Early repeat hospitalization for fluid overload in individuals with cardiovascular disease and risks: a retrospective cohort study

AIMS

Fluid overload is a common manifestation of cardiovascular and kidney disease and a leading cause of hospitalizations. To identify patients at risk of recurrent severe fluid overload, we evaluated the incidence and risk factors associated with early repeat hospitalization for fluid overload among individuals with cardiovascular disease and risks.

METHODS

Single-center retrospective cohort study of 3423 consecutive adults with an index hospitalization for fluid overload between January 2015 and December 2017 and had cardiovascular risks (older age, diabetes mellitus, hypertension, dyslipidemia, kidney disease, known cardiovascular disease), but excluded if lost to follow-up or eGFR < 15 ml/min/1.73 m2. The outcome was early repeat hospitalization for fluid overload within 30 days of discharge.

RESULTS

The mean age was 73.9 ± 11.6 years and eGFR was 54.1 ± 24.6 ml/min/1.73 m2 at index hospitalization. Early repeat hospitalization for fluid overload occurred in 291 patients (8.5%). After adjusting for demographics, comorbidities, clinical parameters during index hospitalization and medications at discharge, cardiovascular disease (adjusted odds ratio, OR 1.66, 95% CI 1.27-2.17), prior hospitalization for fluid overload within 3 months (OR 2.52, 95% CI 1.17-5.44), prior hospitalization for any cause in within 6 months (OR 1.33, 95% CI 1.02-1.73) and intravenous furosemide use (OR 1.58, 95% CI 1.10-2.28) were associated with early repeat hospitalization for fluid overload. Higher systolic BP on admission (OR 0.992, 95% 0.986-0.998) and diuretic at discharge (OR 0.50, 95% CI 0.26-0.98) reduced early hospitalization for fluid overload.

CONCLUSION

Patients at-risk of early repeat hospitalization for fluid overload may be identified using these risk factors for targeted interventions.

Renal function in very old critically ill patients

PURPOSE OF REVIEW

Current demographic change leads to higher number of elderly patients admitted to an ICU. Among other organs also the kidneys show age-related changes, which are associated with a decline in various aspects of renal function. The purpose of this review is to provide an overview of structural and functional changes in elderly and also to specifically address the increased risk of acute kidney injury (AKI) in this population.

RECENT FINDINGS

Ageing in the kidneys is affected by many different factors, such as low grade chronic inflammation, called inflammageing, and various comorbidities. Nevertheless, a decrease of glomerular filtration rate (GFR) occurs independent of the presence of comorbidities and a steady decline of GFR has been reported in both healthy men and women. Pharmacodynamic of many drugs is altered by these changes. Additionally the rate of diuretic resistance appears to be increased. The cause of AKI occurrence in older age is, multifactorial and includes preventable triggers (hypovolemia, hypotension, nephrotoxins) as well as changes associated with aging.

SUMMARY

Age-related alterations of the kidneys were found at microscopic and macroscopic levels of the cell. These changes lead to a reduced renal reserve and subsequently to an increased vulnerability of aged kidneys when an additional stressor is added. Age is an independent risk factor for developing AKI. Physicians should take into account the altered renal function in elderly patients and take renal protective measures at an early stage.

Diuretic-resistant heart failure and the role of ultrafiltration: A proposed protocol

Acute heart failure (HF) decompensation generally manifests with signs and symptoms of congestion that strongly predict poor poor patient outcome. Loop diuretics are the cornerstone of therapy to counteract fluid overload and are widely used for acute management and chronic stabilization of HF. However, a diminished response to loop diuretics is a common problem, affecting the patient's clinical course and potentially prolonging hospitalization. Diuretic resistance is defined as failure to decongest despite appropriate and escalating loop diuretic therapy. We propose a protocol for the management of diuretic resistance. The initial approach should include an assessment of causes of pseudo-diuretic resistance. Adjustments to loop diuretic therapy, such as increasing doses and frequency of administration and sequential nephron blockade, may be successful. For hospitalized patients with progressive disease there are more invasive methods for fluid removal. Switching from oral to intravenous loop diuretics is essential to avoid variable absorption and for symptomatic relief. Extracorporeal ultrafiltration is also an option since this technique is highly effective at removing plasma fluid from blood. While extracorporeal ultrafiltration is an invasive solution, peritoneal dialysis is a home-based, intermittent therapeutic option that can enable efficient management of fluid overload, preventing HF-related hospital admission, and improving quality of life. As a last resort for fluid removal, a peritoneal dialysis regimen should fully exploit its decongestive properties and should be tailored to the patient's characteristics and clinical needs.

Wall Tension and Tubular Resistance in Kidney Cystic Conditions

The progressive formation of single or multiple cysts accompanies several renal diseases. Specifically, (i) genetic forms, such as adult dominant polycystic kidney disease (ADPKD), and (ii) acquired cystic kidney disease (ACKD) are probably the most frequent forms of cystic diseases. Adult dominant polycystic kidney disease (ADPKD) is a genetic disorder characterized by multiple kidney cysts and systemic alterations. The genes responsible for the condition are known, and a large amount of literature focuses on the molecular description of the mechanism. The present manuscript shows that a multiscale approach that considers supramolecular physical phenomena captures the characteristics of both ADPKD and acquired cystic kidney disease (ACKD) from the pathogenetic and therapeutical point of view, potentially suggesting future treatments. We first review the hypothesis of cystogenesis in ADPKD and then focus on ACKD, showing that they share essential pathogenetic features, which can be explained by a localized obstruction of a tubule and/or an alteration of the tubular wall tension. The consequent tubular aneurysms (cysts) follow Laplace's law. Reviewing the public databases, we show that ADPKD genes are widely expressed in various organs, and these proteins interact with the extracellular matrix, thus potentially modifying wall tension. At the kidney and liver level, the authors suggest that altered cell polarity/secretion/proliferation produce tubular regions of high resistance to the urine/bile flow. The increased intratubular pressure upstream increases the difference between the inside (Pi) and the outside (Pe) of the tubules (∆P) and is counterbalanced by lower wall tension by a factor depending on the radius. The latter is a function of tubule length. In adult dominant polycystic kidney disease (ADPKD), a minimal reduction in the wall tension may lead to a dilatation in the tubular segments along the nephron over the years. The initial increase in the tubule radius would then facilitate the progressive expansion of the cysts. In this regard, tubular cell proliferation may be, at least partially, a consequence of the progressive cysts' expansion. This theory is discussed in view of other diseases with reduced wall tension and with cysts and the therapeutic effects of vaptans, somatostatin, SGLT2 inhibitors, and potentially other therapeutic targets.

The Importance of the Nephrologist in the Treatment of the Diuretic-Resistant Heart Failure

Heart failure is not only a global problem but also significantly limits the life prospects of these patients. The epidemiology and presentation of heart failure are intensively researched topics in cardiology. The risk factors leading to heart failure are well known; however, the real challenge is to provide effective treatments. A vicious cycle develops in heart failure of all etiologies, sooner or later compromising both cardiac and kidney functions simultaneously. This can explain the repeated hospital admissions due to decompensation and the significantly reduced quality of life. Moreover, diuretic-refractory heart failure represents a distinct challenge due to repeated hospital admissions and increased mortality. In our narrative review, we wanted to draw attention to nephrology treatment options for severe diuretic-resistant heart failure. The incremental value of peritoneal dialysis in severe heart failure and the feasibility of percutaneous peritoneal dialysis catheter insertion have been well known for many years. In contrast, the science and narrative of acute peritoneal dialysis in diuretic-resistant heart failure remains underrepresented. We believe that nephrologists are uniquely positioned to help these patients by providing acute peritoneal dialysis to reduce hospitalization dependency and increase their quality of life.

Diuretic resistance in patients with kidney disease: Challenges and opportunities

Edema caused by kidney disease is called renal edema. Edema is a common symptom of many human kidney diseases. Patients with renal edema often need to take diuretics.However, After taking diuretics, patients with kidney diseases are prone to kidney congestion, decreased renal perfusion, decreased diuretics secreted by renal tubules, neuroendocrine system abnormalities, abnormal ion transporter transport, drug interaction, electrolyte disorder, and hypoproteinemia, which lead to ineffective or weakened diuretic use and increase readmission rate and mortality. The main causes and coping strategies of diuretic resistance in patients with kidney diseases were described in detail in this report. The common causes of DR included poor diet (electrolyte disturbance and hypoproteinemia due to patients' failure to limit diet according to correct sodium, chlorine, potassium, and protein level) and poor drug compliance (the patient did not take adequate doses of diuretics. true resistance occurs only if the patient takes adequate doses of diuretics, but they are not effective), changes in pharmacokinetics and pharmacodynamics, electrolyte disorders, changes in renal adaptation, functional nephron reduction, and decreased renal blood flow. Common treatment measures include increasing in the diuretic dose and/or frequency, sequential nephron blockade,using new diuretics, ultrafiltration treatment, etc. In clinical work, measures should be taken to prevent or delay the occurrence and development of DR in patients with kidney diseases according to the actual situation of patients and the mechanism of various causes. Currently, there are many studies on DR in patients with heart diseases. Although the phenomenon of DR in patients with kidney diseases is common, there is a relatively little overview of the mechanism and treatment strategy of DR in patients with kidney diseases. Therefore, this paper hopes to show the information on DR in patients with kidney diseases to clinicians and researchers and broaden the research direction and ideas to a certain extent.

Review the factors associated with dietary sodium adherence in patients with heart failure from selected research-based literatures

Background

Low-sodium dietary is an important measure to avoid heart failure patient’s body fluid volume overload. There are still more than 50% of heart failure patients who are incapable of complying low-sodium dietary. This study utilized the systematic literature review method, with the purpose to understand the related factors towards the compliance behavior of low-sodium dietary of patients with heart failure.

Methods

This study typed keywords (congestive heart failure, adherence, compliance, low sodium diet, low salt diet, dietary sodium restriction) from computer databases (CINAHL, Cochrane, Medline, ProQuest Nursing Allied Health, PubMed, and ScienceDirect) and according to inclusion criteria were as follows: (1) Research objects were adult patients admitted to HF, (2) Research content were related to sodium diet compliance behavior. (3) Non-intervention research. Exclusion criteria were as follows: (1) participants who was pregnant women, (2) qualitative research, (3) studies on development of tool, (4) poster. Select needed 14 articles that meet the purposes of this study. In addition, the study also collected 4 more studies with the same purpose from the references that were included in the retrieved articles, and finally a total of 18 studies were included in the analysis of this study. Data analysis uses descriptive statistics (percentage, frequency distribution) and content analysis method.

Results

This study use a systematic literature review method, it was found that the results of the studies use nonintervention method, which explored the relevant factors of low-sodium dietary compliance in heart failure patients over the past 20 years, could be summarized in 4 dimensions as social and economic conditions, patient conditions, disease conditions and therapy conditions.

Conclusions

Heart failure patients’ compliance behavior toward low-sodium dietary is multi-dimensional. Therefore, this study recommends when the health care providers evaluating patients’ compliance behavior of low-sodium dietary, it is necessary to consider more different aspects.

Usefulness of Incorporating Hypochloremia into the Get With The Guidelines-Heart Failure Risk Model in Patients With Acute Heart Failure

Although hypochloremia is strongly associated with adverse prognosis in acute heart failure (AHF), it is unknown whether incorporating hypochloremia into the preexisting risk model improves the model performance. We calculated the Get With The Guidelines-Heart Failure (GWTG-HF) risk score in 1,428 patients with AHF (derivation cohort) and developed 2 risk scores incorporating brain natriuretic peptide (BNP) into the GWTG-HF risk score (GWTG-BNP risk score) and incorporating both BNP and hypochloremia (GWTG-BNP-Cl risk score). Hypochloremia was defined as <98 mmol/L. The external validation and comparison of model performance were performed in an independent group of 1,256 patients with AHF (validation cohort). All models were tested for in-hospital mortality. Hypochloremia was observed in 9.4% and 12.2% of the derivation and validation cohorts, respectively. Hypochloremia was an independent predictor of in-hospital mortality in the derivation cohort (odds ratio 2.02; p = 0.028). In the validation cohort, the GWTG-HF, GWTG-BNP, and GWTG-BNP-Cl risk scores demonstrated good discrimination (area under the curve: 0.742, 0.749, and 0.763, respectively). However, the GWTG-BNP-Cl risk score was more reliable than the GWTG-HF and GWTG-BNP risk scores in risk reclassification (net reclassification improvement: 0.491 and 0.408, respectively; p <0.01 for both). Moreover, this score demonstrated a good calibration of the GWTG-BNP-Cl model (Hosmer-Lemeshow test: p = 0.479). In conclusion, incorporating hypochloremia into the preexisting risk model improves the model performance.

Patterns of Calcium- and Chloride-Ion Disorders and Predictors among Obese Outpatient Adults in Southern Ethiopia

BACKGROUND

Obesity is a condition characterized by abnormal or excess accumulation of fat in body tissue, which may impair health and result in electrolyte derangement. Hypercalcemia and hypochloremia are significant problems in obese patients, and can cause substantial morbidity and mortality. Determination of patterns of calcium and chloride may play a major role in the management of obese patients. Therefore, this study aimed to determine calcium and chloride disorders and their predictors among obese adults in the outpatient department at Wolkite University Specialized Hospital, southern Ethiopia from May to August 2020.

METHODS

This institution-based cross-sectional study was conducted on 250 obese adults attending the outpatient department from May to August 2020. Structured questionnaires through face-to-face interviews and participants' medical records were used to collect information on determinants related to calcium- and chloride-ion disturbances. Levels of serum calcium and chloride were measured using an ion-selective electrode analyzer. Bivariate and multivariate logistic regression analyses were done to identify determinants associated with calcium and chloride disorders. Using ORs and 95% CIs,P<0.05 was considered significant.

RESULTS

Among the 250 patients, 18% (95% CI 53.02-111) and 17.6% (95% CI 0.78-12) of study participants were hypochloremic and hypercalcemic, respectively. Age ≥50 years (AOR 3.58, 95% CI 2.57-11.10), diuretic use (AOR 2.35, 95% CI 1.31-4.23), and obesity (AOR, 6.82, 95% CI 2.26-14.62) were independent predictors of hypochloremia on multivariate logistic regression, and obesity (AOR 9.21, 95% CI 2.50-14.81), overweight (AOR 8.32, 95% CI 1.61-10.20) and physical inactivity (AOR 4.28, 95% CI 1.71-10.44) were predictors of hypercalcemia.

CONCLUSION

High burdens of hypochloremia (18%) and hypercalcemia (17.6%) were observed in these patients. Increased age, diuretic use, being overweight, and physical inactivity were predictors of electrolyte disorders. The findings of this study should be taken into consideration to implement preventive interventions on these predictors in obese patients. Promoting sufficient fruit and vegetable consumption and physical exercise and determination of serum-chloride and -calcium levels in adult overweight/obese patients are recommended to minimize the emergence of electrolyte disorders.

Clinical Characteristics of De Novo Heart Failure and Acute Decompensated Chronic Heart Failure: Are They Distinctive Phenotypes That Contribute to Different Outcomes?

Heart failure is currently one of the leading causes of morbidity and mortality. Patients with heart failure often present with acute symptoms and may have a poor prognosis. Recent evidence shows differences in clinical characteristics and outcomes between de novo heart failure (DNHF) and acute decompensated chronic heart failure (ADCHF). Based on a better understanding of the distinct pathophysiology of these two conditions, new strategies may be considered to treat heart failure patients and improve outcomes. In this review, the authors elaborate distinctions regarding the clinical characteristics and outcomes of DNHF and ADCHF and their respective pathophysiology. Future clinical trials of therapies should address the potentially different phenotypes between DNHF and ADCHF if meaningful discoveries are to be made.

Diabetes prevalence and outcomes in hospitalized cardiorenal-syndrome patients with and without hyponatremia

BACKGROUND

Hyponatremia is known to be associated with a worse patient outcome in heart failure. In cardiorenal syndrome (CRS), the prognostic role of concomitant hyponatremia is unclear. We sought to evaluate potential risk factors for hyponatremia in patients with CRS presenting with or without hyponatremia on hospital admission.

METHODS

In a retrospective study, we investigated 262 CRS patients without sepsis admitted to the University Hospital Halle over a course of 4 years. CRS diagnosis was derived from an electronic search of concomitant diagnoses of acute or chronic (NYHA 3-4) heart failure and acute kidney injury (AKIN 1-3) or chronic kidney disease (KDIGO G3-G5_nonD). A verification of CRS diagnosis was done based on patient records. Depending on the presence (Na < 135 mmol/L) or absence (Na ≥ 135 mmol/L) of hyponatremia on admission, the CRS patients were analyzed for comorbidities such as diabetes, presence of hypovolemia on admission, need for renal replacement therapy and prognostic factors such as in-hospital and one-year mortality.

RESULTS

Two hundred sixty-two CRS patients were included in this study, thereof, 90 CRS patients (34.4%) with hyponatremia (Na < 135 mmol/L). The diabetes prevalence among CRS patients was high (> 65%) and not related to the serum sodium concentration on admission. In comparison to non-hyponatremic CRS patients, the hyponatremic patients had a lower serum osmolality, hypovolemia was more prevalent (41.1% versus 16.3%, p < 0.001). As possible causes of hypovolemia, diarrhea, a higher number of diuretic drug classes and higher diuretic dosages were found. Hyponatremic and non-hyponatremic CRS patients had a comparable need for renal-replacement therapy (36.7% versus 31.4%) during the hospital stay. However, after discharge, relatively more hyponatremic CRS patients on renal replacement therapy switched to a non-dialysis therapy regimen (50.0% versus 22.2%). Hyponatremic CRS patients showed a trend for a higher in-hospital mortality (15.6% versus 7.6%, p = 0.054), but no difference in the one-year mortality (43.3% versus 40.1%, p = 0.692).

CONCLUSIONS

All CRS patients showed a high prevalence of diabetes mellitus and a high one-year mortality. In comparison to non-hyponatremic CRS patients, hyponatremic ones were more likely to have hypovolemia, and had a higher likelihood for temporary renal replacement therapy.

Atherosclerotic-nephropathy: an updated narrative review

The increased prevalence of chronic kidney disease (CKD) in elderly patients recognizes, as main cause, the long-term exposure to atherosclerosis and hypertension. Chronic ischemic damage due to critical renal arterial stenosis induces oxidative stress and intra-renal inflammation, resulting in fibrosis and microvascular remodelling, that is the histological picture of atherosclerotic renal vascular disease (ARVD). The concomitant presence of a long history of hypertension may generate intimal thickening and luminal narrowing of renal arteries and arterioles, glomerulosclerosis, interstitial fibrosis and tubular atrophy, more typically expression of hypertensive nephropathy. These complex mechanisms contribute to the development of CKD and the progression to End Stage Kidney Disease. In elderly CKD patients, the distinction among these nephropathies may be problematic; therefore, ischemic and hypertensive nephropathies can be joined in a unique clinical syndrome defined as atherosclerotic nephropathy. The availability of novel diagnostic procedures, such as intra-vascular ultrasound and BOLD-MRI, in addition to traditional imaging, have opened new scenarios, because these tools allow to identify ischemic lesions responsive to renal revascularization. Indeed, although trials have deflated the role of renal revascularization on the renal outcomes, it should be still used to avoid dialysis initiation and/or to reduce blood pressure in selected elderly patients at high risk. Nonetheless, lifestyle modifications (smoking cessation, increased physical activity), statins and antiplatelet use, as well as cautious use of renin-angiotensin system inhibitors, remain the main therapeutic approach aimed at slowing the renal damage progression. Mesenchymal stem cells and Micro-RNA are promising target of anti-fibrotic therapy, which might provide potential benefit in ARVD patients, though safety and efficacy profile in humans is unknown too.

Multicomponent Compression Bandaging Combined with Diuretic Therapy of Anasarca Secondary to Palliative Chemotherapy: A Case Report

Background: Although decongestive physiotherapy combined with diuretics may be efficient in limb edemas, no such therapy has been described in the context of anasarca. Case Description: A bedbound 62-year-old man with stage IV pancreatic cancer, presenting with progressing severe dyspnea at rest and anasarca, was admitted to the free-standing hospice 3 weeks after receiving nab-paclitaxel with gemcitabine. Two weeks before admission, oral loop and potassium-sparing diuretics were started for bilateral lower limb edema, which progressed to anasarca even though the drug dose was increased. Hypotension hindered further dose escalation of diuretics. Supportive multicomponent bandage compression on both legs with concurrent intravenous furosemide in hypersaline infusion was implemented with good clinical toleration. Afterward, the loop diuretic dose was increased, and supplemented with dexamethasone. A spectacular edema decrease and marked dyspnea improvement with 19 kg body weight reduction were observed within 7 days. Furosemide was switched to oral route and the patient was discharged needing only occasional assistance in daily living. Conclusion: Compression bandaging with diuretic therapy may be considered even in advanced generalized edemas; however, further studies are needed to determine the adequate therapeutic regime.