Showing papers in "CardioRenal Medicine in 2023"

Vascular calcification exacerbates abnormal blood pressure variability in chronic kidney disease: a "two-step" study in rats.

Abstract: Introduction Vascular calcification (VC) is a common complication of chronic kidney disease (CKD) with poor cardiovascular prognosis. The aim of this study is to explore the impact of VC on blood pressure variability (BPV) in animal models of CKD. Methods Two optimal modelling methods, adenine high-phosphorus (HP) diet + calcitriol and 5/6 nephrectomy (Nx) + HP diet + calcitriol, for CKD-VC were chosen from the first-step experiment for the next step. A total of 36 male Wistar rats were randomly assigned to the standard-chow, sham-operated, adenine, 5/6Nx, adenine-VC, and 5/6Nx-VC groups. Continuous blood pressure (BP) measurement using the BP-2000 animal noninvasive BP analyser was started at the 9th week for the standard-chow, adenine, and adenine-VC groups and at the 7th week for the sham-operated, 5/6Nx, and 5/6Nx-VC groups. BPV metrics (BPVs), including the difference between maximum and minimum values, standard deviation, coefficient of variation, average real variability, and residuals derived from the generalized linear model of BP, were calculated. Results The first experiment showed that the use of calcitriol accelerated the progression of VC in CKD rats (the modelling period was shortened from 16 weeks to 4-8 weeks) and confirmed the occurrence of VC at weeks 8 and 6 in the adenine-VC and 5/6Nx-VC groups, respectively. In the second experiment, 13 of 20 hour-to-hour BPVs increased significantly with the development of CKD and VC. BPV differences among the standard-chow, adenine, and adenine-VC groups were mainly due to the differences between the standard-chow and adenine-VC groups (7 of 10 BPVs were significantly different), followed by the differences between the standard-chow and adenine groups (3 of 10). BPV differences among the sham-operated, 5/6Nx, and 5/6Nx-VC groups were caused by the differences between the 5/6Nx-VC and 5/6Nx groups (4 of 10) or the 5/6Nx-VC and sham-operated groups (3 of 10). Conclusion An increased BPV is observed in CKD rats, and VC further aggravates the abnormality of BPVs independent of CKD.

Transcatheter Aortic Valve Replacement (TAVR)-associated Acute Kidney Injury: An Update.

Abstract: BACKGROUND Transcatheter Aortic Valve Replacement (TAVR) is a relatively novel minimally invasive procedure for the treatment of symptomatic patients with severe aortic stenosis. Although it has been proven effective in improving mortality and quality of life, TAVR is associated with serious complications, such as acute kidney injury (AKI). SUMMARY TAVR-associated AKI is likely due to several factors such as sustained hypotension, transapical approach, volume of contrast use and baseline low GFR. This narrative review aims to present an overview of the latest literature and evidence regarding the definition of TAVR-associated AKI, its risk factors, and its impact on morbidity and mortality. The review used a systematic search strategy with multiple health-focused databases (Medline, EMBASE), and identified 8 clinical trials and 27 observational studies concerning TAVR-associated AKI. Results showed that TAVR-associated AKI is linked to several modifiable and non-modifiable risk factors, and is associated with higher mortality. A variety of diagnostic imaging modalities have the potential to identify patients at high-risk for development of TAVR-AKI; however, there are no existing consensus recommendations regarding their use as of this time. The implications of these findings highlight the importance of identifying high-risk patients for which preventive measures may play a crucial role, and should be maximized. KEY MESSAGE This study reviews the current understanding of TAVR-associated AKI including its pathophysiology, risk factors, diagnostic modalities, and preventative management for patients.

Aortic Stenosis and Aortic Valve Replacement Among Patients with Chronic Kidney Disease: A Narrative Review.

Abstract: BACKGROUND Aortic stenosis (AS) can present with dyspnea, angina, syncope, and palpitations and this presents a diagnostic challenge as chronic kidney disease (CKD) and other commonly found comorbid conditions may present similarly. While medical optimization is an important aspect in management, aortic valve replacement (AVR) by surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) is the definitive treatment. Patients with concomitant CKD and AS require special consideration as it is known that CKD is associated with progression of AS and poor long-term outcomes. AIMS AND OBJECTIVES To summarize and review current existing literature on patients with both CKD and AS regarding disease progression, dialysis method, surgical intervention, and post operative outcomes. CONCLUSION The incidence of aortic stenosis increases with age but has also been independently associated with chronic kidney disease and furthermore with hemodialysis. Regular dialysis with hemodialysis vs. peritoneal dialysis and female gender have been associated with progression of AS. Management of aortic stenosis is multidisciplinary and requires planning and interventions by the "Heart-Kidney Team" to decrease risk of further inducing kidney injury among high-risk population. Both TAVR and SAVR are effective interventions for patients with severe symptomatic AS, but TAVR has been associated with better short-term renal and cardiovascular outcomes. IMPLICATIONS FOR PRACTICE Special consideration must be taken in patients with both CKD and AS. The choice of whether to undergo hemodialysis (HD) vs. peritoneal dialysis (PD) among patients with CKD is multifactorial but studies have shown benefit regarding AS progression among those who undergo PD. The choice regarding AVR approach is likewise the same. TAVR has been associated with decreased complications among CKD patients, but the decision is multifactorial and requires a comprehensive discussion with the Heart-Kidney Team as many other factors play a role in the decision including preference, prognosis, and other risk factors.

Tackling Congestion in Acute Heart Failure; Is It the Primetime for "Combo Diuretic Therapy"?

Abstract: Symptoms and signs of congestion are the primary reason for hospitalization of patients with acute heart failure. Efficient fluid and sodium removal remains the main goal of therapy and loop diuretics are the recommended agents in this setting. However, the therapeutic response to these medications is known to be variable and a significant subset of patients are discharged from the hospital with residual fluid overload. Therefore, sequential blockade of nephron has been proposed as a more effective decongestive strategy. Pilot studies have suggested significant increase in diuresis and natriuresis with combination diuretic therapy. Recently, two groups of investigators examined this hypothesis on a larger scale in randomized placebo-controlled trials; one targeted the proximal tubules upstream of the loop of Henle (Acetazolamide in Decompensated Heart Failure with Volume Overload - ADVOR) while the other one blocked sodium-chloride cotransporters in the distal convoluted tubules (Combination of Loop with Thiazide Diuretics for Decompensated Heart Failure - CLOROTIC). Herein, we discuss the results of these two trials with special focus on their impact on extraction of sodium, i.e. the main determinant of extracellular volume, and put them in the context of previous studies of combination diuretic therapy as well as extracorporeal ultrafiltration.

One heartbeat away from a prediction model for cardiovascular diseases in patients with chronic kidney disease: a systematic review.

Abstract: BACKGROUND Patients with chronic kidney disease (CKD) have a high risk of cardiovascular disease (CVD). Prediction models, combining clinical and laboratory characteristics, are commonly used to estimate an individual's CVD risk. However, these models are not specifically developed for patients with CKD and may therefore be less accurate. In this review we aim to give an overview of CVD prognostic studies available, and their methodological quality, specifically for patients with CKD. METHODS MEDLINE was searched for papers reporting CVD prognostic studies in patients with CKD published between 2012 and 2021. Characteristics regarding patients, study design, outcome measurement, and prediction models were compared between included studies. The risk of bias of studies reporting on prognostic factors or the development/validation of a prediction model were assessed with, respectively, the QUIPS and PROBAST tool. RESULTS In total, 134 studies were included, of which 123 studies tested the incremental value of one or more predictors to existing models or common risk factors, while only 11 studies reported on the development or validation of a prediction model. Substantial heterogeneity in cohort and study characteristics, such as sample size, event rate, and definition of outcome measurements, was observed across studies. The most common predictors were age (87%), sex (75%), diabetes (70%), and estimated glomerular filtration rate (eGFR) (69%). Most of the studies on prognostic factors have methodological shortcomings, mostly due to a lack of reporting on clinical and methodological information. Of the 11 studies on prediction models, six developed and internally validated a model and four externally validated existing or developed models. Only one study on prognostic models showed a low risk of bias and high applicability. DISCUSSION A large quantity of prognostic studies has been published, yet their usefulness remains unclear due to incomplete presentation, and lack of external validation of prognostic models. Our review can be used to select the most appropriate prognostic model depending on the patient population, outcome, and risk of bias. Future collaborative efforts should aim at improving existing models by externally validating them, evaluate the addition of new predictors, and assessment of the clinical impact.

The relationship between vascular aging phenotypes and renal damage among individuals with type 2 diabetes.

Abstract: OBJECTIVE To investigate the relationship between vascular aging (VA) phenotypes and renal damage in type 2 diabetic population. METHODS In this cross-sectional study, we included 8,141 individuals with type 2 diabetes who participated in the Kailuan Study during 2010 to 2018 and completed the brachial-ankle pulse wave velocity (baPWV) assessment for arterial stiffness, an indicator for VA. The age- and sex-specific 10th and 90th percentiles of baPWV based on a reference cohort were used as cutoffs to define supernormal VA (SUPERNOVA, baPWV<10th percentiles), normal VA (NVA, baPWV 10th to 90th percentiles), and early VA (EVA, baPWV>90th percentiles). The estimated glomerular filtration rate (eGFR) and proteinuria levels were used to assess renal damage, including isolated proteinuria, isolated kidney function decline (eGFR<60ml/min/1.73m2), and proteinuria combined with kidney function decline. Multivariable logistic regression analysis was used to analyze the relationship between VA phenotypes and diabetic kidney damage. RESULTS The prevalence of isolated proteinuria, isolated kidney function decline, and proteinuria combined with kidney function decline was 17.0%, 12.2%, and 5.4%, respectively. Compared with NVA, SUPERNOVA was associated with 34% lower odds (95% confidence interval [CI]: 0.46-0.96) of isolated proteinuria after adjusting for age, sex, and other potential confounders. EVA was associated with higher odds of all three types of kidney damage; the adjusted odds ratio (95% CI) was 1.42 (1.20-1.67) for proteinuria, 1.24 (1.01-1.51) for kidney function decline, and 1.56 (1.18-2.06) for proteinuria combined with kidney function decline. CONCLUSIONS Vascular aging phenotypes are associated with renal damage, especially isolated proteinuria. SUPERNOVA was associated with lower odds of isolated proteinuria and EVA was associated with higher odds of proteinuria and kidney function decline.

Effects of ulinastatin on postoperative renal function in patients undergoing cardiac surgery with cardiopulmonary bypass: a prospective cohort study with ten years follow up

Abstract: The present study aimed to explore the potential effect of ulinastatin on renal function and long-term survival in patients receiving cardiac surgery with CPB.This prospective cohort study was conducted at Fuwai Hospital, Beijing, China. The ulinastatin was applied after induction anesthesia. The primary outcome was the rate of new-onset postoperative acute kidney injury (AKI). Moreover, a ten-year follow-up was conducted until Jan 2021.The rate of new-onset AKI was significantly lower in the ulinastatin group than in the control group (20.00% vs. 32.40%, p=0.009). There was no significant difference in RRT between the two groups (0.00% vs. 2.16%, p=0.09). The postoperative pNGAL and IL-6 levels were significantly lower in the ulinastatin group compared with the control group(pNGAL: p=0.007; IL-6: p=0.001). A significantly lower incidence of respiratory failure in the ulinastatin group compared with the control group (0.76% vs. 5.40%, p=0.02). The nearly 10-year follow-up(9.37,95CI%:9.17-9.57) survival rates did not differ significantly between the two groups ( p=0.076 ).Ulinastatin significantly reduced postoperative AKI and respiratory failure in patients receiving cardiac surgery with CPB. However, ulinastatin did not reduce ICU and hospital stay, mortality, and long-term survival rate.ulinastatin, acute kidney injury, cardiac surgical procedures, cardiopulmonary bypass.

Usefulness of a Novel Vascular Access Management Method Using a Laser Blood Flowmeter.

Abstract: INTRODUCTION Various methods for vascular access (VA) management have been studied. We investigated the usefulness a new, simple, and quantitative VA management method using the Pocket LDF® laser blood flowmeter (hereinafter "LDF") that non-invasively measures peripheral circulation flow. METHODS Peripheral circulation flow was measured in 82 patients (43 men) on maintenance hemodialysis with an arteriovenous fistula (AVF). The shunt symmetry index (SSI) was calculated as peripheral circulation flow in the AVF limb divided by that in the non-AVF limb. SSI was used for microcirculation evaluation and also compared by AVF site. Patients undergoing vascular access interventional therapy (VAIVT) underwent ultrasound evaluation (Doppler ultrasonography) of the AVF and SSI measurement before and after VAIVT. SSI was compared between those who did and did not require VAIVT, and the cutoff value for SSI was determined by receiver operating characteristic curve (ROC) analysis. RESULTS As many as 86% of the patients who were measured peripheral circulation flow had SSI < 1.0, which indicates that AVF reduced peripheral circulation flow. All patients who underwent VAIVT showed a decrease in SSI to < 1.0 after VAIVT, probably due to improvement of stenosis. SSI differed significantly between patients who did and did not require VAIVT (1.20 ± 0.49 vs 0.65 ± 0.33, p < 0.001), which indicates that SSI is affected by the presence of stenosis in the proximal vein of the VA anastomosis. In patients with SSI ≥ 1.0, stenosis of the proximal vein of the AVF caused stasis of blood flow resulting in increased peripheral blood flow. AVF site seems to have no impact on peripheral circulation flow. The SSI cutoff value for the screening of proximal vein stenosis was 1.06 (sensitivity: 0.69, specificity: 0.93, area under the curve: 0.81). DISCUSSION/CONCLUSION Based on the ROC analysis, we recommend considering AVF ultrasound for SSI > 1.06. Our results suggest the usefulness of the described VA management method using the LDF.

Diuretics and ultrafiltration in heart failure.

Abstract: Fluid overload is a risk factor for increased morbidity and mortality, especially in patients with heart disease. The treatment options for decongestion are limited to diuretics and mechanical fluid removal using ultrafiltration or renal replacement therapy. This paper provides an overview of the challenges of managing fluid overload, outlines the risks and benefits of different pharmacological options and extracorporeal techniques, and provides guidance for clinical practice.

New Miniaturized System for Ultrafiltration: Rationale and Design of a Single-Center, Crossover, Randomized, Open-Label, Pilot Study Protocol.

Abstract: INTRODUCTION Fluid overload and congestion are common features in patients with heart failure and are associated with negative clinical outcomes. Therapies for these conditions are diuretic-centered but frequently fail to achieve patient-adequate hydration status, prompting the use of extracorporeal ultrafiltration. Artificial Diuresis 1 (AD1) is a miniaturized, portable, and wearable system designed to deliver isolated ultrafiltration with the finest degree of simplicity and practicality. METHODS/DESIGN Single-center, crossover, randomized, open-label pilot study to investigate the safety and the efficacy (concerning ultrafiltration accuracy) of extracorporeal ultrafiltration with the device AD1 in comparison to isolated ultrafiltration with a traditional machine (PrisMaX). Patients with chronic kidney disease stage 5D (on hemodialysis) or intensive care patients presenting acute kidney injury stage 3D (requiring hemodialysis) will carry out a single session of isolated ultrafiltration with each of the machines. The safety primary outcomes will be the occurrence of adverse events. The efficacy primary outcome will be the accuracy of ultrafiltration rate (delivered/prescribed) on each of the devices. CONCLUSION AD1 is a novel miniaturized device for extracorporeal ultrafiltration. This study will be the first-in-human use of AD1 in patients with fluid overload.

Serum IGFBP7 deriving from spleen and lung could be used for early recognition of cardiac surgery-associated acute kidney injury.

Abstract: INTRODUCTION The utility of arithmetic product of urinary tissue metalloproteinase inhibitor 2 (TIMP2) and insulin-like growth factor-binding protein 7 (IGFBP7) concentrations has been widely accepted on early diagnosis of acute kidney injury (AKI). However, which organ is the main source of those two factors and how the concentration of IGFBP7 and TIMP2 changed in serum during AKI still remain to be defined. METHODS In mice, gene transcription and protein levels of IGFBP7/TIMP2 in the heart, liver, spleen, lung, and kidney were measured in both ischaemia-reperfusion injury (IRI)- and cisplatin-induced AKI models. Serum IGFBP7 and TIMP2 levels were measured and compared in patients before cardiac surgery, and at inclusion (0 h), 2 h, 6 h and 12 h after Intensive Care Unit (ICU) admission, and compared with serum creatinine, blood urea nitrogen (BUN), estimated glomerular filtration rate (eGFR) and serum uric acid (UA). RESULTS In mouse IRI-AKI model, compared with the sham group, the expression levels of IGFBP7 and TIMP2 did not change in the kidney, but significantly upregulated in the spleen and lung. Compared with patients who did not develop AKI, the concentration of serum IGFBP7 at as early as 2 h after ICU admission (s[IGFBP7]-2 h) was significantly higher in patients who developed AKI. The relationships between s[IGFBP7]-2 h in AKI patients and log2(SCr), log2(BUN), log2(eGFR), and log2(UA) were statistically significant. The diagnostic performance of s[IGFBP7]-2 h measured by the macro-averaged area under the receiver operating characteristic curve (AUC) was 0.948 ([95% CI], 0.853 to 1.000; P<0.001). DISCUSSION/CONCLUSION The spleen and lung might be the main source of serum IGFBP7 and TIMP2 during AKI. The serum IGFBP7 value demonstrated good predictive accuracy for AKI following cardiac surgery within 2 h after ICU admission.

Artificial Diuresis: animal studies on efficacy and safety of a new miniaturized device for extracorporeal ultrafiltration.

Abstract: INTRODUCTION We have recently developed a new miniaturized device for extracorporeal ultrafiltration to be used in patients with fluid overload: Artificial Diuresis-1, or AD1 (Medica S.p.A., Medolla, Italy). The device has a reduced priming volume and operates at very low pressure and flow regimes and is designed to perform extracorporeal UF at bedside. After accurate experiments carried out in vitro, we report in this paper the results of in vivo tests ultrafiltration session carried out in selected animals according to veterinary best practice. MATERIALS AND METHODS The AD1 kit is pre-filled with sterile isotonic solution and operates with a polysulfone mini-filter MediSulfone (Polysulfone at 50000 Dalton). A collection bag with a volumetric scale is connected to the UF line and the ultrafiltrate is obtained by gravity based on the height at which the ultrafiltrate collection bag is placed. Animals were prepared and anesthetized. Jugular vein was cannulated with a double lumen catheter. Three six hours sessions of ultrafiltration were scheduled with a target fluid removal of 1500 ml. Heparin was used as anticoagulant. RESULTS In all treatments the target value of ultrafiltration was obtained in the absence of major clinical or technical problems with a maximum deviation from the scheduled ultrafiltration rate lower than 10%. The device resulted safe, reliable, accurate and easily usable thanks to a user friendly interface and the very small dimensions. CONCLUSIONS This study opens the way for clinical trials in different settings including departments with low intensity of care and even in ambulatory centers or patient's home.

Prevalence, Clinical Characteristics and Prognostic Impact of Kidney Disease on Heart Failure Patients: An Observational Study of the Colombian Heart Failure Registry (RECOLFACA).

Abstract: INTRODUCTION Chronic kidney disease (CKD) represents one of the most frequent comorbidities observed in heart failure (HF) patients and has been observed to increase this population's risk of adverse outcomes. Nevertheless, evidence analyzing kidney dysfunction in HF is scarce in Latin American populations. We aimed to analyze the prevalence of kidney dysfunction and assess its association with mortality in patients diagnosed with HF enrolled in the Colombian Heart Failure Registry (RECOLFACA). METHODS RECOLFACA enrolled adult patients with HF diagnosis from 60 centers in Colombia during the period 2017-2019. The primary outcome was all-cause mortality. A Cox proportional hazards regression model was used to assess the impact of the different categories of eGFR in mortality risk. A p-value of <0.05 was considered significant. All statistical tests were two-tailed. RESULTS From the total 2514 evaluated patients, 1501 (59.7%) patients had moderate kidney dysfunction (eGFR<60 mL/min/1.73 m2), while 221 (8.8%) were classified as having a severe kidney dysfunction (eGFR<30 mL/min/1.73 m2). Patients with lower kidney function were most commonly males, had higher median age and reported a higher prevalence of cardiovascular comorbidities. Moreover, different patterns of medications prescription were observed when comparing CKD vs. non-CKD patients. Finally, eGFR<30 mL/min/1.73 m2 was significantly associated with a higher mortality risk compared to eGFR>90 mL/min/1.73 m2 status (HR 1.87; 95% CI, 1.10-3.18), even after an extensive adjustment by relevant covariates. CONCLUSION CKD represents a prevalent condition in the setting of HF. Patients with CKD and HF present with multiple sociodemographic, clinical, and laboratory differences compared with those only diagnosed with HF and present a significantly higher risk of mortality. A timely diagnosis and optimal treatment and follow-up of CKD in the setting of HF may improve the prognosis of these patients and prevent adverse outcomes.

Prognosis of heart valve calcification on cardiovascular events in hemodialysis patients without central venous catheters.

Abstract: INTRODUCTION Heart valvular calcification (HVC) is an important predictor of cardiovascular events (CEs) and all-cause mortality in dialysis patients. Patients in the early stage of dialysis or those with central venous catheters (CVCs) are also at high risk of cardiovascular and all-cause mortality. It could be a confounding factor for the prognosis of HVC on CE. METHODS From March 2017 to April 2022, the prognosis of HVC on CE and all-cause mortality was studied retrospectively in 158 hemodialysis (HD) patients who used arteriovenous fistulas (AVFs) or arteriovenous grafts (AVGs) as vascular access and entered HD for more than 12 months. RESULTS Out of 158 patients, 70 (44.3%) were diagnosed with HVC via echocardiography. A total of 180 CEs occurred during follow-up. Among them, acute heart failure (AHF) accounted for 62.66%, and its prevalence was significantly higher in the HVC group than that in the non-HVC group (p <0.0001). The cumulative incidence of CE-free survival in the HVC group was significantly lower than that in the non-HVC group (p = 0.030). Only 11 patients died and there was no significant difference in all-cause mortality between the two groups (p = 0.560). Multivariate COX regression analyses showed that HD vintage, mitral valve calcification (MVC), and aortic valve regurgitation (AR)/aortic valve stenosis (AS) but not aortic valve calcification (AVC) were risk factors for CE (p <0.05). CONCLUSION After excluding the factors of the early stage of HD and CVC, HVC remained a predictor of adverse CE in HD patients.

Soluble CD14 and osteoprotegerin associate with ankle-brachial index as a measure of arterial stiffness in patients with mild to moderate chronic kidney disease in a five-year prospective study.

Abstract: Introduction Vascular lesions and arterial stiffness appear at early stages of chronic kidney disease (CKD) and follow an accelerated course with disease progression, contributing to high cardiovascular mortality. There are limited prospective data on mechanisms contributing to progression of arterial stiffness in mild to moderate CKD (stages 2-3). Methods We applied an affinity proteomics approach to identify candidates of circulating biomarkers with potential impact on vascular lesions in CKD and selected soluble cluster of differentiation 14 (sCD14), angiogenin (ANG) and osteoprotegerin (OPG) for further analysis. We studied their association with Ankle-brachial index (ABI) and carotid intima-media thickness (CIMT), as measures of arteriosclerosis and atherosclerosis respectively, in 48 patients with CKD stages 2-3, who were prospectively followed and intensively treated for five years, and 44 healthy controls. Results Concentrations of both sCD14 (p<0.001), ANG (p<0.001) and OPG (p<0.05) were higher in patients with CKD 2-3 at baseline, and sCD14 (p<0.001) and ANG (p<0.001) remained elevated in CKD patients at follow-up. There were positive correlations between ABI and sCD14 levels (r=0.36, p=0.01) and between ABI and OPG (r=0.31, p=0.03) at five years. The changes in sCD14 during follow-up correlated to changes in ABI from baseline to five years (r=0.41, p=0.004). Conclusion Elevated levels of circulating sCD14 and OPG in patients with CKD 2-3 were significantly associated with ABI, a measure of arterial stiffness. An increase in sCD14 over time in CKD 2-3 patients was associated with a corresponding increase in ABI. Further studies are needed to examine if early intensive multifactorial medication to align with international treatment targets may influence cardiovascular outcomes.

The Science of Extracorporeal Ultrafiltration: Introducing a Novel Miniaturized Device.

Abstract: INTRODUCTION Fluid overload has been associated with untoward outcomes in a variety of clinical settings. Isolated extracorporeal ultrafiltration (UF) allows for mechanical extraction of excess fluid and optimization of volume status without the established risks associated with use of high dose diuretics. Conventional machines for renal replacement therapy can be used to perform isolated UF. However, they typically need high blood flow rates with high circuit volumes and the therapy has to be performed by trained nurses. Herein, we describe a novel device, the Artificial Diuresis-1, or AD 1 (Medica S.p.A., Medolla, Italy), which is a portable technology designed to perform extracorporeal UF at bedside. MATERIALS AND METHODS The AD 1 uses a polysulfone mini-filter to generate ultrafiltrate with the help of two forces: blood flow (Qb) and gravity (based on the height at which the ultrafiltrate collection bag is placed). In vitro experiments were performed using human blood to evaluate vascular access pressures and ultrafiltrate volumes using various central venous catheters (12 Fr bilume, 10 Fr with 2 separate lumens, pediatric catheter 7 Fr). A variety of combinations were tested with Qb of 20, 35, 50 mL/min and collection bag height at 20, 40, 60 cm, measuring the UF rate per minute each while monitoring the pressures in the venous and arterial lines and filtration fraction. RESULTS The device's performance was as expected. Regarding the pediatric CVC, it was possible to perform measurements only with a Qb of 20 mL/min due to increased venous pressure. Ultrafiltration rates when lines were directly connected to the blood container as well as for CVC Tesio ranged from 3.7 to 11 mL/min, for the CVC Niagara™ from 4.5 to 12.5 mL/min and for the CVC 7 Fr from 8.5 to 10 mL/min. The pressures of the vascular accesses were kept within a range of -5/-40 mmHg for the artery and +10/+70 mmHg for the vein. The highest venous pressure values were found with the CVC 7 Fr (+80/+100 mmHg). CONCLUSIONS This novel device allows to treat patients with fluid overload in a variety of settings, from low-intensity department such as long-term care facilities to the intensive care unit. The device is small and portable, has a simple design, and is user-friendly. Future studies will be needed to evaluate whether gentle ultrafiltration and treatment of volume overload will translate into improvement in clinical outcomes such as a reduction in congestion-related hospital admission.

Prognosis of Patients with Acute Kidney Injury due to Type 1 Cardiorenal Syndrome Receiving Continuous Renal Replacement Therapy.

Abstract: Introduction The prognosis of patients with acute kidney injury (AKI) caused by type 1 cardiorenal syndrome (CRS) requiring continuous renal replacement therapy (CRRT) is unclear. We investigated the in-hospital mortality and prognostic factors in these patients. Methods We retrospectively identified 154 consecutive adult patients who received CRRT for AKI caused by type 1 CRS between January 1, 2013, and December 31, 2019. We excluded patients who underwent cardiovascular surgery and those with chronic kidney disease stage 5. The primary outcome was in-hospital mortality. Cox proportional hazards analysis was performed to analyze independent predictors of in-hospital mortality. Results The median age of patients at admission was 74.0 years (interquartile range: 63.0-80.0); 70.8% were male. The in-hospital mortality rate was 68.2%. Age ≥80 years (hazard ratio, 1.87; 95% confidence interval [CI], 1.21-2.87; P=0.004); previous hospitalization for acute heart failure (hazard ratio, 1.67; 95% CI, 1.13-2.46; P=0.01), vasopressor or inotrope use (hazard ratio, 5.88; 95% CI, 1.43 - 24.1; P=0.014), and mechanical ventilation (hazard ratio, 2.24; 95% CI, 1.46 -3.45; P<0.001) at CRRT initiation were associated with in-hospital mortality. Discussion/Conclusion In our single-center study, the use of CRRT for AKI due to type 1 CRS was associated with high in-hospital mortality. .

Impact of dapagliflozin treatment on serum sodium concentrations in acute heart failure.

Abstract: Introduction The dynamics of serum sodium are important in acute heart failure (AHF), and hyponatremia is associated with a poor prognosis. The effect of sodium-glucose cotransporter type 2 inhibitors (SGLT2i) on serum sodium concentrations in AHF is unknown. Methods In a single-centre, controlled, randomized study, patients were prescribed dapagliflozin in addition to standard treatment during the first 24 hours of hospitalization, versus standard treatments. The pre-specified outcome was an absolute change in plasma sodium concentrations between randomization (first 24 hours after admission) and discharge. The secondary outcomes were an absolute change in serum sodium concentrations within 48 hours of randomization, and the persistence of hyponatremia. Results The sample comprised 285 patients (53% males; average age 73.26 ± 13 years); 140 of these were randomized to the dapagliflozin group. The average ejection fraction (EF) was 46 ± 14%; 155 patients (54%) had ischaemic heart failure; and 35% had diabetes mellitus. Median N-terminal pro b-type natriuretic peptide (NT-proBNP) was 4225 [2120; 9105] pg/ml. The average estimated glomerular filtration rate (eGFR) was 53.9 ± 17.2 ml/min. Hospital mortality was 6.7%. At randomization, serum sodium concentrations were 139.8 ± 4.32 mmol/l in the dapagliflozin group vs. 140.85 ± 4.04 mmol/l in the control group; р = 0.048. 48 hours later, there was an increase in serum sodium in the dapagliflozin group (2 [-2; 4] mmol/l), as compared to the control group (-1 [-3.75; 2]); р < 0.001. This was accompanied by equilibration of the sodium levels between the groups (141.08 ± 4.08 mmol/l in the dapagliflozin group vs 140.05 ± 4.82 mmol/l in the control group; р = 0.096). At the time of discharge, there was no difference in serum sodium concentrations (140.98 ± 4.77 mmol/l vs 139.86 ± 4.45 mmol/l; р = 0.082). The increase in serum sodium concentrations during the period of observation [randomization; discharge] was small but statistically significant in the dapagliflozin group (1 [-3; 3.75] mmol/l vs -2 [-4.5; 2] mmol/l; р = 0.015). Of 36 patients (21 in the dapagliflozin group and 15 in the control group) with baseline hyponatraemia, this persisted in 6 (16.6%) in the dapagliflozin group and in 11 (73.3%) in the control group (р = 0.008). Conclusion The use of dapagliflozin in AHF is associated with a tendency to the increase in serum sodium concentrations and lesser persistence of hyponatremia. This effect occurred within the first 48 hours and persisted until discharge. The impact of dapagliflozin on serum sodium was more pronounced in patients with hyponatremia at randomization.