Intrarenal Venous Doppler as a novel marker for optimal decongestion, patient management, and prognosis in Acute Decompensated Heart Failure

AIMS

An increase in right atrial pressure is a common feature of acute decompensated heart failure (ADHF). Such increased pressure leads to persistent kidney congestion. A marker to guide optimal diuretic therapy is missing. We aim to correlate intrarenal Doppler (IRD) ultrasound in ADHF patients with clinical outcomes to assess whether renal haemodynamic parameter changes are useful for monitoring kidney congestion.

METHODS AND RESULTS

Between December 2018 and January 2020, ADHF patients requiring intravenous diuretic therapy for at least 48 h were considered for study selection. An IRD blinded examination was performed on Days 1, 3, and 5, and clinical and laboratory parameters were recorded. Venous Doppler profiles (VDP) were classified as continuous (C), pulsatile (P), biphasic (B), or monophasic (M) according to the congestion degree; B and M profiles were considered deranged. A VDP improvement (VDPimp) was defined as a change of ≥1 pattern degree or maintenance of C or P patterns. An arterial resistive index (RI) > 0.8 was considered elevated. Outcomes of death and rehospitalization were gathered at 60 days. Data were assessed by regression and Kaplan-Meier analyses. All 177 ADHF patients admitted were screened, and 72 were enrolled [27 females-median age 81 (76-87) years-median ejection fraction 40% (30-52)]. The VDP derangement decreased from 79.2% on Day 1 to 51.4% on Day 5 (P < 0.05). The RI elevation decreased from 60.6% on Day 1 to 43.1% on Day 5 (P < 0.05). At Day 5, VDPimp was registered in over half of the patients (59.7%). At Day 5, signs of congestion (dyspnoea/oedema/rales), fluid accumulation (pleural/peritoneal fluid), haematocrit, and brain natriuretic peptide improved (P > 0.05). After 60 days, 12 (16.7%) patients were readmitted and 9 (12.5%) died. The VDPimp was identified as the unique independent factor associated with readmission [Hazard Ratio (HR) 0.22, 95% (confidence interval) CI 0.05-0.94, P = 0.04] and death (HR 0.07, 95% CI 0.01-0.68, P = 0.02), with significantly better outcomes identified in VDPimp patients (log-rank test, P < 0.05).

CONCLUSION

Decongestion may be associated with improvements in many clinical and instrumental parameters, but only VDPimp was associated with better clinical outcomes. The VDPimp should be incorporated in ad hoc ADHF clinical trials to better define its role in everyday practice.

Clinicopathologic correlates and prognostic relevance of the immune checkpoint CD73 (NT5E) in resected biliary cancers (BC)

473

Background: CD73, an ecto-5’-nucleotidase (NT5E), creates an immunosuppressive tumour-promoting microenvironment by converting ATP to adenosine. The expression of CD73 has been linked to poorer patients (pts) outcome across several cancer types and the targeted inhibition of this immunoinhibitory protein has been recently advanced to clinical development. However, the clinicopathologic role of CD73 as well as its potential implications are largely unexplored in BC. Methods: The expression of CD73 was assessed by immunohistochemistry on both tumour (tCD73) and stromal tissue (sCD73) of a clinically-annotated cohort of radically-resected BC and scored for staining intensity as follows: +1, +2 and +3. RNAseq was performed on RNA isolated from surgical specimens. Differences between groups were evaluated using the Chi-square test. Survival functions were estimated by the Kaplan-Meier method and comparisons were made using the log-rank test. The Cox proportional hazards model was used to assess the impact of covariates on survival outcomes. Results: CD73 immunohistochimichal expression was evaluated on resected specimens of 70 BC pts. 43 pts (61%) were tCD73-positive, while 44 pts (62%) were sCD73-positive. Among the former group, the intensity score was 1+ in 19 pts (44%), 2+ in 16 pts (37%), 3+ in 10 pts (23%), while in the latter group was 1+ in 22 pts (50%), 2+ in 10 pts (22%) and 3+ in 12 pts (27%). CD73 positivity was associated with older age (> 70 years, p = 0.01), gallbladder subsite (p = 0.03), and nodal involvement (p = 0.04). Patients with tCD73-positive BC experienced a significantly shorter relapse-free survival (8,4 vs 39,4 months; p = 0.016) and overall survival (60,7 vs 13,7 months; p = 0.017). Notably, high tCD73 expressors (score 3+) displayed the poorest prognosis (12,03 months; p = 0.023). When evaluated on univariate and multivariate analysis, tCD73 positivity was an independent prognostic factor for both relapse-free survival (p = 0.038) and overall survival (p = 0.023), together with ECOG PS and pTNM stage. Whole-transcriptome sequencing is ongoing to correlate CD73 expression with cancer-related pathways. Conclusions: In this study, we provided a clinicopathologic characterization of CD73 expression in resected BC, demonstrating that tCD73 is an independent negative prognostic biomarker in this disease. Although these findings are in need of a validation in larger dataset, they foster novel combination of anti-CD73 agents with conventional therapy in the poorer-prognosis subset of CD73-positive BC.

P2599Echo color doppler evaluation of renal hemodynamic during acute heart failure

Background

Acute heart failure (AHF) is often accompanied by impairment in renal function. A profound derangement of normal abdominal haemodynamic is always present during this clinical phase.

Methods

14 patients (6 F – mean age 80 – mean EF 0.39) admitted for acute heart failure underwent cardiac and renal Echo Doppler examination at day 1-3-5 of Hospital stay. Parameters of arterial and venous flow within cortical right kidney were recorded. Venous Doppler Profile (VDP) was classified as: continuous (C), pulsatile (P), biphasic (B) or monophasic (M) according to the growing degree of derangement. Arterial resistive index (RI) >0.8 was considered elevated. Correlation between renal hemodynamic (and its changes) with biohumoral and echo parameters was sought.

Outcome

At day 1 VDP was M or B in 8 patients (57%) and in four (50%) of them dropped to C or P at day 5. RI was elevated in 8 patients at day 1 while only in 4 at day 5. VDP and RI were not related to EF or BNP values. One patient died before day 5, no other worsening heart failure episodes occurred. Two patients (14%) developed acute kidney injury but their VDP and RI were normal and did not change. Three patients (21%) did not improve their BNP (decrease >30%) but this was not associated with VDP or RI changes. Elevated derived pulmonary artery systolic pressure (>40 mmHg) was present in 6 out of 8 patients (75%) with M or B VDP and in all 4 patients with both elevated RI and M or B VDP.

Venous Pattern Day 1 Day 3 Day 5 Continous 2 8 5 Pulsatile 4 2 4 Biphasic 2 1 2 Monophasic 6 3 2 Arterial RI >0.8 8 6 4 BNP, pg/ml 1060±1180* 372±281* 424±213* Creatinine, mg/dl 1.4±0.6 1.5±0.6 1.3±0.6 Hb, g/dl 12.1±2.3 12.3±3.6 13.2±2.3 *p>0.05.

Conclusions

This is the first study exploring changes in renal hemodynamic by echo Doppler during AHF. With respect to previous studies among stable patients, our preliminary data shows a higher proportion of deranged renal venous and/or arterial pattern. After diuretic therapy a trend towards improvement in VDP was recorded. No clear association with other clinical and hemodynamic parameters seems evident.