Unravelling the interplay between hyperkalaemia, renin-angiotensin-aldosterone inhibitor use and clinical outcomes. Data from 9222 chronic heart failure patients of the ESC-HFA-EORP Heart Failure Long-Term Registry

AIMS

We assessed the interplay between hyperkalaemia (HK) and renin-angiotensin-aldosterone system inhibitor (RAASi) use, dose and discontinuation, and their association with all-cause or cardiovascular death in patients with chronic heart failure (HF). We hypothesized that HK-associated increased death may be related to RAASi withdrawal.

METHODS AND RESULTS

The ESC-HFA-EORP Heart Failure Long-Term Registry was used. Among 9222 outpatients (HF with reduced ejection fraction: 60.6%, HF with mid-range ejection fraction: 22.9%, HF with preserved ejection fraction: 16.5%) from 31 countries, 16.6% had HK (≥5.0 mmol/L) at baseline. Angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) was used in 88.3%, a mineralocorticoid receptor antagonist (MRA) in 58.7%, or a combination in 53.2%; of these, at ≥50% of target dose in ACEi: 61.8%; ARB: 64.7%; and MRA: 90.3%. At a median follow-up of 12.2 months, there were 789 deaths (8.6%). Both hypokalaemia and HK were independently associated with higher mortality, and ACEi/ARB prescription at baseline with lower mortality. MRA prescription was not retained in the model. In multivariable analyses, HK at baseline was independently associated with MRA non-prescription at baseline and subsequent discontinuation. When considering subsequent discontinuation of RAASi (instead of baseline use), HK was no longer found associated with all-cause deaths. Importantly, all RAASi (ACEi, ARB, or MRA) discontinuations were strongly associated with mortality.

CONCLUSIONS

In HF, hyper- and hypokalaemia were associated with mortality. However, when adjusting for RAASi discontinuation, HK was no longer associated with mortality, suggesting that HK may be a risk marker for RAASi discontinuation rather than a risk factor for worse outcomes.

Sclerodermatous Chronic Graft-versus-Host Disease Treated With Imatinib: A Dermatological Perspective

INTRODUCTION

Chronic graft-versus-host disease (cGVHD) is the most important cause of late non-relapse mortality after allogeneic hematopoietic stem cell transplantation. Sclerodermatous cGVHD is usually steroid refractory and remains a therapeutic challenge. Activating antibodies against the PDGFR have been reported in patients with sclerodermatous cGVHD. These antibodies induce PDGFR phosphorylation and lead to fibrosis. There is increasing evidence of successful treatment of sclerodermatous cGVHD with imatinib, a tyrosine kinase inhibitor.

OBJECTIVE

To evaluate the response of cutaneous sclerodermatous cGVHD to imatinib.

MATERIALS AND METHODS

Retrospective study of 18 patients with sclerodermatous cGVHD refractory to immunosuppressants treated with imatinib in a single center. Evaluation of treatment response was performed by clinicians' assessment and patients' subjective response at one, 3, 6, 9, 12 and 18 months after initiation of imatinib. Response was assessed as complete, partial, significant, no change or progression. Tapper off steroids was complete, partial or not possible.

RESULTS

In our series, 4 (22%) patients achieved complete response, 9 (50%) patients partial response, 2 (11%) patients significant response, 2 (11%) patients had no change and one (6%) patient progressive disease at last follow-up. Mean time from initiation of imatinib to any degree of response was 2,75 months (range 1-9 months).

CONCLUSIONS

This study provides further evidence of the role of imatinib for the treatment of steroid refractory sclerodermatous cGVHD.

Systolic volume index by Doppler echocardiography is an useful marker for stratification and prognostic evaluation in patients with severe aortic stenosis and preserved ejection fraction

INTRODUCTION AND OBJECTIVES

The prognosis of patients with severe aortic stenosis, low aortic gradient and preserved ejection fraction is controversial. Our study analyzed the prognosis of these patients and its relation to pressure gradient and aortic valve flow.

METHODS

We performed a retrospective cohort study of 363 consecutive patients with severe aortic stenosis and preserved ejection fraction, divided into 4 groups, based on the presence of a systolic volume index greater or lower than 35 mL/m(2) and the presence of a mean aortic gradient greater or lower than 40 mmHg. Group I: normal flow, high gradient (n=169, 47%); group II: normal flow, low gradient (n=98, 27%); group III: low flow, high gradient (n=54, 15%), and group IV: low flow, low gradient (n=42, 12%). The primary endpoint was overall mortality.

RESULTS

Independent risk factors for mortality were age (hazard ratio=1.04; 95% confidence interval, 1.01-1.08) and atrial fibrillation (hazard ratio=2.21; 95% confidence interval, 1.24-3.94). Surgical treatment was associated with longer survival in all groups (hazard ratio=0.25; 95% confidence interval: 0.13-0.49). Mortality was higher in patients with low flow than in those with with normal flow (26.6% vs 13.6%; P=.004). The most favorable mean prognosis was found in group II (hazard ratio=0.4; 95% confidence interval, 0.2-0.9).

CONCLUSIONS

Patients with severe aortic stenosis, normal ejection fraction and low aortic flow have a worse prognosis. Analysis of aortic flow by Doppler echocardiography is useful in risk stratification and therapeutic decision-making in patients with aortic stenosis.

Comparison of three strategies to evaluate uncertainty from in-house validation data. A case study: mercury determination in sediments

In the present paper, three approaches are compared for the evaluation of the combined uncertainty in the determination of mercury in aquatic sediments by an aqua regia extraction procedure. For this, the data obtained in validation studies from five certified reference materials (CRMs), covering a range of concentrations from 0.8 to 130 mg kg(-1) of mercury and analysed by three atomic spectroscopic techniques (cold vapour generation atomic fluorescence spectrometry, CV-AFS, cold vapour generation atomic absorption spectroscopy, and inductively coupled plasma mass spectroscopy), were considered. The combined uncertainty was firstly assessed by considering separately the data obtained for each CRM analysed (approach A). Moreover, this assessment was also performed with two other calculation approaches (B and C) based on the pooled data obtained from the validation step. The comparison of the results obtained for the different techniques showed a clear bias effect when using CV-AFS with nitric acid as a diluent. In relation to the strategies tested for the combined uncertainty assessment, approach C proved to be the easiest and friendliest method for uncertainty assessment.

Effect of chloride on heavy metal mobility of harbour sediments

To evaluate the environmental impact of polluted sediments, several operationally defined sequential extraction procedures (SEPs) have been described. Salinity has long been recognised as an important variable determining the physicochemical behaviour of heavy metals in marine sediments. Thus, in the present paper, the modified BCR-SEP has been applied to harbour sediments in order to assess to what extent trace metal mobility (Cd, Cr, Cu, Ni, Pb and Zn) could be influenced by chloride content in sediments. For this, washed (W) and non-washed (NW) sediments were compared. The relative mobility order observed for the six trace metals studied was not seen to be influenced by the presence of chloride in the sediments, but an increase of mobility was observed for Cd and Zn (the most mobile metals) when chloride was present in the sediments. Characterisation of the sediments and of the pseudo-total metal contents by means of an aqua regia extraction was also assessed.

Assessment of metal mobility in dredged harbour sediments from Barcelona, Spain

In order to assess heavy metal mobility in dredged harbour sediments, six superficial sediment samples covering a range of pollution levels and environments were collected in Barcelona Harbour. Samples were characterised in terms of major compounds (Al, Ca, Fe, Mn, Si, Ti, Mg, K and Na); total C, N and S contents; organic matter; and water content. Pseudo-total trace metal contents were assessed after aqua regia digestion (ISO 11466:1995). The modified BCR three-step sequential extraction procedure (BCR-SEP) was applied, and both major compounds (Al, Ca, Fe and Mn) and trace metals (Cd, Cr, Cu, Ni, Pb and Zn) were determined in the different extracts. Both the pseudo-total digestion method and the BCR-SEP were validated using two sediment certified materials from lakes (BCR CRM 701 and BCR CRM 601). The highest metal concentrations were observed in one of the sampling points which receives an urban discharge. The observed mobility order (percentage of metal extracted in the first step) of the six trace metals studied was Cd>Zn>Pb>Cu>Ni>Cr. The good agreement observed with the results obtained as the sum of the four steps (extractable+residue) and the pseudo-total content shows that laboratory working conditions were under control.

Mercury determination in solid phases from application of the modified BCR-sequential extraction procedure: a valuable tool for assessing its mobility in sediments

The present paper presents a feasibility study for the evaluation of mercury mobility in sediments by application of the modified BCR three-step sequential extraction procedure (BCR-SEP). The aim of the study was to evaluate the effect of acidification, reduction and oxidation processes on mercury mobility from sediments, once the SEP was validated with other trace metals. As extractable mercury amounts were mostly found below detection limits of the advanced mercury analyser (AMA-254) used for measuring the extracts (L.D.<0.5 ng), the use of a solid sampling atomic absorption spectrometer with a specially designed furnace for Hg atomisation was found to be an optimal technique to quantify Hg in the solid residues coming from the SEP. With this approach, mercury was found to be hardly mobile and only for one of the moderately polluted sediments (BCR CRM 320), extractable mercury (exchangeable fraction, BCR procedure step 1) has been found. An oxidation step with H(2)O(2) was required to obtain extractability up to 64% of the total content in a highly polluted lagoon sediment.

Comparison of leaching tests for the study of trace metals remobilisation in soils and sediments

Several leaching tests were applied and compared to study metal remobilisation on various unpolluted and contaminated soils and on several contaminated sediments. The trace elements considered were Cd, Cr, Cu, Ni, Pb and Zn, and leaching tests consisted of the application of reagents with contrasting characteristics and strengths in order to assess the information provided. An extraction with aqua regia permitted the estimation of the pseudo-total metal content in the sample. Mild extractants such as H2O, CaCl2 and NaNO3 showed low and similar leaching capacities. Acid (CH3COOH) and complexing (EDTA) agents were more effective in remobilising trace metals from soils and sediments. Cd and Zn showed similar extraction characteristics under both extractant solutions, whereas Cu and Pb were more sensitive to complexation, and Ni and Cr to acidification processes. Sequential chemical extractions provided additional information on the association of the trace elements with the different soil and sediment phases. Cd and Zn showed the highest mobility, Pb was associated to reducible solid phases, Cu and Ni to oxidisable phases, and Cr remained mostly in the residual fraction. The results obtained in this paper provided valuable information for choosing a leaching test, which is an instrument of environmental analysis for the estimation of trace metal mobility.

Application of a modified BCR sequential extraction (three-step) procedure for the determination of extractable trace metal contents in a sewage sludge amended soil reference material (CRM 483), complemented by a three-year stability study of acetic acid and EDTA extractable metal content

This paper provides additional data on a sewage sludge amended soil certified reference material, CRM 483, which was certified in 1997 for its EDTA and acetic acid extractable contents of some trace metals, following standardised extraction procedures. The additional work aimed to test the long-term stability of the material and the applicability of an improved version of the BCR three-step sequential extraction procedure on the sewage sludge amended soil (CRM 483). The paper demonstrates the CRM 483 long-term stability for EDTA and acetic acid extractable contents of Cd, Cr, Cu, Ni, Pb and Zn and gives the results (obtained in the framework of an interlaboratory study) for the extractable contents of the same elements in the CRM 483, following the BCR three-step sequential extraction scheme. The aqua regia extractable contents following the ISO 11466 Standard are also given. The data are given as indicative (not certified) values.

Application of focused-microwave wet digestion to the determination of trace metals in human gallstones by ICP/AES

We propose an analytical digestion method for trace metal determination (Co, Cr, Cu, Fe, Mn, Ni and Zn) in gallstones, in an attempt to facilitate detection of their origin. The method consists of sample digestion with HNO3 and H2O2 by means of focused microwave. Metals are quantified by inductively coupled plasma atomic emission spectroscopy. The effect of calcium concentration in the analytical solutions was studied. Cu, Fe, Mn and Zn were detected in all the samples analysed and the highest concentrations were obtained for Cu and Fe, especially in black-pigmented gallstones. The reproducibility in terms of %RSD, determined in the gallstones with the lowest metal content, was below 5% for Cu, between 10% and 15% for Mn and Zn and up to 25% for Fe.

Improvement of the BCR three step sequential extraction procedure prior to the certification of new sediment and soil reference materials

The Standards, Measurements and Testing Programme (formerly BCR) of the European Commission proposed a three-step sequential extraction procedure for sediment analysis, following extensive expert consultations and two interlaboratory studies. This scheme was recently used to certify the extractable trace element contents of a sediment reference material (CRM 601). Although this procedure offers a means to ensure the comparability of data in this field, some difficulties concerning the interlaboratory reproducibility still remain, and a new project is currently being conducted to determine the causes of poor reproducibility in the extraction scheme. The final objective of the project is the certification of new sediment and soil reference materials for their extractable contents of Cd, Cr, Cu, Ni, Pb and Zn. This paper presents the results of a small-scale interlaboratory study, which aimed to test a revised version of the extraction schemes by comparing the original and the modified protocols using the CRM 601 sample. This work offers an improvement to the BCR sequential extraction procedure through intercomparison exercises. This improved procedure will allow the obtaining of CRMs to validate analytical data in the analysis of soils and sediments, and it will also facilitate comparability of data in the European Union.