostic role of 11 biomarkers with different pathophysiological backgrounds. Materials & methods/results: Blood samples from 144 patients with heart failure were analyzed. After 10 years of follow-up (median follow-up was 104 months), data regarding all-cause mortality were acquired. Regarding Kaplan-Meier analysis, all markers, except TIMP-1 and GDF-15, were significant predictors for all-cause mortality. We created a multimarker model with nt-proBNP, hs-TnT and IGF-BP7 and found that patients in whom all three markers were elevated had a significantly worse long-time prognosis than patients without elevated markers. Conclusion: In a 10-year follow-up, a combination of three biomarkers (NT-proBNP, hs-TnT, IGF-BP7) identified patients with a high risk of mortality.
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Affiliation(s)
- Susanne Bauer
- University Hospital Regensburg, Department for Cardiology, Franz-Josef-Strauss Allee 11, Regensburg, 93053, Germany
| | - Christina Strack
- University Hospital Regensburg, Department for Cardiology, Franz-Josef-Strauss Allee 11, Regensburg, 93053, Germany
| | - Ekrem Ücer
- University Hospital Regensburg, Department for Cardiology, Franz-Josef-Strauss Allee 11, Regensburg, 93053, Germany
| | - Stefan Wallner
- University Hospital Regensburg, Department for Clinical Chemistry and Laboratory Medicine, Franz-Josef-Strauss Allee 11, Regensburg, 93053, Germany
| | - Ute Hubauer
- University Hospital Regensburg, Department for Cardiology, Franz-Josef-Strauss Allee 11, Regensburg, 93053, Germany
| | - Andreas Luchner
- Hospital Barmherzige Brüder, Department for Cardiology, Prüfeninger Straße 86, Regensburg, 93049, Germany
| | - Lars Siegfried Maier
- University Hospital Regensburg, Department for Cardiology, Franz-Josef-Strauss Allee 11, Regensburg, 93053, Germany
| | - Carsten Jungbauer
- University Hospital Regensburg, Department for Cardiology, Franz-Josef-Strauss Allee 11, Regensburg, 93053, Germany
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Wang Y, Cao X, Yu J, Zhang Y, Li X, Chen X, Zou J, Shen B, Ding X. Association of N-Terminal Pro-brain Natriuretic Peptide With Volume Status and Cardiac Function in Hemodialysis Patients. Front Cardiovasc Med 2021; 8:646402. [PMID: 33693039 PMCID: PMC7937607 DOI: 10.3389/fcvm.2021.646402] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 02/01/2021] [Indexed: 12/16/2022] Open
Abstract
Introduction: N-terminal-pro-brain natriuretic peptide (NT-pro BNP) is secreted by cardiomyocytes in cases of cardiac structure disorder and volume overload. However, the relationship between NT-pro BNP level and body fluid status in dialysis patients with reduced cardiac ejection function (EF) is uncertain. Therefore, we aimed to investigate this relationship. Methods: We enrolled patients who had been receiving hemodialysis for >3 months. Blood sample, transthoracic echocardiographic, and bioimpedance spectroscopy measurements were performed during a midweek non-dialysis day. The predictive value of NT-pro BNP in hemodialysis patients with volume overload was analyzed. Results: A total of 129 hemodialysis patients (74 men and 55 women; mean age: 59.4 ± 13.0 years) were recruited. The average hemodialysis duration was 55.5 (23.9–93.4) months, the NT-pro BNP level was 4992 (2,033–15,807) pg/mL, and the value of overhydration was 2.68 ± 0.19 (−1.9 to 12.2) L. The NT-pro BNP level was independently correlated with overhydration in both the LVEF ≥ 60% (β = 0.236, P = 0.044) and LVEF <60% (β = 0.516, P = 0.032) groups, even after adjustments for potentially confounding variables. In receiver operating characteristic curves of NT-pro BNP for predicting volume overload, the area under the curve was 0.783 [95% CI (0.688–0.879), P < 0.001) and 0.788 [95% CI (0.586–0.989), P < 0.001] in the LVEF ≥ 60% and LVEF < 60% groups, respectively. Conclusions: NT-pro BNP is a predictive factor for volume overload in hemodialysis patients with or without EF declines.
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Affiliation(s)
- Yaqiong Wang
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Department of Nephrology, Shanghai Institute of Kidney and Dialysis, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China.,Hemodialysis Quality Control Center of Shanghai, Shanghai, China
| | - Xuesen Cao
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Department of Nephrology, Shanghai Institute of Kidney and Dialysis, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China.,Hemodialysis Quality Control Center of Shanghai, Shanghai, China
| | - Jinbo Yu
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Department of Nephrology, Shanghai Institute of Kidney and Dialysis, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China.,Hemodialysis Quality Control Center of Shanghai, Shanghai, China
| | - Yongmei Zhang
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Department of Nephrology, Shanghai Institute of Kidney and Dialysis, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China.,Hemodialysis Quality Control Center of Shanghai, Shanghai, China
| | - Xianzhe Li
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Department of Nephrology, Shanghai Institute of Kidney and Dialysis, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China.,Hemodialysis Quality Control Center of Shanghai, Shanghai, China
| | - Xiaohong Chen
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Department of Nephrology, Shanghai Institute of Kidney and Dialysis, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China.,Hemodialysis Quality Control Center of Shanghai, Shanghai, China
| | - Jianzhou Zou
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Department of Nephrology, Shanghai Institute of Kidney and Dialysis, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China.,Hemodialysis Quality Control Center of Shanghai, Shanghai, China
| | - Bo Shen
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Department of Nephrology, Shanghai Institute of Kidney and Dialysis, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China.,Hemodialysis Quality Control Center of Shanghai, Shanghai, China
| | - Xiaoqiang Ding
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Department of Nephrology, Shanghai Institute of Kidney and Dialysis, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China.,Hemodialysis Quality Control Center of Shanghai, Shanghai, China
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Low Intracellular Water, Overhydration, and Mortality in Hemodialysis Patients. J Clin Med 2020; 9:jcm9113616. [PMID: 33182670 PMCID: PMC7697083 DOI: 10.3390/jcm9113616] [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: 09/28/2020] [Revised: 10/28/2020] [Accepted: 11/06/2020] [Indexed: 12/22/2022] Open
Abstract
Background: In hemodialysis patients, extracellular water (ECW) overload predicts all-cause and cardiovascular mortality. The primary aim of the present study was to analyze changes in post-dialysis (i.e., following removal of excess ECW) ECW, intracellular water (ICW), and the overhydration (OH) parameter over time. Additionally, the association of these parameters with mortality was explored. Patients and methods: Prospective study of prevalent hemodialysis patients (n = 124) followed for a median of 20 (interquartile range (IQR) 8–31) months. In three visits, inflammation (C-reactive protein) and post-dialysis fluid status (bioimpedance, BIS) were assessed. Results: During follow-up, the overhydration (OH) parameter increased (−0.696 ± 1.6 vs. 0.268 ± 1.7 L; p = 0.007) at the expense of a decrease in intracellular water (ICW) (19.90 ± 4.5 vs. 18.72 ± 4.1 24 L; p = 0.006) with a non-significant numerical increase in ECW/ICW ratio (0.795 ± 0.129 vs. 0.850 ± 0.143; p = 0.055). Baseline ICW positively correlated with muscle mass and energy intake and negatively with C-reactive protein and it was lower in those who died than in survivors (15.09 ± 2.36 vs. 18.87 ± 4.52 L; p = 0.004). In Kaplan–Meier analysis, patients with low baseline ICW (≤17 L) and high ECW/ICW ratio (≥0.84) were at an increased risk of death. Baseline ICW was also associated with the risk of death in adjusted Cox proportional hazards models (HR 0.62 (0.40–0.98) p = 0.04). Conclusions: In hemodialysis patients, the post-dialysis OH parameter increased over time while ICW decreased, without changes in ECW. Low baseline post-dialysis ICW correlated with muscle wasting and inflammation and was an independent risk factor for mortality.
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Yang WL, Fahim M, Johnson DW. Pathophysiology and significance of natriuretic peptides in patients with end-stage kidney disease. Clin Biochem 2020; 83:1-11. [PMID: 32511964 DOI: 10.1016/j.clinbiochem.2020.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 05/24/2020] [Accepted: 05/25/2020] [Indexed: 12/30/2022]
Abstract
Natriuretic peptides (NP), especially B type (BNP) and its N-terminal pro-B type natriuretic peptide (NT-proBNP), have long been regarded as biomarkers of volume overload and tools to exclude heart failure in the general population. However, their role in end-stage kidney disease (ESKD) is less certain given that BNP and NT-proBNP are excreted by the kidney and so serum concentrations of NPs are nearly universally elevated compared to controls. Nevertheless, the accumulated evidence suggests thatserum concentrations of NPs in patients with ESKD show moderate or strong positive relationships with underlying heart disease, abnormal cardiac structure or function and mortality. Limited evidence also supports the role of BNP including NT-proBNP, ANP in some studies, rather than CNP or DNP in risk stratification among ESKD patients as well as the utility of BNP samplings pre- and post- hemodialysis. However, studies of the cut-off values of NPs have yielded inconsistent results, such that further large-scale studies are needed to clarify these issues. This review summarizes the pathophysiology and significance of NPs in ESKD patients, especially their potential role as risk stratification biomarkers in clinical management.
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Affiliation(s)
- Wen-Ling Yang
- Department of Nephrology, Peking University Third Hospital, Beijing, China; Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia; Centre for Kidney Disease Research, The University of Queensland, Queensland, Australia
| | - Magid Fahim
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia; Centre for Kidney Disease Research, The University of Queensland, Queensland, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia; Centre for Kidney Disease Research, The University of Queensland, Queensland, Australia; Translational Research Institute, Brisbane, Australia.
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Jean G, Deleaval P, Chazot C. [Natriuretic peptides in dialysis: From theory to clinical practice]. Nephrol Ther 2020; 17:1-11. [PMID: 32409292 DOI: 10.1016/j.nephro.2019.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 08/25/2019] [Indexed: 10/24/2022]
Abstract
Cardiologists and emergency-wards physicians are used to check natriuretic peptides serum level, mainly B-type natriuretic peptide and N-terminal pro-Brain natriuretic peptide for acute cardiac failure diagnosis. Due to their accumulation in chronic kidney disease and their elimination by dialysis, natriuretic peptides sampling remains debatable in chronic kidney disease patients. In dialysis patients, high natriuretic peptides values are associated with mortality, left ventricular hypertrophy and cardiac failure. However, a single value cannot provide a reliable diagnosis. Our clinical practice is as follows: First, we prefer B-type natriuretic peptide to N-terminal pro-Brain natriuretic peptide because of its shorter half-life, with less impact of renal function and dialysis, making its interpretation easier in case of advanced chronic kidney disease or in dialysis patients; second, we define a reference value of B-type natriuretic peptide at dry weight from serial measurements; third, the B-type natriuretic peptide changes are interpreted according to extracellular fluid and cardiac status, but also from the arteriovenous fistula blood flow. In stable dialysis patients, B-type natriuretic peptide is sampled monthly and weekly in unstable patients. We illustrate our experience using clinical cases of overhydration, new cardiac disease onset, hypovolemia and arteriovenous fistula with high blood flow. Longitudinal follow-up of B-type natriuretic peptide is an important advance in dialysis patients in order to detect and treat extracellular fluid variations and cardiac disease status early, both important factors associated with hard outcomes.
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Affiliation(s)
- Guillaume Jean
- Service de néphrologie et dialyse, NephroCare Tassin-Charcot, 7, avenue du Maréchal-Foch, 69110 Sainte-Foy-les-Lyon, France.
| | - Patrik Deleaval
- Service de néphrologie et dialyse, NephroCare Tassin-Charcot, 7, avenue du Maréchal-Foch, 69110 Sainte-Foy-les-Lyon, France
| | - Charles Chazot
- Service de néphrologie et dialyse, NephroCare Tassin-Charcot, 7, avenue du Maréchal-Foch, 69110 Sainte-Foy-les-Lyon, France
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Cheng X, Qin Q, Lu L, Chen C, Wei Y, Wang D, Li H, Li G, Liang H, Li S, Cheng D, Liang Z. The independent risks and specific biomarker of breast cancer-related ischemic stroke. Int J Neurosci 2020; 131:135-143. [PMID: 32083954 DOI: 10.1080/00207454.2020.1733562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIM This retrospective study was designed to investigate the independent risks and specific biomarker for breast cancer-related ischemic stroke (BCRS). METHODS Clinical features and laboratory findings were compared between BCRS group and breast cancer group without stroke, and further multivariate analyses were performed to predict independent risks factors for BCRS patients. A receiver operator characteristic (ROC) curve analysis was configured to estimate the diagnostic efficacy of each independent risk and the product of these risks and to obtain the optimal cut-off value of diagnosis, which was termed the BCRS Index. RESULTS BCRS patients had elevated plasma D-dimer and CA153 levels and platelet-to-lymphocyte ratio (PLR), as well as more patients received endocrine therapy (all p < 0.05). Moreover, multivariate analysis revealed that D-dimer levels (odds ratio [OR]: 1.002; 95% confidence interval [CI]: 1.001-1.003; p = 0.000), CA153 levels (OR: 1.005; 95% CI: 1.001-1.008; p = 0.007), PLR (OR: 1.010; 95% CI: 1.004-1.015; p = 0.001), and endocrine therapy (OR: 1.268; 95% CI: 1.087-1.479; p = 0.003) were identified as independent risks of BCRS. Furthermore, ROC analysis displayed that the product of risks had the best diagnostic efficacy, of which the area under the curve was 0.846 ± 0.28. The optimum cut-off point was 2.37 × 106/mL, which was termed the BCRS Index with higher diagnostic accuracy and validity. CONCLUSIONS Endocrine therapy, as well as elevated plasma D-dimer and CA153 levels and PLR values may be independent risks for BCRS. Furthermore, BCRS Index should be served as a novel specific biomarker for BCRS, which is useful to distinguish BCRS for clinicians.
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Affiliation(s)
- Xuemin Cheng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Qixiong Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Lizhi Lu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Chunyong Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Yunfei Wei
- Department of Neurology, The Second Affliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Dacheng Wang
- Department of Neurology, The Ninth Affiliated Hospital of Guangxi Medical University, Beihai, Guangxi, China
| | - Haihua Li
- Department of Neurology, Fusui County People's Hospital, Chongzuo, Guangxi, China
| | - Guohui Li
- Department of Neurology, Wuzhou Red Cross Hospital, Wuzhou, Guangxi, China
| | - Hongbin Liang
- Department of Neurology, Cenxi People's Hospital, Cenxi, Guangxi, China
| | - Shengyu Li
- Department of Neurology, Wuming County People's Hospital, Nanning, Guangxi, China
| | - Daobin Cheng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
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Brandstrup B, Møller AM. The Challenge of Perioperative Fluid Management in Elderly Patients. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00349-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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