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Zeder K, Siew ED, Kovacs G, Brittain EL, Maron BA. Pulmonary hypertension and chronic kidney disease: prevalence, pathophysiology and outcomes. Nat Rev Nephrol 2024; 20:742-754. [PMID: 38890546 DOI: 10.1038/s41581-024-00857-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2024] [Indexed: 06/20/2024]
Abstract
Pulmonary hypertension (PH) is common in patients with chronic kidney disease (CKD) or kidney failure, with an estimated prevalence of up to 78% in those referred for right-heart catheterization. PH is independently associated with adverse outcomes in CKD, raising the possibility that early detection and appropriate management of PH might improve outcomes in at-risk patients. Among patients with PH, the prevalence of CKD stages 3 and 4 is estimated to be as high as 36%, and CKD is also independently associated with adverse outcomes. However, the complex, heterogenous pathophysiology and clinical profile of CKD-PH requires further characterization. CKD is often associated with elevated left ventricular filling pressure and volume overload, which presumably leads to pulmonary vascular stiffening and post-capillary PH. By contrast, a distinct subgroup of patients at high risk is characterized by elevated pulmonary vascular resistance and right ventricular dysfunction in the absence of pulmonary venous hypertension, which may represent a right-sided cardiorenal syndrome defined in principle by hypervolaemia, salt avidity, low cardiac output and normal left ventricular function. Current understanding of CKD-PH is limited, despite its potentially important ramifications for clinical decision making. In particular, whether PH should be considered when determining the suitability and timing of kidney replacement therapy or kidney transplantation is unclear. More research is urgently needed to address these knowledge gaps and improve the outcomes of patients with or at risk of CKD-PH.
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Affiliation(s)
- Katarina Zeder
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- The University of Maryland-Institute for Health Computing, Bethesda, MD, USA
| | - Edward D Siew
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury, Nashville, TN, USA
| | - Gabor Kovacs
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Evan L Brittain
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bradley A Maron
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
- The University of Maryland-Institute for Health Computing, Bethesda, MD, USA.
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Forado-Benatar I, Caravaca-Pérez P, Rodriguez-Espinosa D, Guzman-Bofarull J, Cuadrado-Payán E, Moayedi Y, Broseta JJ, Farrero M. Tricuspid regurgitation, right ventricular function, and renal congestion: a cardiorenal triangle. Front Cardiovasc Med 2023; 10:1255503. [PMID: 37859684 PMCID: PMC10583553 DOI: 10.3389/fcvm.2023.1255503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 09/18/2023] [Indexed: 10/21/2023] Open
Abstract
There is a growing interest in the evaluation of tricuspid regurgitation due to its increasing prevalence and detrimental impact on clinical outcomes. Historically, it has been coined the "forgotten" defect in the field of valvular heart disease due to the lack of effective treatments to improve prognosis. However, the development of percutaneous treatment techniques has led to a new era in its management, with promising results and diminished complication risk. In spite of these advances, a comprehensive exploration of the pathophysiological mechanisms is essential to establish clear indications and optimal timing for medical and percutaneous intervention. This review will address the most important aspects related to the diagnosis, pathophysiology and treatment of tricuspid regurgitation from a cardiorenal perspective, with a special emphasis on the interaction between right ventricular dysfunction and the development of hepatorenal congestion.
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Affiliation(s)
| | | | - Diana Rodriguez-Espinosa
- Department of Nephrology and Renal Transplantation, Hospital Clínic of Barcelona, Barcelona, Spain
| | | | - Elena Cuadrado-Payán
- Department of Nephrology and Renal Transplantation, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Yasbanoo Moayedi
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - José Jesús Broseta
- Department of Nephrology and Renal Transplantation, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Marta Farrero
- Department of Cardiology, Hospital Clínic of Barcelona, Barcelona, Spain
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Elder GJ. Current Status of Mineral and Bone Disorders in Transplant Recipients. Transplantation 2023; 107:2107-2119. [PMID: 36788445 DOI: 10.1097/tp.0000000000004538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Most patients with end-stage kidney disease undergoing kidney transplantation are affected by the chronic kidney disease-mineral and bone disorder. This entity encompasses laboratory abnormalities, calcification of soft tissues, and the bone abnormalities of renal osteodystrophy that together result in an increased risk of fracture, cardiovascular events, and mortality. Although many biochemical disturbances associated with end-stage kidney disease improve in the first year after transplantation, hyperparathyroidism commonly persists, and residual changes of renal osteodystrophy are slow to resolve. When superimposed on common, traditional risk factors, post-transplant glucocorticoid treatment, the possibility of tubular disturbances and post-transplant chronic kidney disease, rates of incident fracture remain high. This review examines hormonal and biochemical changes before and after kidney transplantation, fracture risk assessment tools and imaging modalities, a staged approach to management and concerns associated with antiresorptive and anabolic therapies. A multidisciplinary approach is proposed as the best means to improve patient-level outcomes.
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Affiliation(s)
- Grahame J Elder
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia
- Skeletal Biology Program, Garvan Institute of Medical Research, Sydney, Australia
- School of Medicine, University of Notre Dame, Sydney, Australia
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Guerrero Cervera B, López-Vilella R, Sánchez Lázaro I, Carbonell Vayá R, Donoso Trenado V, Almenar Bonet L. [Usefulness of short-term peripheral ambulatory ultrafiltration in heart failure refractory to diuretics. Initial experience]. Med Clin (Barc) 2023; 161:154-157. [PMID: 37244855 DOI: 10.1016/j.medcli.2023.04.008] [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: 10/24/2022] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION AND OBJECTIVE In heart failure congestion is the most common symptom and diuretic resistance is frequent. This study aims to analyse whether short-term peripheral outpatient ultrafiltration (UF) is useful and safe in these patients. MATERIAL AND METHODS The first 5 patients ultrafiltrated for diuretic resistance in a fast-track unit of a referral hospital for 12hours were analysed. RESULTS These patients were on treatment with at least 3 oral diuretics; UF made it possible to reduce and/or withdraw some of them. The volume extracted during the procedure was 1520±271ml. There were significant changes in diuresis (PreUF: 1360±164, PostUF: 1670±254ml; P=.035), weight (PreUF: 69.6±14, PostUF: 66.2±15kg; P=.0001) and creatinine (PreUF: 2.1±0.3, PostUF: 1.8±0.4mg; P= 0.023). CONCLUSIONS In outpatients with heart failure and diuretic resistance, short-course peripheral UF was effective and safe.
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Affiliation(s)
| | - Raquel López-Vilella
- Servicio de Cardiología, Hospital Universitari i Politècnic La Fe, Valencia, España; Unidad de Insuficiencia Cardiaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - Ignacio Sánchez Lázaro
- Servicio de Cardiología, Hospital Universitari i Politècnic La Fe, Valencia, España; Unidad de Insuficiencia Cardiaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - Rafael Carbonell Vayá
- Servicio de Urgencias, Hospital Universitari i Politècnic La Fe, Valencia, España; Unidad de Técnicas Médicas, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - Víctor Donoso Trenado
- Servicio de Cardiología, Hospital Universitari i Politècnic La Fe, Valencia, España; Unidad de Insuficiencia Cardiaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - Luis Almenar Bonet
- Servicio de Cardiología, Hospital Universitari i Politècnic La Fe, Valencia, España; Unidad de Insuficiencia Cardiaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, España; Departamento de Medicina, Universidad de Valencia, Valencia, España
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Voicehovska JG, Trumpika D, Voicehovskis VV, Bormane E, Bušmane I, Grigane A, Moreino E, Lejnieks A. Cardiovascular Consequences of Acute Kidney Injury: Treatment Options. Biomedicines 2023; 11:2364. [PMID: 37760806 PMCID: PMC10526099 DOI: 10.3390/biomedicines11092364] [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: 07/31/2023] [Revised: 08/16/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023] Open
Abstract
Soon after haemodialysis was introduced into clinical practice, a high risk of cardiac death was noted in end-stage renal disease. However, only in the last decade has it become clear that any renal injury, acute or chronic, is associated with high overall and cardiovascular lethality. The need for early recognition of kidney damage in cardiovascular pathology to assess risk and develop tactics for patient management contributed to the emergence of the concept of the "cardiorenal syndrome" (CRS). CRS is a pathophysiological disorder of the heart and kidneys in which acute or chronic dysfunction of one of these organs leads to acute or chronic dysfunction of the other. The beneficial effect of ultrafiltration as a component of renal replacement therapy (RRT) is due to the elimination of hyperhydration, which ultimately affects the improvement in cardiac contractile function. This review considers the theoretical background, current status of CRS, and future potential of RRT, focusing on the benefits of ultrafiltration as a therapeutic option.
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Affiliation(s)
- Julija G. Voicehovska
- Department of Internal Diseases, Medical Faculty, Riga Stradins University, LV-1007 Riga, Latvia; (D.T.); (V.V.V.); (E.M.); (A.L.)
- Department of Kidney Diseases and Renal Replacement Therapy, Riga East Clinical University Hospital, LV-1038 Riga, Latvia; (E.B.); (I.B.); (A.G.)
| | - Dace Trumpika
- Department of Internal Diseases, Medical Faculty, Riga Stradins University, LV-1007 Riga, Latvia; (D.T.); (V.V.V.); (E.M.); (A.L.)
- Department of Kidney Diseases and Renal Replacement Therapy, Riga East Clinical University Hospital, LV-1038 Riga, Latvia; (E.B.); (I.B.); (A.G.)
| | - Vladimirs V. Voicehovskis
- Department of Internal Diseases, Medical Faculty, Riga Stradins University, LV-1007 Riga, Latvia; (D.T.); (V.V.V.); (E.M.); (A.L.)
| | - Eva Bormane
- Department of Kidney Diseases and Renal Replacement Therapy, Riga East Clinical University Hospital, LV-1038 Riga, Latvia; (E.B.); (I.B.); (A.G.)
| | - Inara Bušmane
- Department of Kidney Diseases and Renal Replacement Therapy, Riga East Clinical University Hospital, LV-1038 Riga, Latvia; (E.B.); (I.B.); (A.G.)
| | - Anda Grigane
- Department of Kidney Diseases and Renal Replacement Therapy, Riga East Clinical University Hospital, LV-1038 Riga, Latvia; (E.B.); (I.B.); (A.G.)
| | - Eva Moreino
- Department of Internal Diseases, Medical Faculty, Riga Stradins University, LV-1007 Riga, Latvia; (D.T.); (V.V.V.); (E.M.); (A.L.)
| | - Aivars Lejnieks
- Department of Internal Diseases, Medical Faculty, Riga Stradins University, LV-1007 Riga, Latvia; (D.T.); (V.V.V.); (E.M.); (A.L.)
- Riga East Clinical University Hospital, LV-1038 Riga, Latvia
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Khariton Y, Hassan OA, Hernandez-Montfort JA. Update on cardiogenic shock: from detection to team management. Curr Opin Cardiol 2023; 38:108-115. [PMID: 36718620 DOI: 10.1097/hco.0000000000001017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW The following review is intended to provide a summary of contemporary cardiogenic shock (CS) profiling and diagnostic strategies, including biomarker and hemodynamic-based (invasive and noninvasive) monitoring, discuss clinical differences in presentation and trajectory between acute myocardial infarction (AMI)-CS and heart failure (HF)-CS, describe transitions to native heart recovery and heart replacement therapies with a focus on tailored management and emerging real-world data, and emphasize trends in team-based initiatives and interventions for cardiogenic shock including the integration of protocol-driven care. RECENT FINDINGS This document provides a broad overview of contemporary scientific consensus statements as well as data derived from randomized controlled clinical trials and observational registry working groups focused on cardiogenic shock management. SUMMARY This review highlights the increasingly important role of pulmonary artery catheterization in AMI-CS and HF-CS cardiogenic shock and advocates for routine application of algorithmic approaches with interdisciplinary care pathways. Cardiogenic shock algorithms facilitate the integration of clinical, hemodynamic, and imaging data to determine the most appropriate patient hemodynamic support platform to achieve adequate organ perfusion and decongestion.
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Abassi Z, Khoury EE, Karram T, Aronson D. Edema formation in congestive heart failure and the underlying mechanisms. Front Cardiovasc Med 2022; 9:933215. [PMID: 36237903 PMCID: PMC9553007 DOI: 10.3389/fcvm.2022.933215] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
Congestive heart failure (HF) is a complex disease state characterized by impaired ventricular function and insufficient peripheral blood supply. The resultant reduced blood flow characterizing HF promotes activation of neurohormonal systems which leads to fluid retention, often exhibited as pulmonary congestion, peripheral edema, dyspnea, and fatigue. Despite intensive research, the exact mechanisms underlying edema formation in HF are poorly characterized. However, the unique relationship between the heart and the kidneys plays a central role in this phenomenon. Specifically, the interplay between the heart and the kidneys in HF involves multiple interdependent mechanisms, including hemodynamic alterations resulting in insufficient peripheral and renal perfusion which can lead to renal tubule hypoxia. Furthermore, HF is characterized by activation of neurohormonal factors including renin-angiotensin-aldosterone system (RAAS), sympathetic nervous system (SNS), endothelin-1 (ET-1), and anti-diuretic hormone (ADH) due to reduced cardiac output (CO) and renal perfusion. Persistent activation of these systems results in deleterious effects on both the kidneys and the heart, including sodium and water retention, vasoconstriction, increased central venous pressure (CVP), which is associated with renal venous hypertension/congestion along with increased intra-abdominal pressure (IAP). The latter was shown to reduce renal blood flow (RBF), leading to a decline in the glomerular filtration rate (GFR). Besides the activation of the above-mentioned vasoconstrictor/anti-natriuretic neurohormonal systems, HF is associated with exceptionally elevated levels of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP). However, the supremacy of the deleterious neurohormonal systems over the beneficial natriuretic peptides (NP) in HF is evident by persistent sodium and water retention and cardiac remodeling. Many mechanisms have been suggested to explain this phenomenon which seems to be multifactorial and play a major role in the development of renal hyporesponsiveness to NPs and cardiac remodeling. This review focuses on the mechanisms underlying the development of edema in HF with reduced ejection fraction and refers to the therapeutic maneuvers applied today to overcome abnormal salt/water balance characterizing HF.
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Affiliation(s)
- Zaid Abassi
- Department of Physiology, Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
- Department of Laboratory Medicine, Rambam Health Care Campus, Haifa, Israel
- *Correspondence: Zaid Abassi,
| | - Emad E. Khoury
- Department of Physiology, Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Tony Karram
- Department of Vascular Surgery and Kidney Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Doron Aronson
- Department of Cardiology, Rambam Health Care Campus, Haifa, Israel
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