The anemia of primary autonomic failure and its reversal with recombinant erythropoietin

The contribution of the AT1 receptor to erythropoiesis

The renin-angiotensin system (RAS) comprises a broad set of functional peptides and receptors that play a role in cardiovascular homeostasis and contribute to cardiovascular pathologies. Angiotensin II (Ang II) is the most potent peptide hormone produced by the RAS due to its high abundance and its strong and pleiotropic impact on the cardiovascular system. Formation of Ang II takes place in the bloodstream and additionally in tissues in the so-called local RAS. Of the two Ang II receptors (AT1 and AT2) that Ang II binds to, AT1 is the most expressed throughout the mammalian body. AT1 expression is not restricted to cells of the cardiovascular system but in fact AT1 protein is found in nearly all organs, hence, Ang II takes part in several modulatory physiological processes one of which is erythropoiesis. In this review, we present multiple evidence supporting that Ang II modulates physiological and pathological erythropoiesis processes trough the AT1 receptor. Cumulative evidence indicates that Ang II by three distinct mechanisms influences erythropoiesis: 1) stimulation of renal erythropoietin synthesis; 2) direct action on bone marrow precursor cells; and 3) modulation of sympathetic nerve activity to the bone marrow. The text highlights clinical and preclinical evidence focusing on mechanistic studies using rodent models.

Orthostatic Hypotension: Management of a Complex, But Common, Medical Problem

Orthostatic hypotension (OH), a common, often overlooked, disorder with many causes, is associated with debilitating symptoms, falls, syncope, cognitive impairment, and risk of death. Chronic OH, a cardinal sign of autonomic dysfunction, increases with advancing age and is commonly associated with neurodegenerative and autoimmune diseases, diabetes, hypertension, heart failure, and kidney failure. Management typically involves a multidisciplinary, patient-centered, approach to arrive at an appropriate underlying diagnosis that is causing OH, treating accompanying conditions, and providing individually tailored pharmacological and nonpharmacological treatment. We propose a novel streamlined pathophysiological classification of OH; review the relationship between the cardiovascular disease continuum and OH; discuss OH-mediated end-organ damage; provide diagnostic and therapeutic algorithms to guide clinical decision making and patient care; identify current gaps in knowledge and try to define future research directions. Using a case-based learning approach, specific clinical scenarios are presented highlighting various presentations of OH to provide a practical guide to evaluate and manage patients who have OH.

Blood pressure regulation in autonomic failure by dietary sodium, blood volume and posture

In normal subjects natriuresis is tightly coupled to dietary salt ingestion to maintain sodium balance. Likewise, blood pressure remains unchanged over a wide range of salt intake because of pressure natriuresis, whereby an increase in blood pressure stimulates renal sodium excretion to restore homeostasis. These sodium handling mechanisms are impaired in autonomic failure. When exposed to salt restriction, autonomic failure patients are unable to reduce renal sodium excretion, and their orthostatic hypotension worsens. It follows that increased dietary salt would improve orthostatic tolerance. Indeed, most clinical practice guidelines emphasize a high salt intake (6-10 g/day) in the treatment of neurogenic orthostatic hypotension. This approach has been shown to improve other conditions such as syncope and postural tachycardia syndrome, but surprisingly there is no empirical evidence to support this recommendation in orthostatic hypotension. Even though there is expert opinion consensus in its favor, it would be reassuring if at least mechanistic proof of concept studies were available. Fludrocortisone is often added to a high salt diet to improve sodium retention and increase plasma volume, but these effects are transient. Fludrocortisone is contraindicated in patients with heart failure and should be used with caution, if at all, if supine hypertension is present. In patients with supine hypertension posture is an important determinant of sodium balance; blood pressure substantially increases while supine, triggering pressure natriuresis and extensive sodium loss. Thus, avoiding the supine posture may be as important as increasing dietary salt in the management of orthostatic hypotension.

Clinical presentation and long-term follow-up of dopamine beta hydroxylase deficiency

Dopamine beta hydroxylase (DBH) deficiency is an extremely rare autosomal recessive disorder with severe orthostatic hypotension, that can be treated with L-threo-3,4-dihydroxyphenylserine (L-DOPS). We aimed to summarize clinical, biochemical, and genetic data of all world-wide reported patients with DBH-deficiency, and to present detailed new data on long-term follow-up of a relatively large Dutch cohort. We retrospectively describe 10 patients from a Dutch cohort and 15 additional patients from the literature. We identified 25 patients (15 females) from 20 families. Ten patients were diagnosed in the Netherlands. Duration of follow-up of Dutch patients ranged from 1 to 21 years (median 13 years). All patients had severe orthostatic hypotension. Severely decreased or absent (nor)epinephrine, and increased dopamine plasma concentrations were found in 24/25 patients. Impaired kidney function and anemia were present in all Dutch patients, hypomagnesaemia in 5 out of 10. Clinically, all patients responded very well to L-DOPS, with marked reduction of orthostatic complaints. However, orthostatic hypotension remained present, and kidney function, anemia, and hypomagnesaemia only partially improved. Plasma norepinephrine increased and became detectable, while epinephrine remained undetectable in most patients. We confirm the core clinical characteristics of DBH-deficiency and the pathognomonic profile of catecholamines in body fluids. Impaired renal function, anemia, and hypomagnesaemia can be part of the clinical presentation. The subjective response to L-DOPS treatment is excellent and sustained, although the neurotransmitter profile in plasma does not normalize completely. Furthermore, orthostatic hypotension as well as renal function, anemia, and hypomagnesaemia improve only partially.

Risk Factors for Acute Coronary Syndrome in Upper Gastrointestinal Bleeding Patients

Background

Upper gastrointestinal bleeding (UGIB) is a common critical disease with a certain fatality rate. Acute coronary syndrome (ACS), another critical ill condition, is a regular occurrence in the UGIB. We identified risk factors for ACS in UGIB.

Methods

676 patients diagnosed with UGIB were enrolled retrospectively. We assessed the occurrence of ACS in UGIB patients and identified the risk factors for ACS by logistic regression analysis and random forest analysis.

Results

After propensity score matching (PSM), the ACS group (n = 69) and non-ACS group (n = 276) were analyzed. Logistic regression analysis showed that syncope (P = 0.001), coronary heart disease history (P = 0.001), Glasgow Blatchford score (P ≤ 0.001), Rockall risk score (P = 0.004), red blood cell distribution width (RDW) (P ≤ 0.001), total bilirubin (TBil) (P = 0.046), fibrinogen (P ≤ 0.001), and hemoglobin (P = 0.001) had important roles in ACS patients. With Mean Decrease Gini (MDG) sequencing, fibrinogen, RDW, and hemoglobin were ranked the top three risk factors associated with ACS. In ROC analysis, fibrinogen (AUC = 0.841, 95% CI: 0.779-0.903) and RDW (AUC = 0.826, 95% CI: 0.769-0.883) obtained good discrimination performance. According to sensitivity > 80%, the pAUC of fibrinogen and RDW were 0.077 and 0.101, respectively, and there was no significant difference (P = 0.326). However, according to specificity > 80%, the pAUC of fibrinogen was higher than that of RDW (0.126 vs. 0.088, P = 0.018).

Conclusion

Fibrinogen and RDW were important risk factors for ACS in UGIB. Additionally, combination with coronary heart disease, syncope, hemoglobin, and TBil played important roles in the occurrence of ACS. Meanwhile, it was also noted that Rockall score and Glasgow Blatchford score should be performed to predict the risk.

Management of Orthostatic Hypotension

PURPOSE OF REVIEW

This article reviews the management of orthostatic hypotension with emphasis on neurogenic orthostatic hypotension.

RECENT FINDINGS

Establishing whether the cause of orthostatic hypotension is a pathologic lesion in sympathetic neurons (ie, neurogenic orthostatic hypotension) or secondary to other medical causes (ie, non-neurogenic orthostatic hypotension) can be achieved by measuring blood pressure and heart rate at the bedside. Whereas fludrocortisone has been extensively used as first-line treatment in the past, it is associated with adverse events including renal and cardiac failure and increased risk of all-cause hospitalization. Distinguishing whether neurogenic orthostatic hypotension is caused by central or peripheral dysfunction has therapeutic implications. Patients with peripheral sympathetic denervation respond better to norepinephrine agonists/precursors such as droxidopa, whereas patients with central autonomic dysfunction respond better to norepinephrine reuptake inhibitors.

SUMMARY

Management of orthostatic hypotension is aimed at improving quality of life and reducing symptoms rather than at normalizing blood pressure. Nonpharmacologic measures are the key to success. Pharmacologic options include volume expansion with fludrocortisone and sympathetic enhancement with midodrine, droxidopa, and norepinephrine reuptake inhibitors. Neurogenic supine hypertension complicates management of orthostatic hypotension and is primarily ameliorated by avoiding the supine position and sleeping with the head of the bed elevated.

Synucleinopathies

PURPOSE OF REVIEW

This article reviews the α-synucleinopathies pure autonomic failure, multiple system atrophy, dementia with Lewy bodies, and Parkinson disease with respect to autonomic failure.

RECENT FINDINGS

The pattern and severity of autonomic involvement in the synucleinopathies is related to differences in cellular deposition and neuronal populations affected by α-synuclein aggregation, which influences the degree and manifestation of autonomic failure. Clinical and laboratory autonomic features distinguish the different synucleinopathies based on pattern and severity. These features also determine which patients are at risk for evolution from pure autonomic failure to the synucleinopathies with prominent motor involvement, such as multiple system atrophy, dementia with Lewy bodies, or Parkinson disease.

SUMMARY

Autonomic failure is a key feature of the synucleinopathies, with varying type and degree of dysfunction from predominantly peripheral involvement in the Lewy body disorders to central involvement in multiple system atrophy.

The relationship between red cell distribution width and cardiac autonomic function in heart failure

BACKGROUND

Both increases in red cell distribution width (RDW) levels and autonomic dysfunction are considered to be correlated with worsening heart failure. However, the relation of RDW levels to autonomic function remains uncertain. We aimed to investigate the association of RDW levels in heart failure with autonomic function, evaluated by heart rate variability (HRV) and heart rate turbulence (HRT), and prognosis.

METHODS

We studied 222 hospitalized patients with stable heart failure before discharge, and Holter recordings (HRV and HRT) were performed. Additionally, RDW levels were measured, and high RDW was defined as over 14.5%. We then divided the patients into two groups based on RDW levels: high RDW group (>14.5%, n = 92) and low RDW group (≤14.5%, n = 130). The relation of RDW to autonomic function and prognosis was assessed.

RESULTS

In the high RDW group, severely impaired HRV and HRT were found compared to the low RDW group. In the linear regression analysis after the adjustment of multiple confounders, RDW levels were correlated with a low-frequency (LF) to high-frequency (HF) ratio and very low-frequency (VLF) power (LF to HF ratio, β = -0.146, P = .027, and VLF power, β = -0.137, P = .041, respectively). During the observation period (median 1400 days), cardiac events (re-hospitalization of heart failure, cardiac death or sudden death) were found in 73 (32.8%) patients. The Kaplan-Meier analysis demonstrated that the high RDW group had a higher rate of cardiac events compared to the low RDW group (45.6% vs 23.8%, log-rank P < .001).

CONCLUSION

High RDW levels were correlated with autonomic dysfunction, resulting in poor clinical outcomes.

Management of neurogenic orthostatic hypotension in the heart failure patient

Neurogenic orthostatic hypotension (nOH) is a common comorbidity in patients with neurodegenerative diseases. It is associated with an increased risk of falls, incident cardiovascular disease, and all-cause mortality. There are over 5 million individuals in the U.S. with heart failure (HF) with an associated 50% mortality rate at 5 years. The prevalence of nOH and HF increase with age and, as the population continues to age, will be increasingly common comorbid conditions. Thus, the effective management of these conditions has important implications for public health. The management of orthostatic hypotension in the context of congestive heart failure is challenging due to the fact that the fundamental principles of management of these disease states are in opposition to each other. In this review, we will discuss the principles of management of nOH and HF and outline strategies for the effective treatment of these comorbid conditions.

Cardiovascular Safety Considerations in the Treatment of Neurogenic Orthostatic Hypotension

Neurogenic orthostatic hypotension (nOH), a drop in blood pressure upon standing resulting from autonomic malfunction, may cause debilitating symptoms that can affect independence in daily activities and quality-of-life. nOH may also be associated with cardiovascular comorbidities (e.g., supine hypertension, heart failure, diabetes, and arrhythmias), making treatment decisions complicated and requiring management that should be based on a patient's cardiovascular profile. Additionally, drugs used to treat the cardiovascular disorders (e.g., vasodilators, β-blockers) can exacerbate nOH and concomitant symptoms. When orthostatic symptoms are severe and not effectively managed with nonpharmacologic strategies (e.g., water ingestion, abdominal compression), droxidopa or midodrine may be effective. Droxidopa may be less likely than midodrine to exacerbate supine hypertension, based on conclusions of a limited meta-analysis. In conclusion, treating nOH in patients with cardiovascular conditions requires a balance between symptom relief and minimizing adverse outcomes.

Association of the mean platelet volume and red cell distribution width with dipper and non-dipper blood pressure in prehypertensive non-smokers

OBJECTIVE

Absence of nocturnal blood pressure (BP) dipping is associated with poor health outcomes, including increased mortality. Non-dipper BP seems to be a predictor of cardiovascular damage in hypertensive patients. The aim of this study was to investigate the association of the mean platelet volume (MPV) and red cell distribution width (RDW) with nocturnal dipping/non dipping status in newly diagnosed and untreated prehypertensive non-smokers, using ambulatory BP monitoring.

RESULTS

Twenty-eight patients (15 males) in the dipper group and 24 patients (11 males) in the non-dipper group were evaluated in this study. The age of patients was 41.64 ± 15.01 and 37.96 ± 15.08 years in the dipper and non-dipper groups, respectively. The rate of nocturnal systolic BP drop in the dipper and non-dipper groups was 13.79 ± 3.35% (10.20-22.10) and 5.96 ± 2.87% (1.10-9.30) (P < 0.001), respectively. Also, the mean rate of nocturnal diastolic BP drop in the dipper and non-dipper groups was 17.02 ± 5.09% (10.30-26.90) and 6.19 ± 2.75% (1.20-9.70) (P < 0.001), respectively. RDW and MPV were significantly higher in non-dipper patients than dipper patients (P = 0.001 and P = 0.012, respectively). Bivariate analysis revealed that MPV was inversely correlated with the nocturnal systolic BP drop (P = 0.005, r = - 0.385). Furthermore, RDW was inversely correlated with systolic BP drop (P = 0.019, r = - 0.324).

Pure Autonomic Failure

Pure autonomic failure (PAF) is a neurodegenerative disorder of the autonomic nervous system clinically characterized by orthostatic hypotension. The disorder has also been known as Bradbury-Eggleston syndrome, named for the authors of the 1925 seminal description. Patients typically present in midlife or later with orthostatic hypotension or syncope. Autonomic failure may also manifest as genitourinary, bowel, and thermoregulatory dysfunction. With widespread involvement, patients may present to a variety of different specialties and require multidisciplinary treatment approaches. Pathologically, PAF is characterized by predominantly peripheral deposition of α-synuclein. However, patients with PAF may progress into other synucleinopathies with central nervous system involvement.

Orthostatic Hypotension in Parkinson Disease

Orthostatic hypotension (OH) is a sustained fall in blood pressure on standing that can cause symptoms of organ hypoperfusion. OH is associated with increased morbidity and mortality and leads to a significant number of hospital admissions. OH can be caused by volume depletion, blood loss, cardiac pump failure, large varicose veins, medications, or defective activation of sympathetic nerves and reduced norepinephrine release upon standing. Neurogenic OH is a frequent and disabling problem in patients with synucleinopathies such as Parkinson disease, multiple system atrophy, and pure autonomic failure, and it is commonly associated with supine hypertension. Several therapeutic options are available.

Orthostatic hypotension in hereditary transthyretin amyloidosis: epidemiology, diagnosis and management

Purpose

Neurogenic orthostatic hypotension is a prominent and disabling manifestation of autonomic dysfunction in patients with hereditary transthyretin (TTR) amyloidosis affecting an estimated 40–60% of patients, and reducing their quality of life. We reviewed the epidemiology and pathophysiology of neurogenic orthostatic hypotension in patients with hereditary TTR amyloidosis, summarize non-pharmacologic and pharmacological treatment strategies and discuss the impact of novel disease-modifying treatments such as transthyretin stabilizers (diflunisal, tafamidis) and RNA interference agents (patisiran, inotersen).

Methods

Literature review.

Results

Orthostatic hypotension in patients with hereditary transthyretin amyloidosis can be a consequence of heart failure due to amyloid cardiomyopathy or volume depletion due to diarrhea or drug effects. When none of these circumstances are apparent, orthostatic hypotension is usually neurogenic, i.e., caused by impaired norepinephrine release from sympathetic postganglionic neurons, because of neuronal amyloid fibril deposition.

Conclusions

When recognized, neurogenic orthostatic hypotension can be treated. Discontinuation of potentially aggravating medications, patient education and non-pharmacologic approaches should be applied first. Droxidopa (Northera^®), a synthetic norepinephrine precursor, has shown efficacy in controlled trials of neurogenic orthostatic hypotension in patients with hereditary TTR amyloidosis and is now approved in the US and Asia. Although they may be useful to ameliorate autonomic dysfunction in hereditary TTR amyloidosis, the impact of disease-modifying treatments on neurogenic orthostatic hypotension is still uninvestigated.

R/S ratio in lead II, and the prognostic significance of red cell distribution width in acute coronary syndrome

BACKGROUND

In spite of developing medical technologies to discover the etiopathogenesis of diseases and developments in the treatment of coronary artery disease, acute coronary syndromes (ACS) continue to be the main cause of mortality and morbidity worldwide. New cardiac biomarkers and techniques are needed to help provide rapid diagnosis in order to evaluate risk in coronary artery patients.

AIM

To evaluate the effects of R to S ratio (RSR) in the electrocardiograph of patients with ACS, from the point of the arising complication after myocardial infarction (MI), to three-vessel disease (TVD) and mortality.

METHODS

The data of 1,296 patients with ACS, who presented to the emergency department of our hospital with chest pain between January 2014 and December 2018 and were admitted to the cardiology clinic, were retrospectively included in this cross-sectional cohort study. Patients with an RSR value less than I were assigned to group I, while those with an RSR value greater than I were assigned to group II.

RESULTS

In our study, 466 (35.9%) of the 1,296 patients, 357 (38.3%) in group 1 and 109 (29.9%) in group 2, were female, with a mean age of 61.56 ± 9.42. ST-elevation MI 573 (44.2%), unstable angina (UA) 502 (38.7%) and non ST-elevation MI 220 (17%) were more prevalent in group I. Acute anterior MI 263 (20.3) in group I, and acute inferior MI 184 (14.2) in group II was higher. Ischemic heart failure was the most common complication. In group II, the red cell distribution width (RDW) was 15.42 ± 1.82, the gensini score was 48.39 ± 36.44, the left ventricular ejection fraction was 41.17 ± 10.41, the TVD was 111 (8.5), and the mortality rate was 72 (5.6), which was significantly higher than group I RDW; in MI with ST and non-ST-elevation, in TVD, mortality and complications were high and low in UA. In single and multivariate regression analyses, the variables were associated with ACS risk.

CONCLUSION

RSR levels may be an auxiliary predictive value in ACS in terms of complications developing after MI, TVD, and mortality.

Erythrocytosis is associated with intradialytic hypotension: a case series

Background

For patients with end stage renal disease undergoing hemodialysis, erythrocytosis occurs rarely. Erythrocytosis increases the risk of thrombosis, which is a common complication in hemodialysis patients. The risk of thrombosis may also be increased by hypotension. The purpose of our report is to examine the relationship between intradialytic hypotension and erythrocytosis.

Case presentation

We present a series of five patients with end stage renal disease and erythrocytosis (peak hemoglobin range 15.2–18.5 g/dL). All were erythropoiesis-stimulating agent naïve and non-smokers. Prior to developing erythrocytosis, each patient developed recurring episodes of intradialytic hypotension over several months. A statistically significant inverse correlation was observed between nadir intradialytic systolic blood pressure and hemoglobin concentration. In the index case, midodrine treatment resulted in resolution of the hypotension and erythrocytosis. Most of the patients had multiple acquired renal cysts, which is a potential source of erythropoietin. Four of the five cases developed arteriovenous dialysis access or deep venous thrombosis.

Conclusions

An association between intradialytic hypotension and erythrocytosis was observed in five cases. We postulate that chronic intermittent hypotension and renal ischemia may lead to erythropoietin secretion, and this cascade could represent a newly recognized cause of secondary erythrocytosis.

Association of Hemoglobin and Blood Pressure in a Chinese Community-Dwelling Population

This study investigated the relationship between hemoglobin (Hb) level and blood pressure in a Chinese community-dwelling population with normal glucose metabolism. Hb, fasting plasma glucose, glycated Hb A1c, hepatic and renal function, lipid, electrolytes, and anthropometric parameters were measured. Hb level was found to be positively correlated with systolic (SBP; r = 0.075, p < 0.001) and diastolic (DBP; r = 0.272, p < 0.001) blood pressure in the cohort. The relationship was not affected by age, BMI, serum creatinine (Cr), and low-density lipoprotein (LDL) in both males and females. Multivariate stepwise regression showed that age (β = 0.556, p < 0.001), BMI (β = 1.107, < 0.001), Hb (β = 0.082, p < 0.001), Cr (β = -0.032, p < 0.001), and LDL (β = 1.023, p < 0.001) were independent factors for SBP, and Hb (β = 0.168, p < 0.001), BMI (β = 0.519, p = 0.001), and LDL (β = 0.331, p < 0.001) for DBP. Hb level is positively associated with both SBP and DBP in a Chinese community-dwelling population with normal glucose metabolism.

Orthostatic hypotension: A review

Orthostatic hypotension, defined by a drop in blood pressure of at least 20mmHg for systolic blood pressure and at least 10mmHg for diastolic blood pressure within 3minutes of standing up, is a frequent finding, particularly in elderly patients. It is associated with a significant increase in morbidity and mortality. Although it is often multifactorial, the first favoring factor is medications. Other etiologies are divided in neurogenic orthostatic hypotension, characterized by autonomic failure due to central or peripheral nervous system disorders, and non-neurogenic orthostatic hypotension, mainly favoured by hypovolemia. Treatment always requires education of the patient regarding triggering situations and physiological countermanoeuvers. Pharmacological treatment may sometimes be necessary and mainly relies on volume expansion by fludrocortisone and/or a vasopressor agents such as midodrine. There is no predefined blood pressure target, the goal of therapy being the relief of symptoms and fall prevention.

Relationship between high-density lipoprotein cholesterol and the red cell distribution width in patients with coronary artery disease

Background

The red cell distribution width (RDW) is a numerical measurement of variability in the size of red blood cells. Many studies have shown that high-density lipoprotein cholesterol (HDL-C), has an anti-inflammatory effect. The aim of this study was to investigate the relationship between the serum HDL-C level and RDW in patients with coronary artery disease (CAD).

Methods

Patients who underwent coronary angiography were reviewed. Patients who had moderate or severe heart failure, moderate or severe renal failure, significant systemic disease, anemia, a blood transfusion within the last 3 months, or a hematologic disease, as well as those who were taking lipid-lowering medication, were excluded from the study. The Gensini scoring system was used to determine the severity of CAD. Biochemical and hematological parameters were measured from venous blood samples taken after the patient fasted for at least 8 h. The RDW was routinely obtained from a hemogram.

Results

In total, 328 patients were included in the study. The patients were categorized according to quartiles. There were 80 patients in Quartile 1 (RDW < 13.2), 84 patients in Quartile 2 (13.2 ≥ RDW < 14.15), 81 patients in Quartile 3 (14.15 ≥ RDW < 16), and 83 patients in Quartile 4 (RDW ≥ 16). There was a significant and inverse relationship between the serum HDL level and RDW. Regression analysis showed that the HDL-C, hemoglobin, and hs-CRP levels and Gensini score were predictors for the RDW.

Conclusion

We found an inverse and gradual association between the serum HDL-C level and RDW, and the serum HDL-C level was an independent predictor for the RDW.

Treatment of autonomic dysfunction in Parkinson disease and other synucleinopathies

Dysfunction of the autonomic nervous system afflicts most patients with Parkinson disease and other synucleinopathies such as dementia with Lewy bodies, multiple system atrophy, and pure autonomic failure, reducing quality of life and increasing mortality. For example, gastrointestinal dysfunction can lead to impaired drug pharmacodynamics causing a worsening in motor symptoms, and neurogenic orthostatic hypotension can cause syncope, falls, and fractures. When recognized, autonomic problems can be treated, sometimes successfully. Discontinuation of potentially causative/aggravating drugs, patient education, and nonpharmacological approaches are useful and should be tried first. Pathophysiology-based pharmacological treatments that have shown efficacy in controlled trials of patients with synucleinopathies have been approved in many countries and are key to an effective management. Here, we review the treatment of autonomic dysfunction in patients with Parkinson disease and other synucleinopathies, summarize the nonpharmacological and current pharmacological therapeutic strategies including recently approved drugs, and provide practical advice and management algorithms for clinicians, with focus on neurogenic orthostatic hypotension, supine hypertension, dysphagia, sialorrhea, gastroparesis, constipation, neurogenic overactive bladder, underactive bladder, and sexual dysfunction. © 2018 International Parkinson and Movement Disorder Society.

Red cell distribution width associated with adverse cardiovascular outcomes in patients with chronic kidney disease

Background

Recent studies have demonstrated that red cell distribution width (RDW) is associated with cardiovascular (CV) events and mortality. Patients with chronic kidney disease (CKD) are often anemic and have high RDW levels. In this study, we investigated the effect of RDW on major composite CV outcomes among patients with CKD.

Methods

We retrospectively analyzed patients with CKD who were admitted to the department of cardiology of a tertiary hospital in 2011. The patients were divided into 2 groups: normal RDW (RDW < 14.5%) and elevated RDW (RDW ≥ 14.5%). Demographic characteristics, comorbidities, blood investigation results, prescriptions, and outcomes were analyzed after a 3-year follow-up period. Six adjustment levels were performed to evaluate the effect of RDW on outcomes.

Results

This study involved 282 patients with CKD: 213 in the elevated RDW group and 69 in the normal RDW group. The elevated RDW group had older patients, a lower proportion of male patients, lower left ventricular ejection fraction (LVEF) values, lower hemoglobin levels, lower serum albumin levels, and higher creatinine levels, compared with the normal RDW group. A linear trend was observed toward higher RDW in patients with deteriorating renal function. In the final adjusted model, RDW ≥ 14.5%, older age, and lower LVEF were associated with an increased risk of major composite CV outcomes.

Conclusion

RDW is a potentially useful cost-effective indicator of major composite CV outcomes in patients with CKD.

Evidence-based treatment of neurogenic orthostatic hypotension and related symptoms

Neurogenic orthostatic hypotension, postprandial hypotension and exercise-induced hypotension are common features of cardiovascular autonomic failure. Despite the serious impact on patient’s quality of life, evidence-based guidelines for non-pharmacological and pharmacological management are lacking at present. Here, we provide a systematic review of the literature on therapeutic options for neurogenic orthostatic hypotension and related symptoms with evidence-based recommendations according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Patient’s education and non-pharmacological measures remain essential, with strong recommendation for use of abdominal binders. Based on quality of evidence and safety issues, midodrine and droxidopa reach a strong recommendation level for pharmacological treatment of neurogenic orthostatic hypotension. In selected cases, a range of alternative agents can be considered (fludrocortisone, pyridostigmine, yohimbine, atomoxetine, fluoxetine, ergot alkaloids, ephedrine, phenylpropanolamine, octreotide, indomethacin, ibuprofen, caffeine, methylphenidate and desmopressin), though recommendation strength is weak and quality of evidence is low (atomoxetine, octreotide) or very low (fludrocortisone, pyridostigmine, yohimbine, fluoxetine, ergot alkaloids, ephedrine, phenylpropanolamine, indomethacin, ibuprofen, caffeine, methylphenidate and desmopressin). In case of severe postprandial hypotension, acarbose and octreotide are recommended (strong recommendation, moderate level of evidence). Alternatively, voglibose or caffeine, for which a weak recommendation is available, may be useful.

The Pharmacology of Autonomic Failure: From Hypotension to Hypertension

Primary neurodegenerative autonomic disorders are characterized clinically by loss of autonomic regulation of blood pressure. The clinical picture is dominated by orthostatic hypotension, but supine hypertension is also a significant problem. Autonomic failure can result from impairment of central autonomic pathways (multiple system atrophy) or neurodegeneration of peripheral postganglionic autonomic fibers (pure autonomic failure, Parkinson's disease). Pharmacologic probes such as the ganglionic blocker trimethaphan can help us in the understanding of the underlying pathophysiology and diagnosis of these disorders. Conversely, understanding the pathophysiology is crucial in the development of effective pharmacotherapy for these patients. Autonomic failure patients provide us with an unfortunate but unique research model characterized by loss of baroreflex buffering. This greatly magnifies the effect of stimuli that would not be apparent in normal subjects. An example of this is the discovery of the osmopressor reflex: ingestion of water increases blood pressure by 30-40 mm Hg in autonomic failure patients. Animal studies indicate that the trigger of this reflex is related to hypo-osmolality in the portal circulation involving transient receptor potential vanilloid 4 receptors. Studies in autonomic failure patients have also revealed that angiotensin II can be generated through noncanonical pathways independent of plasma renin activity to contribute to hypertension. Similarly, the mineralocorticoid receptor antagonist eplerenone produces acute hypotensive effects, highlighting the presence of non-nuclear mineralocorticoid receptor pathways. These are examples of careful clinical research that integrates pathophysiology and pharmacology to advance our knowledge of human disease.

Epidemiology, Diagnosis, and Management of Neurogenic Orthostatic Hypotension

BACKGROUND

Orthostatic hypotension (OH) is a sustained fall in blood pressure on standing which can cause symptoms of organ hypoperfusion. OH is associated with increased morbidity and mortality and leads to a significant number of hospital admissions particularly in the elderly (233 per 100,000 patients over 75 years of age in the US). OH can be due to volume depletion, blood loss, large varicose veins, medications, or due to defective activation of sympathetic nerves and reduced norepinephrine release upon standing (i.e., neurogenic OH).

METHODS AND FINDINGS

Literature review. Neurogenic OH is a frequent and disabling problem in patients with synucleinopathies such as Parkinson disease, multiple system atrophy, and pure autonomic failure, and is commonly associated with supine hypertension. Several pharmacological and non-pharmacological therapeutic options are available.

CONCLUSIONS

Here we review the epidemiology, diagnosis, and management of neurogenic OH, and provide an algorithm for its treatment emphasizing the importance of removing aggravating factors, implementing non-pharmacologic measures, and selecting appropriate pharmacological treatments.

Cross-sectional and longitudinal association between hemoglobin concentration and hypertension: A population-based cohort study

We investigated the cross-sectional and longitudinal associations between hemoglobin concentration and hypertension in a Korean population.Between 2006 and 2013, we examined 4899 participants with mean age of 56.6 years (range 35-88 years) from a rural community. We excluded 298 participants with a history of myocardial infarction or stroke and 264 participants with very low hemoglobin levels (men: <13.3 g/dL; women: <11.6 g/dL). Finally, we performed a cross-sectional analysis on 1629 men and 2708 women. Longitudinal associations were evaluated in 654 men and 1099 women, after excluding 2584 people with hypertension at baseline and those who did not participate in follow-up examinations. Hypertension was defined as systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or use of antihypertensive treatment.The mean hemoglobin level was significantly higher in people with hypertension than in those without hypertension (P = 0.002 for men, P = 0.006 for women). On cross-sectional analysis, the odds ratio (95% confidence interval) for hypertension per 1 standard deviation increase in hemoglobin concentration (1.2 g/dL) was 1.11 (1.05-1.18) before adjustment and 1.20 (1.09-1.32) after adjusting for age, sex, body mass index, kidney markers, lifestyle factors, and comorbidities. On longitudinal analysis, the relative risk (95% confidence interval) for incident hypertension per 1 standard deviation increase in hemoglobin concentration was 1.09 (0.96-1.23) before adjustment and 0.91 (0.78-1.08) after adjusting for age, sex, body mass index, lifestyle factors, baseline blood pressure, baseline comorbidities, and baseline kidney markers.This study suggests that hemoglobin per se does not cause hypertension development.

Orthostatic hypotension: definition, diagnosis and management

Orthostatic hypotension commonly affects elderly patients and those suffering from diabetes mellitus and Parkinson's disease. It is a cause of significant morbidity in the affected patients. The goal of this review is to outline the pathophysiology, evaluation, and management of the patients suffering from orthostatic hypotension.

Orthostatic hypotension: managing a difficult problem

Orthostatic hypotension (OH) leads to a significant number of hospitalizations each year, and is associated with significant morbidity and mortality among affected individuals. Given the increased risk for cardiovascular events and falls, it is important to identify the underlying etiology of OH and to choose appropriate therapeutic agents. OH can be non-neurogenic or neurogenic (arising from a central or peripheral lesion). The initial evaluation includes orthostatic vital signs, complete history and a physical examination. Patients should also be evaluated for concomitant symptoms of post-prandial hypotension and supine hypertension. Non-pharmacologic interventions are the first step for treatment of OH. The appropriate selection of medications can also help with symptomatic relief. This review highlights the pathophysiology, clinical features, diagnostic work-up and treatment of patients with neurogenic OH.

Less known pathophysiological mechanisms of anemia in patients with diabetic nephropathy

Diabetes mellitus (DM) is currently considered a modern global epidemic, and diabetic nephropathy (DN) is the most common cause of chronic kidney disease (CKD). Anemia is one of the most significant complications of CKD, and it is mainly attributed to insufficient erythropoietin (EPO) production. However, anemia develops earlier in the course of CKD among patients with DM, and the severity of anemia tends to be more marked in these patients compared to nondiabetic subjects, regardless of the stage of CKD. In this review, we focus on the "less known" complex interacting mechanisms which are involved in the pathophysiology of anemia associated with DN. Although the major cause of anemia in DN is considered to be an inappropriate response of the plasma EPO concentration to anemia, several other possible mechanisms have been suggested. Glomerular hyperfiltration, proteinuria, renal tubular dysfunction and interstitial fibrosis are among the main culprits. On the other hand, systemic effects such as chronic inflammation, autonomic neuropathy and the renin-angiotensin system are also involved. Finally, several medications are considered to aggravate anemia associated with DN. Since anemia is an important predictor of quality of life and is implicated in the increased burden of cardiovascular morbidity and mortality, further research is required to elucidate its pathogenesis in diabetic patients.

Management of neurogenic orthostatic hypotension in patients with autonomic failure

The maintenance of blood pressure in the upright position requires intact autonomic cardiovascular reflexes. Diseases that affect the sympathetic innervation of the cardiovascular system result in a sustained fall in blood pressure upon standing (i.e., neurogenic orthostatic hypotension) that can impair the blood supply to the brain and other organs and cause considerable morbidity and mortality. Here we review treatment options for neurogenic orthostatic hypotension and include an algorithm for its management that emphasizes the importance of non-pharmacologic measures and provides guidance on pharmacologic treatment options.

Association between the hemoglobin levels and hypertension in relation to the BMI status in a rural Japanese population: the Nagasaki Islands Study

OBJECTIVE

The hemoglobin levels and blood pressure has been reported in a few studies, and a positive association between the hemoglobin levels and the body mass index (BMI) status has also been documented. A higher BMI may therefore affect the association between the hemoglobin levels and hypertension. However, no published studies have examined this association in relation to the BMI status. The primary purpose of this study was to assess the association between the hemoglobin levels and hypertension in relation to the BMI status.

METHODS

A cross-sectional study of 3,203 non-anemic subjects (1,191 men and 2,012 women, 30-79 years old) who were undergoing general health checkups was conducted.

RESULTS

A positive association between the hemoglobin levels and hypertension was established for both men and women. For a one SD (standard deviation) increment in hemoglobin, the multivariable odds ratio (ORs) and 95% confidence interval (CIs) for hypertension were 1.21 (95%CI: 1.05-1.40) for men and 1.25 (95%CI: 1.13-1.39) for women. We also found that a significant association was confined to the participants with a BMI of <25 kg/m(2). Among the participants with a BMI of <25 kg/m(2), the multivariable ORs and 95% CIs for hypertension of a one SD increment in hemoglobin were 1.34 (95%CI: 1.12-1.60) for men and 1.31 (95%CI: 1.16-1.47) for women. Meanwhile, among those with a BMI of ≥25 kg/m(2), the corresponding values were 1.01 (95%CI: 0.79-1.30) and 1.09 (95%CI: 0.87-1.37).

CONCLUSION

An independent positive association between the hemoglobin levels and the risk of hypertension was observed for both non-anemic Japanese men and women, confined to participants with a BMI of <25 kg/m(2).

Low iron storage and mild anemia in postural tachycardia syndrome in adolescents

OBJECTIVE

We reported low iron storage in neurally mediated syncope (NMS). While reduced red cell mass indicative of anemia has been reported in POTS, iron indices and hemoglobin (Hb) data were not reported. We investigated whether POTS, like NMS, is associated with low iron storage and anemia.

METHODS

Thirty two children evaluated in 2007 and 2008 for probable POTS by a standing or tilt test or both at Texas Children's Hospital were included in a retrospective study. We measured serum ferritin (SF) and Hb values. We defined iron deficiency as SF < 12 μg/L, low iron storage as SF ≤ 25 μg/L, anemia as low Hb values for age and sex, and POTS as ≥2 symptoms of orthostatic intolerance >3 months and increased HR of >30 BPM or HR of >120 BPM within 10 min of standing or 70° tilt.

RESULTS

Twenty four children had POTS, ages 12-18 years, 17 (71 %) were females. Value range (median) of SF 2-289 μg/L (25), Hb 11.5-14.6 (12.5) in females and 12-15.9 g/L (13.6) in males. Patients with POTS, when compared with normal US pediatric population had higher prevalence of low iron storage (50 vs. 14 %), iron deficiency (25 % of teenage girls vs. 9 %, and 16 % of teenage boys vs. 1 %), and anemia (18 % of teenage girls vs. 1.5 %, and 43 % of teenage boys vs. 0.1 %).

INTERPRETATION

Low iron storage and mild anemia are associated with POTS suggesting that low iron storage is a potentially pathophysiologic factor in both POTS and NMS.

Update on the theory and management of orthostatic intolerance and related syndromes in adolescents and children

Orthostasis means standing upright. One speaks of orthostatic intolerance (OI) when signs, such as hypotension, and symptoms, such as lightheadedness, occur when upright and are relieved by recumbence. The experience of transient mild OI is part of daily life. 'Initial orthostatic hypotension' on rapid standing is a normal form of OI. However, other people experience OI that seriously interferes with quality of life. These include episodic acute OI, in the form of postural vasovagal syncope, and chronic OI, in the form of postural tachycardia syndrome. Less common is neurogenic orthostatic hypotension, which is an aspect of autonomic failure. Normal orthostatic physiology and potential mechanisms for OI are discussed, including forms of sympathetic hypofunction, forms of sympathetic hyperfunction and OI that results from regional blood volume redistribution. General and specific treatment options are proposed.

Confounders of vasovagal syncope: orthostatic hypotension

A syncope evaluation should start by identifying potentially life-threatening causes, including valvular heart disease, cardiomyopathies, and arrhythmias. Most patients who present with syncope, however, have the more benign vasovagal (reflex) syncope. A busy syncope practice often also sees patients with neurogenic orthostatic hypotension presenting with syncope or severe recurrent presyncope. Recognition of these potential confounders of syncope might be difficult without adequate knowledge of their presentation, and this can adversely affect optimal management. This article reviews the presentation of the vasovagal syncope confounder and the putative pathophysiology of orthostatic hypotension, and suggests options for nonpharmacologic and pharmacologic management.

Medical therapy and physical maneuvers in the treatment of the vasovagal syncope and orthostatic hypotension

Patients with vasovagal syncope and neurogenic orthostatic hypotension can both present with pre-syncope and syncope resulting from systemic hypotension. While not directly responsible for increased mortality, both of these conditions can have a tremendous deleterious impact on the daily lives of patients. This negative impact can take the form of both physical symptoms and injury, but also a psychological impact from living in fear of the next syncopal episode. Despite these similarities, these are different disorders with fixed damage to the autonomic nerves in neurogenic orthostatic hypotension, as opposed to a transient reflex hypotension in "neurally mediated" vasovagal syncope. The treatment approaches for both disorders are parallel. The first step is to educate the patient about the pathophysiology and prognosis of their disorder. Next, offending medications should be withdrawn when possible. Non-pharmacological therapies and maneuvers can be used, both in an effort to prevent the symptoms and to prevent syncope at the onset of presyncope. This is all that is required in many patients with vasovagal syncope. If needed, pharmacological options are also available for both vasovagal syncope and neurogenic orthostatic hypotension, many of which are focused on blood volume expansion, increasing cardiac venous return, or pressor agents to increase vascular tone. There is a paucity of high-quality clinical trial data to support the use of these pharmacological agents. We aim to review the literature on these different therapy choices and to give recommendations on tailored approaches to the treatment of these conditions.

Anaemia, diabetes and chronic kidney disease: where are we now?

Anaemia is a common finding in people with diabetes and chronic kidney disease and failure of the kidney to produce erythro-poietin in response to a falling haemoglobin concentration is a key component, correlating with the degree of albuminuria, renal dysfunction and iron deficiency. Anaemia in diabetes is associated with a number of adverse outcomes, including increased risk of all cause and cardiovascular mortality. Whether or not anaemia is a marker or mediator of adverse outcome still remains to be completely resolved. Treatment of anaemia in diabetes has quality of life benefits and reduces transfusion requirements. Correction of anaemia to normal haemoglobin concentrations is associated with significant adverse cardiovascular outcomes and is not recommended, escalating doses of erythropoiesis-stimulating agents should be avoided. The treatment of anaemia in people with diabetes and chronic kidney disease should begin with optimisation of iron stores. An aspirational haemoglobin concentration range of 10-12 g/dl with anaemia management, balances proven benefits of anaemia treatment with potential cardiovascular risk.

Neurogenic orthostatic hypotension: pathophysiology, evaluation, and management

Neurogenic orthostatic hypotension is a distinctive and treatable sign of cardiovascular autonomic dysfunction. It is caused by failure of noradrenergic neurotransmission that is associated with a range of primary or secondary autonomic disorders, including pure autonomic failure, Parkinson’s disease with autonomic failure, multiple system atrophy as well as diabetic and nondiabetic autonomic neuropathies. Neurogenic orthostatic hypotension is commonly accompanied by autonomic dysregulation involving other organ systems such as the bowel and the bladder. In the present review, we provide an overview of the clinical presentation, pathophysiology, epidemiology, evaluation and management of neurogenic orthostatic hypotension focusing on neurodegenerative disorders.

Hemoglobin level is positively associated with blood pressure in a large cohort of healthy individuals

It has been hypothesized that an increased hemoglobin level elevates blood pressure. The present study investigated the association between hemoglobin level and systolic blood pressure and diastolic blood pressure in healthy persons. The study population was composed of 101 377 whole blood and plasma donors, who made 691 107 visits to the blood bank. At each visit, hemoglobin level and blood pressure were measured as part of the standard procedure before a blood donation. We used repeated measurement analysis to analyze the data. We used generalized estimating equation models to assess the between-person effect and linear mixed models to assess the within-person effect. All of the analyses were done separately for men and women. In the study population, 50% were men. The mean age in men was 49.3 years (±12.5 years), and in women it was 42.4 years (±13.7 years). Hemoglobin level was positively associated with both systolic and diastolic blood pressures. With respect to the between-person effect, regression coefficients for systolic blood pressure were 1.3 mm Hg per millimole per liter increase in hemoglobin level for men and 1.8 mm Hg per millimole per liter increase in hemoglobin level for women. With respect to the within-person effect, regression coefficients for systolic blood pressure were 0.7 mm Hg and 0.9 mm Hg per millimole per liter increase in hemoglobin level, for men and women, respectively. For diastolic blood pressure, results were comparable. The results show that hemoglobin level is positively associated with both systolic and diastolic blood pressures in healthy individuals. We observed consistent effects between persons but also within persons.

Red cell distribution width in patients with prehypertension and hypertension

OBJECTIVE

Red cell distribution width (RDW) which is reported as part of complete blood count in routine clinical practice, is a measure of variability in size of the erythrocytes in the circulation. It is a novel predictor of mortality both in unselected populations and in some selected group of patients. We aimed to search whether RDW values differ between the healthy population and the patients with pre-hypertension and hypertension who are otherwise healthy, considering the widely accepted role of RDW as a prognostic marker especially for mortality.

PATIENTS AND METHODS

Patients who were diagnosed with prehypertension or hypertension for the first time according to the Joint National Committee (JNC) 7 criteria and otherwise healthy were enrolled to the study. One-hundred and twenty-eight patients with hypertension, 74 patients with prehypertension and 36 healthy controls participated in the study. Complete blood count, biochemistry and erythrocyte sedimentation rates were measured by standard methods. Hemoglobin, white blood cell count, mean corpuscular volume, platelet count and RDW were recorded.

RESULTS

After adjustment for age, hemoglobin level, presence of anemia, serum uric acid level, erythrocyte sedimentation rate and mean corpuscular volume, mean RDW values were 15.26 ± 0.82, 16.54 ± 0.91 and 13.87 ± 0.94 in prehypertensive, hypertensive and control groups, respectively (p < 0.05). Systolic and diastolic blood pressures were strongly correlated with RDW (r = 0.848 and r = 0.748, respectively; p < 0.01).

CONCLUSION

RDW is higher in prehypertensive and hypertensive patients compared with healthy controls independently of age, inflammatory status and anemia. Higher RDW values are strongly correlated with higher systolic and diastolic blood pressures.

Timing and determinants of erythropoietin deficiency in chronic kidney disease

BACKGROUND AND OBJECTIVES

Anemia in patients with CKD is highly related to impaired erythropoietin (EPO) response, the timing and determinants of which remain unknown.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study measured EPO levels and studied their relation to GFR measured by 51Cr-EDTA renal clearance (mGFR) in 336 all-stage CKD patients not receiving any erythropoiesis-stimulating agent.

RESULTS

In patients with anemia defined by World Health Organization criteria (hemoglobin [Hb] <13 g/dl in men and 12 g/dl in women), EPO response to Hb level varied by mGFR level. EPO and Hb levels were negatively correlated (r=-0.22, P=0.04) when mGFR was >30 ml/min per 1.73 m(2), whereas they were not correlated when mGFR was <30 (r=0.09, P=0.3; P for interaction=0.01). In patients with anemia, the ratio of observed EPO to the level predicted by the equation for their Hb level decreased from 0.72 (interquartile range, 0.57-0.95) for mGFR ≥60 ml/min per 1.73 m(2) to 0.36 (interquartile range, 0.16-0.69) for mGFR <15. Obesity, diabetes with nephropathy other than diabetic glomerulopathy, absolute iron deficiency, and high C-reactive protein concentrations were associated with increased EPO levels, independent of Hb and mGFR.

CONCLUSIONS

Anemia in CKD is marked by an early relative EPO deficiency, but several factors besides Hb may persistently stimulate EPO synthesis. Although EPO deficiency is likely the main determinant of anemia in patients with advanced CKD, the presence of anemia in those with mGFR >30 ml/min per 1.73 m(2) calls for other explanatory factors.