Prognostic Impact of Induced Natriuresis in Acute Decompensated Heart Failure and Its Association with Intraabdominal Pressure and Other Congestion Markers: A Multimodal Approach to Congestion Assessment

BACKGROUND

Congestion is an essential issue in patients with heart failure (HF). Standard treatments do not usually achieve decongestion, and various strategies have been proposed to guide treatment, such as determination of natriuresis. After starting treatment with loop diuretics, we postulate that initial natriuresis might help treatment titration, decongestion, and improve prognosis.

METHODS

It was a prospective and observational study. Patients admitted with the diagnosis of HF decompensation were eligible. An assessment of congestion was performed during the first 48 h.

RESULTS

A total of 113 patients were included. A poor diuretic response was observed in 39.8%. After the first 48 h, patients with a greater diuretic response on admission (NaU > 80 mmol/L) showed fewer pulmonary b lines (12 vs. 15; p = 0.084), a lower IVC diameter (18 mm vs. 22 mm; p = 0.009), and lower IAP figures (11 mmHg vs. 13 mmHg; p = 0.041). Survival analysis tests demonstrated significant differences showing a higher proportion of all-cause mortality (ACM) and HF rehospitalization in the poor-diuretic-response group (log-rank test = 0.020).

CONCLUSIONS

Up to 40% of the patients presented a poorer diuretic response at baseline, translating into worse outcomes. Patients with an optimal diuretic response showed significantly higher abdominal decongestion at 48 h and a better prognosis regarding ACM and/or HF rehospitalizations.

The Association Between Intra-abdominal Pressure and Diuretic Response in Heart Failure

PURPOSE OF THE REVIEW

An efficient diuretic response is vital during cardiac decompensation in heart failure (HF) patients. The increase in intra-abdominal pressure (IAP) could be one of the keys for understanding cardiorenal syndrome and guiding diuretic treatment during hospitalization. In this review, we analyze the relationship between IAP and diuretic response in HF patients.

RECENT FINDINGS

Increased IAP is associated with worsening renal function (WRF) in patients with advanced HF. Furthermore, the persistence of a rise in IAP after the first 72 h of intravenous diuretic treatment has been correlated with a worse diuretic response, a higher degree of congestion, and an impaired prognosis. The rise in IAP in HF patients has been associated with impaired renal function and a lower diuretic response. Nonetheless, more studies are needed to elucidate the actual role of IAP in congestive nephropathy and whether it may help guide diuretic therapy during acute decompensations.

Prognostic value of early reassessment of reduced ejection fraction in acute heart failure

BACKGROUND AND OBJECTIVES

An improvement in left ventricular ejection fraction (LVEF) in patients with heart failure (HF) is associated with a better prognosis. Identifying these subjects early after an episode of decompensation, the necessary threshold of LVEF improvement, and its predictive factors are of great interest.

PATIENTS AND METHODS

One hundred and ten patients hospitalized for HF were prospectively reassessed at an early outpatient visit (mean of 38 days).

RESULTS AND CONCLUSIONS

In subjects with depressed LVEF (<50%), 50.7% presented an improvement in LVEF≥5% between the acute episode and the outpatient visit. This improvement in depressed LVEF was found to be useful for identifying patients with a good prognosis (readmission due to HF+cardiovascular mortality, p=0.022) but not in patients with preserved LVEF (≥50%). Patients with improved LVEF were significantly younger and had new-onset HF, a better global longitudinal strain (GLS), and better renal function. A multivariate logistic regression model found GLS, new-onset HF, and a lower LV mass index as predictors of LVEF improvement ≥5% (AUC 0.85).

Comparative analysis of chest radiography and lung ultrasound to predict intra-hospital prognosis of patients admitted for acute SARS-CoV-2 pneumonia (COVID-19)

Background

Point of care lung ultrasound (POCUS) has been recently used to assess prognosis in COVID-19 patients. However, there are no data comparing POCUS and chest-X ray, a technique widely used.

Patients and methods

Retrospective analysis in stable COVID-19 patients. Schalekamp radiological lung scale and LUZ-Score ultrasound scale were compared. Primary end-point was in-hospital death and/or need for Intensive Care Unit admission.

Results

A total of 138 patients were included. Median Schalekamp scale was 2 (2) and median LUZ-Score scale was 21 (10). No significant correlation was observed between both techniques. Patients with a LUZ-Score ≥ 21 points at admission had worse lung function and higher concentrations of LDH, CRP and Interleuquine-6. Schalekamp scale failed to identify patients at a higher risk at admission for the primary end-point. Addition of POCUS to a previous clinical model, improved risk prediction (AUC 0.805 [95% CI: 0.662-0.948]; P = <0.001).

Conclusions

Chest X-ray and POCUS showed no correlation at admission in this analysis. Only POCUS identified a group of patients with greater clinical and analytical involvement. POCUS improved, previous clinical model, while chest X-ray did not add relevant predictive information for the primary endpoint.

Utility of plasma CA125 as a proxy of intra-abdominal pressure in patients with acute heart failure

AIMS

Increased intra-abdominal pressure (IAP) is now considered a potential contributor to organ damage and disease progression in acute heart failure (AHF). In this work, we aimed to determine if antigen carbohydrate 125 (CA125) is associated with IAP and to identify a cutpoint of CA125 useful for ruling out intra-abdominal hypertension (defined as IAP ≥ 12 mmHg).

METHODS AND RESULTS

We prospectively evaluated a cohort of 53 patients admitted with AHF in which IAP was measured within the first 24-h of admission. The mean age was 80 ± 8 years, 31 (58.5%) were female, and 31 (58.5%) had left ventricular ejection fraction ≥50%. The median plasma levels of NT-proBNP and CA125 were 3830 pg/mL (2417-8929) and 45.8 U/mL (29.8-114.0), respectively. The median of IAP was 15 mmHg (11-17), and 39 (73%) patients had an IAP ≥ 12 mmHg. The diagnostic performance of CA125 for identifying an IAP ≥ 12 mmHg was tested using the receiving operating characteristic (ROC) curve. The cut-off for CA125 of 17.1 U/mL showed a sensitivity of 92%, a specificity of 50%, and an area under the ROC curve of 0.71. After multivariate adjustment, CA125 remained non-linearly and positively associated with higher IAP (P-value = 0.003), explaining almost 28% of the model's variability (R2: 27.6%).

CONCLUSIONS

Patients with AHF and intra-abdominal hypertension had higher CA125 plasma levels. A baseline concentration of CA125 below 17.1 U/mL will increase the odds of identifying a subset of patients with normal IAP.

Prognostic value of malnutrition in patients with acute heart failure and its influence on the interpretation of markers of systemic venous congestion

BACKGROUND

Malnutrition is frequent in patients with heart failure (HF) and contributes to increased systemic congestion, but also hinders its correct assessment, especially during decompensations. Estimating the degree of malnutrition and its relationship with systemic congestion is important to optimize treatment during decompensations.

MATERIAL AND METHODS

Retrospective cohort study in patients with acute HF. The population was stratified according to CONUT (Controlling Nutritional Status) and PNI (Prognostic Nutritional Index) nutrition indices in order to analyse their relationship with objective parameters of congestion and the prognostic value of malnutrition.

RESULTS

309 patients were included. More than half presented some degree of malnutrition upon admission. The degree of congestion was significantly higher in malnourished patients, with a higher proportion of «comet tail artifacts» and a higher relative plasma volume. NT-proBNP concentrations, both on admission and at discharge, were also significantly higher in malnourished patients, regardless of the scale used. The univariate analysis identified the CONUT and PNI index as factors associated with one-year mortality from any cause (HR 1.62 [1.22-2.14]; p = 0.001) and PNI (HR 65 [0.53-0.80]; p = < 0.001), respectively.

CONCLUSIONS

A higher degree of malnutrition (determined by means of the CONUT and PNI indices) in patients with acute HF was associated with a higher presence of objective parameters of congestion and a higher one-year all-cause mortality.

Point-of-care lung ultrasound assessment for risk stratification and therapy guiding in COVID-19 patients: a prospective noninterventional study

BACKGROUND

Lung ultrasound is feasible for assessing lung injury caused by coronavirus disease 2019 (COVID-19). However, the prognostic meaning and time-line changes of lung injury assessed by lung ultrasound in COVID-19 hospitalised patients are unknown.

METHODS

Prospective cohort study designed to analyse prognostic value of lung ultrasound in COVID-19 patients by using a quantitative scale (lung ultrasound Zaragoza (LUZ)-score) during the first 72 h after admission. The primary end-point was in-hospital death and/or admission to the intensive care unit. Total length of hospital stay, increase of oxygen flow and escalation of medical treatment during the first 72 h were secondary end-points.

RESULTS

130 patients were included in the final analysis; mean±sd age was 56.7±13.5 years. Median (interquartile range) time from the beginning of symptoms to admission was 6 (4-9) days. Lung injury assessed by LUZ-score did not differ during the first 72 h (21 (16-26) points at admission versus 20 (16-27) points at 72 h; p=0.183). In univariable logistic regression analysis, estimated arterial oxygen tension/inspiratory oxygen fraction ratio (PAFI) (hazard ratio 0.99, 95% CI 0.98-0.99; p=0.027) and LUZ-score >22 points (5.45, 1.42-20.90; p=0.013) were predictors for the primary end-point.

CONCLUSIONS

LUZ-score is an easy, simple and fast point-of-care ultrasound tool to identify patients with severe lung injury due to COVID-19, upon admission. Baseline score is predictive of severity along the whole period of hospitalisation. The score facilitates early implementation or intensification of treatment for COVID-19 infection. LUZ-score may be combined with clinical variables (as estimated by PAFI) to further refine risk stratification.

Early Measurement of Blood sST2 Is a Good Predictor of Death and Poor Outcomes in Patients Admitted for COVID-19 Infection

Although several biomarkers have shown correlation to prognosis in COVID-19 patients, their clinical value is limited because of lack of specificity, suboptimal sensibility or poor dynamic behavior. We hypothesized that circulating soluble ST2 (sST2) could be associated to a worse outcome in COVID-19. In total, 152 patients admitted for confirmed COVID-19 were included in a prospective non-interventional, observational study. Blood samples were drawn at admission, 48-72 h later and at discharge. sST2 concentrations and routine blood laboratory were analyzed. Primary endpoints were admission at intensive care unit (ICU) and mortality. Median age was 57.5 years [Standard Deviation (SD: 12.8)], 60.4% males. 10% of patients (n = 15) were derived to ICU and/or died during admission. Median (IQR) sST2 serum concentration (ng/mL) rose to 53.1 (30.9) at admission, peaked at 48-72 h (79.5(64)) and returned to admission levels at discharge (44.9[36.7]). A concentration of sST2 above 58.9 ng/mL was identified patients progressing to ICU admission or death. Results remained significant after multivariable analysis. The area under the receiver operating characteristics curve (AUC) of sST2 for endpoints was 0.776 (p = 0.001). In patients admitted for COVID-19 infection, early measurement of sST2 was able to identify patients at risk of severe complications or death.

Prognostic value of multimodal assessment of congestion in acute heart failure

BACKGROUND

A physical examination has limited performance in estimating systemic venous congestion and predicting mortality in patients with heart failure. We have evaluated the usefulness of the N-terminal prohormone of brain natriuretic peptide (NT-proBNP), cancer antigen 125 (CA125), lung ultrasound findings, relative plasma volume (rPV) estimation, and the urea/creatinine ratio as surrogate parameters of venous congestion and predictors of mortality.

METHODS

This work is a retrospective study of 203 patients admitted for acute heart failure in a tertiary hospital's internal medicine department with follow-up in a specialized outpatient clinic between 2013 and 2018. Clinical data were collected from hospital records. Treatment was decided upon according to the clinical judgment of each patient's attending physician. The main outcome measure was all-cause mortality at one year of follow-up.

RESULTS

Patients' mean age was 78.8 years and 47% were male. A total of 130 (65%) patients had chronic heart failure, 51 (26.2%) patients were in New York Heart Association class III-IV, and 116 (60%) patients had preserved left ventricular ejection fraction. During follow-up, 42 (22%) patients died. Values ??of NT-proBNP≥3,804pg/mL (HR 2.78 [1.27-6.08]; p=.010) and rPV ≥-4.54% (HR 2.74 [1.18-6.38]; p=.019) were independent predictors of all-cause mortality after one year of follow-up.

CONCLUSIONS

NT-proBNP and rPV are independent predictors of one-year mortality among patients hospitalized for decompensated heart failure.

Consensus on improving the comprehensive care of patients with acute heart failure

The latest acute heart failure consensus document from the Spanish Society of Cardiology, Spanish Society of Internal Medicine, and Spanish Society of Emergency Medicine was published in 2015, which made an update covering the main novelties regarding acute heart failure from the last few years necessary. These include publication of updated European guidelines on heart failure in 2016, new studies on the pharmacological treatment of patients during hospitalization, and other recent developments regarding acute heart failure such as early treatment, intermittent treatment, advanced heart failure, and refractory congestion. This consensus document was drafted with the aim of updating all aspects related to acute heart failure and to create a document that comprehensively describes the diagnosis, treatment, and management of this disease.

Prognostic value of multimodal assessment of congestion in acute heart failure

BACKGROUND

A physical examination has limited performance in estimating systemic venous congestion and predicting mortality in patients with heart failure. We have evaluated the usefulness of the N-terminal prohormone of brain natriuretic peptide (NT-proBNP), cancer antigen 125 (CA125), lung ultrasound findings, relative plasma volume (rPV) estimation, and the urea/creatinine ratio as surrogate parameters of venous congestion and predictors of mortality.

METHODS

This work is a retrospective study of 203 patients admitted for acute heart failure in a tertiary hospital's internal medicine department with follow-up in a specialized outpatient clinic between 2013 and 2018. Clinical data were collected from hospital records. Treatment was decided upon according to the clinical judgment of each patient's attending physician. The main outcome measure was all-cause mortality at one year of follow-up.

RESULTS

Patients' mean age was 78.8 years and 47% were male. A total of 130 (65%) patients had chronic heart failure, 51 (26.2%) patients were in New York Heart Association class III-IV, and 116 (60%) patients had preserved left ventricular ejection fraction. During follow-up, 42 (22%) patients died. Values of NT-proBNP≥3804pg/mL (HR 2.78 [1.27-6.08]; p=.010) and rPV≥-4.54% (HR 2.74 [1.18-6.38]; p=.019) were independent predictors of all-cause mortality after one year of follow-up.

CONCLUSIONS

NT-proBNP and rPV are independent predictors of one-year mortality among patients hospitalized for decompensated heart failure.

Consensus on improving the comprehensive care of patients with acute heart failure

The latest acute heart failure (AHF) consensus document from the Spanish Society of Cardiology (SEC, for its initials in Spanish), Spanish Society of Internal Medicine (SEMI), and Spanish Society of Emergency Medicine (SEMES) was published in 2015, which made an update covering the main novelties regarding AHF from the last few years necessary. These include publication of updated European guidelines on HF in 2016, new studies on the pharmacological treatment of patients during hospitalization, and other recent developments regarding AHF such as early treatment, intermittent treatment, advanced HF, and refractory congestion. This consensus document was drafted with the aim of updating all aspects related to AHF and to create a document that comprehensively describes the diagnosis, treatment, and management of this disease.

Prognostic significance of acute kidney injury and small increases in creatinine concentration during acute decompensation of heart failure

BACKGROUND

Diagnosis of acute kidney injury (AKI) during acute decompensations of heart failure (ADHF) remain challenging. We analysed the incidence and prognosis of AKI, and the significance of small increases of creatinine, during ADHF and after stabilization.

PATIENTS AND METHODS

Patients admitted for ADHF were prospectively included. Creatinine was measured at admission, 48h thereafter and 24h before discharge. AKI was diagnosed when creatinine increased≥50% in 7 days (RIFLE criteria) or≥0.3mg/dL in 48h (AKIN criteria) during admission. Changes between baseline creatinine (measured within 3-month before admission) and one month after discharge were assessed, to seek for residual impairment of renal function and its significance.

RESULTS

Two hundred and four patients were included. Incidence of AKI was 28.4% (n=58). Creatinine peaked by day 5 in patients with AKI vs. non-AKI (1.9 vs. 1.1mg/dL; P<.000) and remained significantly higher among patients with AKI 3 months after discharge (increase of 20 vs. 4%; P=.013). Twelve-months mortality was associated with increases in cystatin C, NT-proBNP and AKI (15.5 vs. 44.8%, P<.000), being the latter the most powerful independent predictor of death ?Exp(B)=5.34; P=.009?. Minor increases in creatinine (20% or 0.2mg/dL) during admission associated lesser 12-months survival (P=.033 and P=.019, respectively). Increases in creatinine≥10% between baseline and one month after discharge are associated with higher mortality (12.6 vs. 22.5%, P=.044).

CONCLUSIONS

AKI is a strong predictor of mortality after ADHF. Minor increments in creatinine concentrations, below the accepted threshold for AKI definition, are prognostically meaningful.

Epidemiology of heart failure with preserved ejection fraction: Results from the RICA Registry

INTRODUCTION AND OBJECTIVES

There is great interest in better characterizing patients with heart failure (HF) with preserved ejection fraction (HF-PEF). The objective of this study is to determine the prevalence, progression over time and to describe the clinical and epidemiological characteristics of patients with HF-PEF.

METHODS

From the National Registry of Heart Failure (RICA, prospective multicentre cohort study) we analysed patients consecutively admitted for HF in Internal Medicine wards over a period of 11 years (2008-2018).

RESULTS

4752 patients were included, 2957 (62.2%) with preserved ejection fraction. This prevalence remained constant from 2008 to 2019. Compared to patients with HF and reduced ejection fraction (HF-REF) patients with HF-PEF are older, more are female, there is a higher prevalence of hypertensive and valvular aetiology, they have a profile of different comorbidities and worse functional status. A high proportion of patients receive disease-modifying treatment for IC-REF (renin-angiotensin-aldosterone system inhibitors and beta-blockers). The overall mortality after one-year follow-up was 24% and 30% in the HF-PEF and the HF-REF, respectively. In the multivariate analysis, the risk of death was higher in patients with HF-REF compared to HF-PEF (OR: 1.84; 95% CI: [1.43-2.36]). The length of hospital stay was also lower in the HF-PEF patients but there were no differences in re-hospitalizations.

CONCLUSIONS

Sixty percent of patients in the RICA registry have preserved ejection fraction. These patients have a higher comorbidity burden and a worse functional status, but lower mortality compared with HF-REF patients.

Investigating self-care in a sample of patients with decompensated heart failure: A cross-sectional study

BACKGROUND

There is scarce evidence relating to self-care of heart failure (HF) in Spain. In particular, there is a need to establish patients' level of understanding of HF, as well as their ability to recognise signs and symptoms of decompensation.

PATIENTS AND METHODS

Cross-sectional study to determine the level of self-care in a population of Spanish patients admitted to hospital with a primary diagnosis of decompensated HF. A convenience sample of 108 patients (50 women and 58 men) aged 83±8 were recruited to participate in this study.

RESULTS

The Self-Care of Heart Failure Index version 6.2 was used to quantify self-care in our sample. Mean and standard deviation from the Self-Care of Heart Failure Index self-care maintenance subscale were: a) "exercise for 30 minutes", 1±1; b) "forget to take one of your medicines", 2±2; c) "ask for low-salt items when eating out or visiting others", 2±1. A percentage of 67.6 had experienced shortness of breath or ankle swelling in the past month. However, the vast majority of our patients were unlikely to independently implement a remedy: a) reduce salt, 2±1; b) reduce fluid intake, 1±1; c) take an extra diuretic, 1±1. Over 50% of our sample felt confident or very confident at following professional advice (3±1), keeping themselves free of symptoms (3±1), recognizing changes in their condition (3±1) and evaluating the significance of such changes (3±1).

CONCLUSIONS

HF patients have a significantly low level of self-care when compared with HF patients from other countries, especially when it comes to managing their condition. Self-care promotion should be a priority for all healthcare professionals involved in the care and management of HF patients.

[Prognostic value of measuring the diameter and inspiratory collapse of the inferior vena cava in acute heart failure]

OBJECTIVES

To assess the utility of measuring the diameter and collapse of the inferior vena cava (IVC) in acute heart failure (AHF), its relationship with the prognosis and serum biomarkers of congestion.

PATIENTS AND METHODS

An observational prospective study was conducted that included 85 patients with AHF, classifying them into 4 groups according to IVC diameter (≤ or >20mm) and inspiratory collapse (< or ≥50%) at admission. The endpoints were mortality due to HF and the combined event of mortality and readmission for HF at 180 days.

RESULTS

Some 24.7% of the patients had an undilated IVC and ≥50% collapse (group 1); 20% had an undilated IVC and <50% collapse (group 2), 5.9% had a dilated IVC and ≥50% collapse (group 3); and 49.4% had a dilated IVC and <50% collapse (group 4). The lack of inspiratory collapse but not IVC dilation was related to higher concentrations of urea (P=.007), creatinine (P=.004), uric acid (P=.008), NT-proBNP (P=.009) and CA125 (P=.005). Survival free of the combined event at 180 days was lower in those patients with no IVC collapse.

CONCLUSIONS

Dilation and the absence of the inspiratory collapse of the IVC are common in the context of AHF. The lack of inspiratory collapse of the IVC during the decompensation phase identifies a subgroup of patients with poorer prognosis at 6 months.

Absence of cystatin C involvement in ventricular remodelling and heart failure

Cystatin C (CysC) is a protease encoded by housekeeping genes. Although its prognostic value in heart failure (HF) is well known, it is debatable whether this value is due to the greater accuracy of CysC in calculating the glomerular filtration rate or to its involvement in pathological ventricular remodelling. The aim of this study was to determine whether CysC expression changes in the myocardium of foetuses of different ages and in the myocardium of adults with various cardiovascular diseases, as well as to analyse the correlation between its serum concentrations and cardiac structure and morphology in a patient group with HF.

PATIENTS AND METHODS

We analysed the correlations (Pearson's r and Spearman's test) between the serum CysC levels and echocardiographic parameters of 351 patients with HF. We also performed immunohistochemical staining for CysC, metalloproteinase-9 (MMP-9) and desmin in 9 cardiac tissue samples from autopsies of 4 foetuses of different gestational ages and 5 healthy adults or adults with cardiovascular disease.

RESULTS

For the patients with HF, there was no correlation between the CysC concentrations and the cardiac parameters measured by 2D echocardiography. The immunohistochemistry showed a weak background staining for CysC in all samples, regardless of age and the presence or absence of cardiovascular diseases.

CONCLUSIONS

Our results suggest that CysC does not have a significant role in the pathological remodelling of the left ventricle in HF.

[Evaluation of the effectiveness of a protocol designed to improve glycemic control in hospitalized internal medicine patients with hyperglycemia]

BACKGROUND

Our aims were to assess the effectiveness of a diabetes (DM) management protocol to increase scheduled insulin therapy and to improve glycemic inpatient control.

PATIENTS AND METHODS

We designed an analytical retrospective cohort study comparing 2 groups of medical services hospitalized patients with a primary of secondary discharge diagnosis of DM, before (group PRE) and after (group POS) the delivery of a DM management protocol. We analyzed the quality of attention by process indicators (cumulative probability of receive scheduled insulin therapy, evaluated with Kaplan-Meier analysis) and result indicators (adjusted glucose differences (group POS - group PRE), evaluated with multivariate regression models).

RESULTS

A number of patients (355) were included (228 group PRE and 127 group POS). The median time to scheduled insulin regimen beginning was 1 (CI 95%: 0-2.5) day in group POS and 4 (CI 95%: 2-6) days in group PRE (p=0.056). First 48 hours mean glucose in patients without scheduled insulin therapy was lower in group POS than in group PRE (163.9 versus 186.7 mg/dl; p=0.025). The first 24 hours mean glucose was significantly lower in patients of group POS, with a difference between both groups of -24.8 mg/dl (CI 95%: -40.5-(-9); p=0.002). Stratified analysis showed statistically significant mean in-hospital glucose difference only in the nothing by mouth situation (-29.8 mg/dl; CI 95%: -58.9-(-0.6); p=0.045).

CONCLUSION

The delivery of an institutional protocol can improve hospitalized DM patients management quality.

Prognostic value of glomerular filtration rate estimation equations in acute heart failure with preserved versus reduced ejection fraction

AIMS

Renal function is an important prognostic factor in heart failure. The aim of this study was to compare the predictive value of estimated renal function calculated by the Chronic Kidney Disease-Epidemiology Collaboration equation (CKD-EPI) and the abbreviated Modification of Diet in Renal Disease (MDRD-4) equation for long-term all-cause mortality in patients admitted for acute decompensated heart failure (ADHF) with both preserved ejection fraction (HF-PEF) and reduced ejection fraction (HF-REF).

METHODS AND RESULTS

We evaluated patients included in the Spanish National Registry of Heart Failure (RICA). RICA is a multicentre, prospective, cohort study that included patients admitted to the Internal Medicine units with ADHF. Estimated glomerular filtration rate (eGFR) was calculated with CKD-EPI and MDRD-4 equations. A total of 1805 patients admitted for ADHF were studied (52% women; median age 80 years, interquartile range 73.9-84.6 years); of these, 1044 (58%) had HF-PEF. eGFR values were lower with the CKD-EPI formula than with the MDRD-4 formula (51 ml/min/1.73 m(2) vs. 55.7 ml/min/1.73 m(2) ; p < 0.001). The two formulas provided independent prognostic information over long-term follow-up, in both HF-PEF and HF-REF patients. However, in HF-PEF patients, CKD-EPI equation was associated with a significant improvement in reclassification analyses (net reclassification improvement 6.78%; p = 0.009).

CONCLUSIONS

In this clinical cohort of ADHF patients, eGFR as calculated by both the CKD-EPI and the MDRD-4 formulas offered similar prognostic information, irrespective of ejection fraction status, but in HF-PEF patients specifically, the CKD-EPI formula seems to improve clinical risk stratification as compared with MDRD-4.

Prognostic importance of glycaemic variability on hospital mortality in patients hospitalised in Internal Medicine Departments

INTRODUCTION

The objective was to assess the prognostic importance of various glycaemic control measures on hospital mortality.

MATERIAL AND METHODS

Retrospective, analytical cohort study that included patients hospitalised in internal medicine departments with a diagnosis related to diabetes mellitus (DM), excluding acute decompensations. The clinical endpoint was hospital mortality. We recorded clinical, analytical and glycaemic control-related variables (scheduled insulin administration, plasma glycaemia at admission, HbA1c, mean glycaemia (MG) and in-hospital glycaemic variability and hypoglycaemia). The measurement of hospital mortality predictors was performed using univariate and multivariate logistic regression.

RESULTS

A total of 384 patients (50.3% men) were included. The mean age was 78.5 (SD, 10.3) years. The DM-related diagnoses were type 2 diabetes (83.6%) and stress hyperglycaemia (6.8%). Thirty-one (8.1%) patients died while in hospital. In the multivariate analysis, the best model for predicting mortality (R(2)=0.326; P<.0001) consisted, in order of importance, of age (χ(2)=8.19; OR=1.094; 95% CI 1.020-1.174; P=.004), Charlson index (χ(2)=7.28; OR=1.48; 95% CI 1.11-1.99; P=.007), initial glycaemia (χ(2)=6.05; OR=1.007; 95% CI 1.001-1.014; P=.014), HbA1c (χ(2)=5.76; OR=0.59; 95% CI 0.33-1; P=.016), glycaemic variability (χ(2)=4.41; OR=1.031; 95% CI 1-1.062; P=.036), need for corticosteroid treatment (χ(2)=4.03; OR=3.1; 95% CI 1-9.64; P=.045), administration of scheduled insulin (χ(2)=3.98; OR=0.26; 95% CI 0.066-1; P=.046) and systolic blood pressure (χ(2)=2.92; OR=0.985; 95% CI 0.97-1.003; P=.088).

CONCLUSION

An increase in initial glycaemia and in-hospital glycaemic variability predict the risk of mortality for hospitalised patients with DM.

[Predictors of mean blood glucose control and its variability in diabetic hospitalized patients]

INTRODUCTION

This study was intended to assess the effectiveness and predictors factors of inpatient blood glucose control in diabetic patients admitted to medical departments.

MATERIAL AND METHODS

A retrospective, analytical cohort study was conducted on patients discharged from internal medicine with a diagnosis related to diabetes. Variables collected included demographic characteristics, clinical data and laboratory parameters related to blood glucose control (HbA1c, basal plasma glucose, point-of-care capillary glucose). The cumulative probability of receiving scheduled insulin regimens was evaluated using Kaplan-Meier analysis. Multivariate regression models were used to select predictors of mean inpatient glucose (MHG) and glucose variability (standard deviation [GV]).

RESULTS

The study sample consisted of 228 patients (mean age 78.4 (SD 10.1) years, 51% women). Of these, 96 patients (42.1%) were treated with sliding-scale regular insulin only. Median time to start of scheduled insulin therapy was 4 (95% CI, 2-6) days. Blood glucose control measures were: MIG 181.4 (SD 41.7) mg/dL, GV 56.3 (SD 22.6). The best model to predict MIG (R(2): .376; P<.0001) included HbA1c (b=4.96; P=.011), baseline plasma glucose (b=.056; P=.084), mean capillary blood glucose in the first 24hours (b=.154; P<.0001), home treatment (versus oral agents) with basal insulin only (b=13.1; P=.016) or more complex (pre-mixed insulin or basal-bolus) regimens (b=19.1; P=.004), corticoid therapy (b=14.9; P=.002), and fasting on admission (b=10.4; P=.098).

CONCLUSION

Predictors of inpatient blood glucose control which should be considered in the design of DM management protocols include home treatment, HbA1c, basal plasma glucose, mean blood glucose in the first 24hours, fasting, and corticoid therapy.

[Results of implementing a programme to improve the quality of the contents in hospital discharge reports in cases of heart failure]

OBJECTIVES

To analyse the information collected in hospital discharge reports (HDR) that are given to patients with a diagnosis of heart failure (HF), and demonstrate the improvement in the content of these reports after the introduction of an intervention.

MATERIAL AND METHODS

HDR with HF as the main diagnosis issued by the Department of Internal Medicine were analysed, and the presence of the diagnosis, prognosis and therapeutic data in these HDR was compared in a sample before and after the intervention, which consisted of reporting the results of analysis of the initial sample to the physicians.

RESULTS

A total of 651 HDR (371 pre-intervention and 280 post-intervention) were analysed. Most of the HDR (over 70%) did not include the functional class. Most of the HDR did not include information about echocardiogram performed before the hospitalization period analysed, and most of the HDR that collected this information did not determine if the HF was diastolic or systolic. In the post-intervention sample there was a lower percentage of HDR that prescribed angiotensin-converting enzyme inhibitors or angiotensin receptor blocker ii (26% vs 32%, P<.001). In 30% of the pre-intervention sample and 38% of the post-intervention sample there was indication of beta-blockers (P=.027).

CONCLUSIONS

A short discussion with the physicians responsible for patients with HF improves the inclusion of important data on the diagnosis, prognosis and treatment in the HDR.

Clinical characteristics and prognostic influence of renal dysfunction in heart failure patients with preserved ejection fraction

BACKGROUND

Renal dysfunction is common in patients with heart failure (HF) and is associated with high mortality. This relationship is well established in HF and reduced ejection fraction (HFREF), however, it is not fully understood in HF and preserved ejection fraction (HFPEF). The aim of this study was to determine the impact of renal dysfunction on all-cause mortality in HFPEF patients and to evaluate the clinical characteristics of patients that deteriorate renal function in the first year of follow-up.

METHODS

We evaluated the patients with HFPEF included in the RICA registry. This is a multi-center and prospective cohort study that includes patients admitted for decompensated HF. Estimated glomerular filtration rate (eGFR), blood urea nitrogen (BUN) and plasma creatinine concentrations were used for renal function assessment at admission and after one year of follow up.

RESULTS

A total of 455 patients (mean age 78±8.1years; 62% women) were included, of whom 265 (58.2%) had eGFR<60mL/min/1.73m(2). After adjustment for covariates, only lower admission eGFR remained significantly predictive of all-cause mortality (HR 2.97; 95% CI 1.59-5.53). After one year of follow-up 16.6% of patients deteriorated at least 25% of eGFR. These patients were more likely to be diabetic (54.5% vs 42.6%; p=0.039) and had a higher rate of prescription of mineralcorticoid receptor antagonist (MRA) agents (47% vs 23.3%; p<0.001).

CONCLUSION

Renal dysfunction is frequently associated with HFPEF. eGFR below normal is strongly associated with mortality. Further decline of renal function is frequent especially among diabetic and patients treated with MRA agents.

Predictive value of serum galectin-3 levels in patients with acute heart failure with preserved ejection fraction

AIMS

This study was conducted to determine whether galectin-3 (Gal3), a β-galactoside-binding lectin, has usefulness to predict outcomes in patients with heart failure (HF) and preserved left ventricular ejection fraction (LVEF).

METHODS AND RESULTS

We measured Gal3, urea, creatinine and natriuretic peptides on admission in 419 selected patients with HF and LVEF over 45%. The primary endpoint was all-cause mortality and/or readmission at one-year follow-up. Multivariable Cox proportional hazards models were generated for Gal3 and classical risk factors. We also evaluated the reclassification of patients on the basis of the different score category after adding Gal3 levels. A total of 219 patients had combined adverse events, and 129 patients died during the follow-up. Kaplan-Meir survival curve showed significantly increased primary endpoint and all-cause mortality according to quartiles of Gal3 (log rank, P<0.001). Serum Gal3 levels above median (13.8 ng/ml) was a significant predictor of primary endpoint risk after adjustment for age, estimated glomerular filtration rate, anemia, diabetes, serum sodium, brain natriuretic peptide levels, NYHA class and urea, respectively (hazard ratio 1.43, 95% CI 1.07-1.91 P=0.015). The reclassification index increased significantly after addition of Gal3 (9.5%, P<0.001) and the integrated discrimination index was 0.022, (P=0.001). The clinical prediction model with Gal3 increased the c-statistic from 0.711 to 0.731 (difference of 0.020, P=0.001).

CONCLUSIONS

Serum Gal3 is a strong and independent predictor of unfavorable outcomes in patients with HF and preserved LVEF. We also demonstrated the improvement of adding the new biomarker to the model.

Prognostic value of serum cystatin C and N-terminal pro b-type natriuretic peptide in patients with acute heart failure

BACKGROUND

Cystatin C (CysC) is a good prognostic marker in heart failure. However, there is not much information of CysC combined with other biomarkers in acute heart failure (AHF).

AIM

To assess prognostic value of CysC and N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients hospitalized for AHF with no apparent deterioration of renal function.

DESIGN

Prospective, multicenter, observational study.

METHODS

CysC and NTpro-BNP were measured in patients consecutively admitted with a diagnosis of AHF. Patients with, NTpro-BNP concentration above 900 pg/mL and serum creatinine below 1.3mg/dL, were included for statistical analysis. End-point of the study was all-cause mortality during a 12-month follow-up.

RESULTS

526 patients with AHF and NTpro-BNP concentration above 900 pg/mL were included in the study. From this group, 367 patients (69.8%) had serum creatinine below 1.3mg/dL. Receiver operating characteristic (ROC) curves were used to determine the best cut-off value for CysC. Patients with a concentration of CsyC above 1.25mg/dL had a 37.8% mortality rate, vs. 13.6% for those below cut-off (p<0.001). After Cox proportional hazard model, age, CysC, low total cholesterol and HF with preserved ejection fraction remained significantly associated with all-cause mortality during one-year follow-up.

CONCLUSIONS

In AHF and normal or slightly impaired renal function, performance of CysC may be superior to NT-proBNP. Hence, CysC may be the preferred biomarker in the assessment of patients with AHF and slightly impaired renal function.

Influence of admission blood pressure on mortality in patients with acute decompensated heart failure

OBJECTIVES

To determine the relationship between admission blood pressure (BP) and prognosis in patients hospitalized for acute decompensated heart failure (HF).

BACKGROUND

The relationship between BP admission blood pressure and outcomes in decompensated HF is controversial. It has been suggested that this presentation may be a specific disorder, but their mechanisms and clinical relationships are poorly defined.

METHODS

We evaluated the association between initial BP (systolic, diastolic and mean BP) with readmission and mortality, as well as potential interactions with age, clinical characteristics, renal function, left ventricular dysfunction, comorbidities and treatment. By using Cox regression models the association between each outcome and BP was tested.

RESULTS

A total of 581 patients (77.5-years-old, range 51-100) were included. At admission, mean BP in quartiles was 77.09 mm Hg (53.3-85.0) (Q1); 91.46 mm Hg (85.0-96.7) (Q2); 103.41 mm Hg (96.7-109.9) (Q3) and 124.79 mm Hg (109.9-209.0) (Q4). Median duration of follow-up was 8 months [95% confidence interval (CI) 5.2-11.1]. Mortality was 15.5% (Q1), 9.2% (Q2), 12.6% (Q3) and 7.3% (Q4). Interquartile hazard ratio (95% CIs) for mortality was 0.40 (0.19-0.85) P=0.017. Body mass index (BMI) was higher in Q4 29.59 k/m2 than in Q1 28.25 k/m2 (P=0.018). There were no differences in age, clinical antecedents, renal function, comorbidities or severity of HF between groups.

CONCLUSION

Higher mean BP at admission is associated with significantly lower mortality during follow-up, in patients hospitalized for HF. With the exception of BMI, positively correlated with blood pressure, this relationship is independent of other clinical factors and medications.

[Atypical presentation of microscopic polyangiitis]

Microscopic polyangiitis is a systemic vasculitis that affects small caliber vessels, with renal and lung compromise. We present the case of a patient with an atypical presentation of this disease and an onset characterized by central nervous system affection in the form of a motor deficit.

Expression and functional characterization of mutated glucocerebrosidase alleles causing Gaucher disease in Spanish patients

BACKGROUND

Gaucher disease (GD) is a heterogeneous disease characterized by an impaired activity of the lysosomal glucocerebrosidase. This heterogeneity is attributed in part to the existence of a large number of mutations in the corresponding gene.

SUBJECTS AND METHODS

To establish genotype-phenotype relationships, we analyzed the residual enzyme activities of six naturally occurring mutations found in Spanish population in the glucocerebrosidase gene [c.160G > A (V15M), c.485T>C (M123T), c.914C>T (P266L), c.1124T>C (L336P), c.1207A>C (S364R) and c.1510-1512delTCT (S465del)]. The mutated genes were subcloned into the mammalian expression vector pCR 3.1 and expressed by transient transfection in COS cells. The enzymatic activity of the expressed protein were measured and compared with the wild-type human glucocerebrosidase cDNA. Also, two previously alleles, c.1226A>G (N370S) and c.1448T>C (L444P), were used for comparative purposes.

RESULTS

The residual activity of the expressed proteins using the synthetic substrate (4-methylumbelliferyl-beta-D-glucopyranoside, 4MU-Glu) ranged from 5.5% (for the 3-bp deletion) to 42.7% (for S364R mutation) of the activity of the wild-type enzyme.

CONCLUSION

The present analyses may help to better understand the molecular basis and the pathogenesis of Gaucher disease. However, results of expression of mutated enzymes are necessary but not sufficient to explain the ultimate clinical outcome of Gaucher disease.

[Effect of enzyme replacement therapy on lipid profile in patients with Gaucher's disease]

BACKGROUND AND OBJECTIVE

Gaucher's disease (GD) is a lysosomal storage disorder, caused by a deficiency of the acid -glucocerebrosidase enzyme, which results in accumulation of lipids within macrophages. GD patients show decreased plasma total cholesterol (TC), low-density lipoprotein cholesterol (LDL-c) and high-density lipoprotein cholesterol (HDL-c) levels, as well as decreased apolipoprotein (apo) A-I and B. Conversely, concentrations of plasma apo E and the chitotriosidase (ChT) activity, a chitinase synthesized by activated macrophages, are increased. Enzyme replacement therapy (ERT) is effective and safe in reversing the clinical manifestations in symptomatic patients. The aim of this study was to evaluate the effect of ERT on the lipid profile of GD patients.

PATIENTS AND METHOD

70 patients, from the Spanish Registry of Gaucher's disease (REEG), were divided into two groups: 54 under ERT, according to stablished criteria, and 16 without ERT. Plasma apolipoprotein, lipoprotein and lipid concentrations, and chitotriosidase activity were analyzed in both groups. Statistical analysis was carried out with the U-Mann Whitney non-parametric test for comparison of data.

RESULTS

The group of GD patients under ERT showed significant increases of HDL-c (+38%) and apo A-I (+18%) levels, whereas no changes were observed in LDL-c and apo B levels. Conversely, chitotriosidase activity (-58%), plasma-apo E (-32%) and HDL-apo E (-26%) levels were dramatically reduced after ERT. No significant modifications were observed in the group without ERT.

CONCLUSIONS

ERT in GD patients displays significant effects on the concentration of plasma lipoproteins, resulting in a less atherogenic lipid profile and in a reduction of activated macrophages.

High prevalence of the 55-bp deletion (c.1263del55) in exon 9 of the glucocerebrosidase gene causing misdiagnosis (for homozygous N370S (c.1226A > G) mutation) in Spanish Gaucher disease patients

Gaucher disease (GD) is the most frequent lysosomal storage disease, caused by mutations in the acid beta-glucosidase gene (GBA). The c.1226A > G (N370S) mutation is associated with non-neuronopathic disease (type 1). However, we have observed some discrepancy between genotype and phenotype in Spanish Gaucher disease patients homozygous for the c.1226A > G mutation. A deletion of 55 bp in the exon 9 GBA gene, corresponding to the deleted portion of the beta-glucosidase pseudogene, has been previously reported as a cause of erroneous assignment of 1226G/1226G homozygous patients when the genotype has been performed by PCR assay. We had originally identified 25 (out of 124) unrelated Gaucher disease patients as being putative homozygotes for the c.1226A > G mutation. By means of a new PCR-based assay, we were able to distinguish between the true homozygous patients and the carriers of the 55-bp deletion in exon 9 of the GBA gene. The 55-bp deletion was detected in 10 out of 25 samples (40%) [7 with the 55-bp deletion, 1 RecTL, 1 RecNciI (both including the deletion) and one rearrangement]. Such a high prevalence in this sample suggests that this allele can be more common than expected among GD patients.

Mutation prevalence among 51 unrelated Spanish patients with Gaucher disease: identification of 11 novel mutations

Gaucher disease is an autosomal recessive disorder caused by mutations in the lysosomal beta-glucocerebrosidase (GBA) gene. Gaucher disease is a very heterogeneous entity due to the large number of different mutations existing in the GBA gene, resulting in a defective protein whose impaired activity is the cause of the disease. We present a mutation analysis of the GBA gene in 51 unrelated Spanish Gaucher disease patients together with clinical findings. Two common mutations, c.1226A>G (N370S) and c.1448T>C (L444P), were determined by restriction enzyme digestion after PCR amplification of genomic DNA. The remaining alleles were screened by amplifying the entire GBA gene followed by nested PCR and SSCP analysis under four different conditions. The c.1226A>G (N370S) and c.1448T>C (L444P) mutations were common, accounting for 56 alleles (55%) and 16 alleles (15%), respectively. In addition, 25 different mutations were found, 11 of which are described here for the first time: c.(-203)A>G, c.160G>A (V15M), c.256C>T (R47X), c.445-2a>g (IVS4-2a>g), c.485T>C (M123T), c.914C>T (P266L), c.953delT, c.1124T>C (L336P), c.1207A>C (S364R), c.1214delG,C, and c.1510delT,C,T (465delSer). Two mutations, S364R and P266L, were associated with neuronopathic forms of Gaucher disease: S364R mutation in heterozygosity with the L444P mutation and the P266L mutation in a homozygous state. Two type 1 patients were found to be carriers of two mutations in the same allele (genotypes [N370S] + [E326K + N188S] and [N370S] + [IVS4-2a>g+c.(-203)A>G]). This study allowed us to identify 100% of mutant alleles, and therefore we conclude that the method used to screen for mutations in the GBA gene is very reliable and there is a broad spectrum of mutations in the GBA gene in the Spanish population.

Chitotriosidase genotype and plasma activity in patients type 1 Gaucher's disease and their relatives (carriers and non carriers)

BACKGROUND AND OBJECTIVES

Chitinases are enzymes that hydolyze chitin and have been found in a wide variety of nonvertebrate species; recently an human analogue of chitinases, chitotriosidase (CT) has been identified. Extreme elevations of plasma CT activity are observed in patients with Gaucher disease (GD), being Gaucher cells the source of the CT. It has been reported a 24 bp duplication in CT gene that results an inactive protein. The carrier prevalence is high as 30 to 40% and the CT activity is half that in wild individuals. However no systematic evaluation of plasma CT activity has been carried in GD patients taken into account status of allele defective for CT and dose in patients on enzyme replacement therapy (ERT).

DESIGN AND METHODS

We had previously study 210 subjects from 99 unrelated Spanish GD families; 121 were non-affected carriers and 89 were non-carriers to establish carrier prevalence of CT genotypes. Plasma CTactivity and CTgenotypes by PCR and gel electrophoresis have been measured in 109 GD patients before treatment. We also evalued CT activity after ERT with alglucerase in 68 patients.

RESULTS

Three patients had defective activities of CT. The carrier prevalence for 24 bp duplication was 35% and the allele frequency 0.20. No correlation between CT activity and GBA genotype was detected and between CT activity and visceral or skeletal disease in GD patients. Untreated affected patients, non-carriers for the duplication, had higher CT activity than carriers (p<.0001). CT activity decreased dramatically during the first 12 months of ERT; even after 3 years of therapy a persistent fall of CT activity was observed. How ever within 3 years of treatment, a significant difference in the mean decrease of CT activity was present among the groups of patients on varying alglucerase doses (p<.01). After 12 months of ERT the activity of plasma CT decline in the same percentage in both groups: heterozygous for the carriers of 24bp duplication and wild type, but thereafter CT activity decline more slowly in carriers than non carriers.

INTERPRETATION AND CONCLUSIONS

The present data can be used as a reference to interpret the CT activity in GD patients with or without ERT, as well as to evaluate the doses response and can be used as a reference to interpret the CTactivity in carriers and non-carriers.

Identification and characterization of a novel mutation c.1090G>T (G325W) and nine common mutant alleles leading to Gaucher disease in Spanish patients

BACKGROUND

Gaucher disease is an autosomal recessive disorder resulting from mutations in the glucocerebrosidase gene (GBA). The lack of full genotype/phenotype correlation complicates counseling regarding clinical outcome and treatment recommendations.

SUBJECTS AND METHODS

Several mutations in the human beta-glucosidase gene associated with Gaucher disease in 16 Spanish families were identified utilizing a combination of methods: enzymatic restriction, PCR-SSCP, and sequence analyses. Expression studies were performed following the introduction of the mutagenized human acid beta-glucosidase cDNA into COS-1 cells, and the residual enzyme activities of the mutant protein were measured and compared with the normal cDNA.

RESULTS

The identified mutations and corresponding residual enzyme activities of the expressed protein are as follows: c.517A>C (T134P), 1%; c.721G>A (G202R), 17%; c.1090G>T (G325W), 13.9%; c.1093G>A (E326K), 26%; c.1208G>A (S364N), 4.1%; c.1226A>G (N370S), 17,8%; c.1246G>A (G377S), 17.6%; c.1289C>T (P391L), 8.5%; c.1448T>C (L444P), 3%; and c.1504C>T (R463C), 24.5%.

CONCLUSIONS

Site-directed mutagenesis and expression in COS-1 cells are useful methods to increase our understanding of causality in Gaucher disease and the correlation between disease severity, gene defects, and residual enzyme activity. Our study demonstrates the functional consequences of the identified human beta-glucosidase mutations (T134P, S364N, G377S, P391L, and G325W) and provide evidence for the molecular and biochemical basis of Gaucher disease, among patients of Spanish ancestry.

[Clinical characteristics of type I Gaucher's disease in Spain. Preliminary results of national survey. Spanish Group on Gaucher's Disease]

BACKGROUND

To know the incidence and distribution of Gauchers's disease (GD) in Spain, a national inquiry was carried out in order to analyze the clinical, genetic and evolutive features of these patients.

PATIENTS AND METHODS

A questionnaire including demographic, clinical, diagnostic, biological, radiological and evolutive data was sent to the hospitals. Each case with a presumptive diagnosis was considered a "censored patient". The cases without enzymatic or genetic diagnosis were studied in a reference laboratory (the same for all the samples). The Zimran's Severity index was employed to evaluate the clinical status. The enzymatic activity of acid beta-glucosidase was studied in cellular extracts of peripheral blood granulocytes by a fluorescent method using an artificial substrate (methyl-umbeliferyl-beta-deglycoside). The characterization of the mutations of the glucosidase gene was determined by PCR molecular analysis in the samples of DNA studying the mutations: N370S, L444P, 84GG and IVS2+1.

RESULTS

Seventy five patients were censored; in 48 the inquiry was completed. These patients belonged to 54 families. The mean age at diagnosis was 24.7 years, being the M/F distribution 16/32. The illness was asymptomatic in 13.3%, visceral disease was present in 83.3% of patients and bone disease in 70.8%. The 45.8% of patients had hemoglobin levels < 110 g/l, 35.4% low leucocyte count < 4,0 x 10(9)/l and 77.0% low platelet count < 150 x 10(9)/l. High acid phosphatase levels were observed in 100% of cases and in 34.7% biochemical hepatic dysfunction was observed. The test for acid glucosidase showed a marked decrease in enzymatic activity. In 71% of the patients morphologic documentation (splenic or hepatic tissue, bone marrow biopsy or aspirates) was performed. The most frequent mutations observed were N370S (47.7% of the alleles detected), and L444P (24.4%). In 18.7% of the cases the disease was stable or slightly progressive, in 27.0% the spleen was removed between 1-14 years of the being made and 45.8% were put onto an alglucerase trial.

CONCLUSIONS

The incidence of GD in Spain is at present lower that the previously reported for other european countries. The clinical features are not different except in the case of bone disease, less frequent in our cases, probably limited by the absence of MR. The pattern of distribution of mutation is also similar.

[Alglucerase treatment of type I Gaucher's disease. Preliminary results in Spain. Spanish Group on Gaucher's Disease]

AIM

To evaluate the efficacy of the treatment with alglucerase (Ceredase) in spanish patients diagnosed of Gaucher disease type 1 (GD).

PATIENTS AND METHODS

A national inquiry has been performed among the hospitals with GD's patients on therapy. A form including pretherapy haemoglobin, platelet levels, liver and spleen size and bone lesions was submitted to the participating centers. A quarterly follow-up was requested. Descriptive statistics and frequency distribution analysis were performed through a Statview 4.02 database.

RESULTS

Participating centers 22; evaluable patients 34. The mean age at diagnosis was 18.9 +/- 12.7 years, being the M/F ratio 0.47. Organomegaly was present in 88.2% and 70.5% had bone disease. Low haemoglobin levels (< 110 g/L) had detected in 48.6%, leucopenia (< 4.0 x 10(9)) were in 36.6% and low platelet level (< 15.0 x 10(9)) in 73.2%. The most frequent mutations observed were N370S (39.7% of the alleles detected), and L444P(20.4%). Time on therapy: between 6-12 months, 18 patients, > 1 year 16 patients, > 2 years 11 (5 reaching 3 years). Dosage schedulle:a) 10-20 U/Kg/week, 8 cases, b) 30-60 U/Kg/ two weeks, 26 cases. Eight patients were splenectomized before therapy. After one year on therapy haemoglobin and platelet levels become normal in 82.3% and 47.0% of patients respectively and the liver and spleen size were reduced 66 and 42%. There are not significant differences among weekly (8 patients) or forthnightly (26 patients) dosages except in the spleen size more reduced in the later group (43% vs 65%). Haemoglobin and platelet levels were similar among splenectomized or non-splenectomized patients, but the reduction of the liver size (80 vs 17%) was significatively greater in the former. One patient developed an asymptomatic antialglucerase antibody during the first month on therapy.

CONCLUSIONS

The infusion of alglucerase is effective in the treatment of the GD type 1, with a significant reduction of organomegalies and a definite improvement in haemoglobin and platelet levels. The efficacy seems to be unrelated with the schedule employed or the splenic removal; nevertheless liver enlargement was more reduced in the splenectomized cases and the spleen size among the patients with the regimen of "high dose/low frequence". Bone healing requires a very long time therapy. The treatment is safe and the antibody production low.