Acute kidney injury in hospitalized patients with COVID-19: A Portuguese cohort

IntroductionThe incidence of acute kidney injury (AKI) in coronavirus disease 2019 (COVID-19) patients ranges from 0.5% to 35% and has been associated with worse prognosis. The purpose of this study was to evaluate the incidence, severity, duration, risk factors and prognosis of AKI in hospitalized patients with COVID-19.MethodsWe conducted a retrospective single-center analysis of 192 hospitalized COVID-19 patients from March to May of 2020. AKI was diagnosed using the Kidney Disease Improving Global Outcome (KDIGO) classification based on serum creatinine (SCr) criteria. Persistent and transient AKI were defined according to the Acute Disease Quality Initiative (ADQI) workgroup definitions.ResultsIn this cohort of COVID-19 patients, 55.2% developed AKI (n = 106). The majority of AKI patients had persistent AKI (n = 64, 60.4%). Overall, in-hospital mortality was 18.2% (n = 35) and was higher in AKI patients (28.3% vs. 5.9%, p < 0.001, unadjusted OR 6.03 (2.22–16.37), p < 0.001). In this multivariate analysis, older age (adjusted OR 1.07 (95% CI 1.02–1.11), p = 0.004), lower Hb level (adjusted OR 0.78 (95% CI 0.60–0.98), p = 0.035), duration of AKI (adjusted OR 7.34 for persistent AKI (95% CI 2.37–22.72), p = 0.001) and severity of AKI (adjusted OR 2.65 per increase in KDIGO stage (95% CI 1.32–5.33), p = 0.006) were independent predictors of mortality.ConclusionAKI was frequent in hospitalized patients with COVID-19. Persistent AKI and higher severity of AKI were independent predictors of in-hospital mortality.     

Acute kidney injury and chronic kidney disease after liver transplant: A retrospective observational study

Background and rationaleChronic kidney disease remains an important risk factor for morbidity and mortality among LT recipients, but its exact incidence and risk factors are still unclear.Material and methodsWe carried out a retrospective cohort study of consecutive adults who underwent liver transplant (January 2009–December 2018) and were followed (at least 6 months) at our institution. CKD was defined following the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guidelines. Long-term kidney function was classified into 4 groups: no CKD (eGFR, ≥60 mL/min/1.73 m²), mild CKD (eGFR, 30–59 mL/min/1.73 m²), severe CKD (eGFR, 15–29 mL/min/1.73 m²), and end-stage renal disease (ESRD).ResultsWe enrolled 410 patients followed for 53.2 ± 32.6 months. 39 had CKD at baseline, and 95 developed de novo CKD over the observation period. There were 184 (44.9%) anti-HCV positive, 47 (11.5%) HBsAg positive, and 33 (8.1%) HBV/HDV positive recipients. Recipient risk factors for baseline CKD were advanced age (P = 0.044), raised levels of serum uric acid (P < 0.0001), and insulin dependent DM (P = 0.0034). Early post-transplant AKI was common (n = 95); logistic regression analysis found that baseline serum creatinine was an independent predictor of early post-LT AKI (P = 0.0154). According to our Cox proportional hazards model, recipient risk factors for de novo CKD included aging (P < 0.0001), early post-transplant AKI (P = 0.007), and baseline serum creatinine (P = 0.0002). At the end of follow-up, there were 116 LT recipients with CKD – 109 (93.9%) and 7 (6.1%) had stage 3 and advanced CKD, respectively. Only two of them are undergoing long-term dialysis.ConclusionThe incidence of CKD was high in our cohort of LT recipients, but only a slight decline in kidney function over time was recorded. Prevention of post-transplant AKI will improve kidney function in the long run. We need more studies to analyze the function of kidneys among LT recipients over extended follow-ups and their impact on mortality.     

Acute kidney injury after allogeneic hematopoietic stem cell transplantation – Predictors and survival impact: A single center retrospective study

Introduction and objectivesAcute kidney injury (AKI) is a frequent complication of hematopoietic stem cell transplantation (HSCT) and appears to be linked to increased morbidity and mortality. The aim of this study was to evaluate the incidence, etiology, predictors and survival impact of early AKI in the post-allogeneic HSCT setting.Patients and methodsWe performed a retrospective single center study that included 155 allogeneic transplant procedures from June 2017 through September 2019.ResultsAKI was observed in 50 patients (32%). In multivariate analysis, age (OR 31.55, 95% CI [3.42; 290.80], p = 0.002), evidence of disease at the time of transplant (OR 2.54, 95% CI [1.12; 5.75], p = 0.025), cytomegalovirus reactivation (OR 5.77, 95% CI [2.43; 13.72], p < 0.001) and hospital stay >35 days (OR 2.66, 95% CI [1.08; 6.52], p = 0.033) were independent predictors for AKI. Increasing age (HR 1.02, 95% CI [1.00; 1.04], p = 0.029), increasing length of hospital stay (HR 1.02, 95% CI [1.01; 1.03], p = 0.002), matched unrelated reduced intensity conditioning HSCT (HR 1.91, 95% CI [1.10; 3.33], p = 0.022), occurrence of grade III/IV acute graft-versus-host disease (HR 2.41, 95% CI [1.15; 5.03], p = 0.019) and need for mechanical ventilation (HR 3.49, 95% CI [1.54; 7.92], p = 0.003) predicted an inferior survival in multivariate analysis. Early AKI from any etiology was not related to worse survival.ConclusionPatients submitted to HSCT are at an increased risk for AKI, which etiology is often multifactorial. Due to AKI incidence, specialized nephrologist consultation as part of the multidisciplinary team might be of benefit.     

Volumen renal total y función renal en pacientes nefrectomizados por neoplasias renales

IntroductionThe reduction of renal mass after radical nephrectomy (RN) for renal neoplasm, could be associated with compensatory hypertrophy of the contralateral kidney. The capacity of compensation will determine the renal function (RF) evolution. Measuring of total renal volume (TRV) of the remaining kidney pre and post RN can help assess the RF evolution.ObjectivesTo determine the correlation between TRV pre and post nephrectomy (a year of follow-up) with RF.Materials and methodsA retrospective cohort study was carried out in 47 patients who had undergone RN from 2014 to 2018, due to renal cell carcinoma (confirmed by histopathology).The TRV was calculated, pre and post (a year of follow-up) RN, using ellipsoid formula equation, which were compared with clinical and analytical data. The results were analyzed by multivariate linear logistic models.ResultsThe median age at the time of RN was 70 years old (range, 40-88 years). Most of them were men, 66%. The estimated glomerular filtration rate (eGFR) pre and post nephrectomy was 78 (40-100) and 53.3 ml/min/ m² (30-90) respectively (P = .01). The TRV pre and post-nephrectomy was 168.2 ml (100.4-257.2) and 187.8 ml (115.5-273.1) respectively (P = .001).The pre-nephrectomy eGFR (β = 0.62; P = .034) and the TRV (β = 1.08; P < .0001) were positively correlated with the post-nephrectomy TRV, while the eGFR at year of follow-up was correlated negatively (β = –1.18; P = .047)ConclusionsThe measurement of pre and post nephrectomy TRV can help to predict renal function evolution at a year of follow-up.     

Neutrophil,lymphocyte and platelet ratio as a predictor of mortality in septic-acute kidney injury patients

BackgroundAKI is frequent in critically ill patients, in whom the leading cause of AKI is sepsis. The role of intrarenal and systemic inflammation appears to be significant in the pathophysiology of septic-AKI. The neutrophils to lymphocytes and platelets (N/LP) ratio is an indirect marker of inflammation. The aim of this study was to evaluate the prognostic ability of N/LP ratio at admission in septic-AKI patients admitted to an intensive care unit (ICU).MethodsThis is a retrospective analysis of 399 septic-AKI patients admitted to the Division of Intensive Medicine of the Centro Hospitalar Universitário Lisboa Norte between January 2008 and December 2014. The Kidney Disease Improving Global Outcomes (KDIGO) classification was used to define AKI. N/LP ratio was calculated as: (Neutrophil count × 100)/(Lymphocyte count × Platelet count).ResultsFifty-two percent of patients were KDIGO stage 3, 25.8% KDIGO stage 2 and 22.3% KDIGO stage 1. A higher N/LP ratio was an independent predictor of increased risk of in-hospital mortality in septic-AKI patients regardless of KDIGO stage (31.59 ± 126.8 vs 13.66 ± 22.64, p = 0.028; unadjusted OR 1.01 (95% CI 1.00–1.02), p = 0.027; adjusted OR 1.01 (95% CI 1.00–1.02), p = 0.015). The AUC for mortality prediction in septic-AKI was of 0.565 (95% CI (0.515–0.615), p = 0.034).ConclusionsThe N/LP ratio at ICU admission was independently associated with in-hospital mortality in septic-AKI patients.     

Acute kidney injury is associated with higher mortality and healthcare costs in hospitalized patients with cirrhosis

Introduction and ObjectivesAKI is known to be associated with increased risk of mortality, however limited information is available on how AKI impacts healthcare costs and resource utilization in hospitalized patients with cirrhosis. Previous studies have had variable definitions of AKI, resulting in inconsistent reporting of the true impact of AKI in patients with cirrhosis.MethodsData from the Nationwide Inpatient Sample (NIS) which contains data from 44 states and 4378 hospitals, accounting for over 7 million discharges were analyzed. The inclusion data were all discharges in the 2012 NIS dataset with a discharge diagnosis of cirrhosis.ResultsA total of 32,605 patients were included in the analysis, incidence of AKI was 12.12% in patients with cirrhosis. Crude mortality was much higher for patients with cirrhosis and AKI (14.9% vs. 1.8%, OR 9.42, p < 0.001) than for patients without AKI. In addition, mean LOS was longer (8.5 vs. 4.3 days, p < 0.001) and median total hospital charges were higher for patients with AKI ($43,939 vs. $22,270, p < 0.001). In multivariate logistic regression, controlling for covariates and mortality risk score, sepsis, ascites and SBP were predictors of AKI.ConclusionsAKI is relatively common in hospitalized patients with cirrhosis. Presence of AKI results in significantly higher inpatient mortality as well as LOS and resource utilization. Median hospitalization cost was twice as high in AKI patients. Early identification of patients at high risk for AKI should be implemented to reduce mortality and contain costs. Prognosis could be enhanced by utilizing biomarkers which could rapidly detect AKI.     

Acute kidney injury and risk of cardiovascular outcomes: A nationwide cohort study

BackgroundAcute kidney injury (AKI) has been associated with cardiovascular disease, but this is sparsely studied in non-selected populations and with little attention to the effect in age and renal function. Using nationwide administrative data, we investigated the hypothesis of increased one-year risk of cardiovascular event or death associated with AKI.MethodsIn a cohort study, we identified all admissions in Denmark between 2008 and 2018. AKI was defined as ≥1.5 times increase from baseline to peak creatinine during admission, or dialysis. We excluded patients with age <50 years, estimated glomerular filtration rate (eGFR) <15 ml/min/1.73 m², renal transplantation, index-admission due to cardiovascular disease or death during index-admission. The primary outcome was cardiovascular risk within one year from discharge, which was a composite of the secondary outcomes ischemic heart disease, heart failure or stroke. To estimate risks, we applied multiple logistic regression fitted by inverse probability of censoring weighting and stratified estimations by eGFR and age. We adjusted for proteinuria in the subcohort with measurements available.ResultsAmong 565,056 hospital admissions, 39,569 (7.0%) cases of AKI were present. In total, 18,642 patients sustained a cardiovascular outcome. AKI was significantly associated with cardiovascular outcome with an adjusted OR [CI] of 1.33 [1.16–1.53], 1.43 [1.33–1.54], 1.23 [1.14–1.34], 1.38 [1.18–1.62] for eGFR ≥90, 60–89, 30–59 and 15–29 ml/min/1.73 m², respectively. When omitting the outcome heart failure, these results were 1.24 [1.06–1.45], 1.22 [1.11–1.33], 1.05 [0.95–1.16], 1.25 [1.02–1.54]. Results did not change substantially in strata of age groups, in AKI stages and in the subcohort adjusted for proteinuria.ConclusionNon-selected patients aged 50 years or above with AKI during admission had significantly higher one-year risk of cardiovascular event or death, especially, but not only due to heart failure, independent of age and eGFR.     

Association of serum soluble Fas concentrations and mortality of septic patients

IntroductionScarce data on Fas, one of the main receptors that activates the apoptosis extrinsic pathway, in septic patients exists. Higher blood soluble Fas (sFas) concentrations in non-survivor septic patients compared with survivors have been found in small studies; however, the association of blood sFas concentrations with mortality controlling for sepsis severity has not been stablished due to this small sample size in those studies. Thus, our main objective study was to determine whether an association between blood sFas concentrations and sepsis mortality controlling for sepsis severity exists.MethodsWe included septic patients in this observational and prospective study carried out in three Spanish Intensive Care Units. We obtained serum samples at sepsis diagnosis sepsis for sFas levels determination.ResultsThirty-day non-surviving patients (n = 85) compared to surviving patients (n = 151) had higher serum sFas levels (p < 0.001). We found in multiple logistic regression analysis an association of serum sFas levels with mortality controlling for age and SOFA (OR = 1.004; 95% CI = 1.002–1.006; p < 0.001), and for age and APACHE-II (OR = 1.004; 95% CI = 1.002–1.006; p < 0.001). Serum sFas levels showed and area under the curve for mortality prediction of 71% (95% CI = 65–71%; p < 0.001). Kaplan–Meier analysis showed higher mortality rate in patients with serum sFas levels > 83.5 ng/mL (Hazard ratio = 3.2; 95% CI = 2.1–5.0; p < 0.001).ConclusionsThat an association between blood sFas concentrations and sepsis mortality controlling for sepsis severity exists was our main new finding study.     

Serum sclerostin in acute kidney injury patients

BackgroundMany of the mineral metabolite abnormalities encountered in chronic kidney disease (CKD) patients were found also associated with acute kidney injury (AKI). In the last decade, sclerostin was found to intimately affect bone mineral metabolism in CKD patients. Nothing is known about sclerostin in AKI.ObjectiveWe looked for serum level of sclerostin in AKI patients in comparison to normal control subjects and if there is an impact on metabolic derangement, endothelial function or clinical outcome.Cases and methodsThis is a cross sectional case control observational study of 219 AKI cases (group I) beside 219 age matched normal control subjects (group II). All cases of group I were in the intensive care because of sepsis; 86 had acute on CKD (group Ib), while 133 had de novo AKI (group Ia). All studied subjects underwent estimation of serum sclerostin, parathyroid hormone (PTH), 25 hydroxy vitamin D (25 OH vit D), fibroblast growth factor 23 (FGF23), C-reactive protein (CRP), interleukin 6 (IL6), Homeostatic Model Assessment for Insulin Resistance (Homa IR), beside the routine CBC, kidney and liver function tests, serum calcium, and phosphorus, and flow mediated vasodilation of brachial artery (FMD). Follow-up of group I cases was done till they recovered or passed away.ResultsSerum sclerostin, PTH, FGF23, phosphorus, CRP, IL6, HOMA IR, creatinine, urea, uric acid, ALT, AST and white blood cell count (WBC) were significantly higher while serum calcium, 25 OH vit D, hemoglobin, platelet count and FMD were significantly lower in group I compared to group II (P < 0.001 in all). On the other hand, there was no significant difference in serum sclerostin, PTH, FGfF23, 25 OH vit D, CRP, IL6, Homa IR and FMD between group Ia and Ib. Survivors were younger in age (median 55.5 vs. 60 years, P < 0.04), had lower AST (30.5 vs. 58 units, P < 0.001), had higher platelet count (206 vs 162 × 10⁹/L, P < 0.001), otherwise, there was no significant difference in any of the other parameters between survivors and patients that were lost. Serum sclerostin had strong correlation with FGF23 in group I (r = 0.99, P < 0.001) and group II (r = 1, P < 0.001). Homa IR had positive correlation with serum sclerostin (r = 0.148, P = 0.014) and serum FGF23 (r = 0.142, P = 0.018) in group I.ConclusionSclerostin is intimately related to FGF23. Sclerostin level increases in AKI patients. Both sclerostin and FGF23 might increase insulin resistance but have no impact on FMD. Neither sclerostin nor FGF23 interfere with AKI outcome.     

Progresión de la enfermedad renal crónica en pacientes con hipertensión resistente sometidos a 2 estrategias terapéuticas: intensificación con diuréticos de asa vs. antagonistas de la aldosterona

IntroductionActualy, there are few data about glomerular filtration rate (eGFR) drop in patients with resistant hypertension and how diferent therapies can modify chronic kidney disease progression (CKD).ObjectiveTo evaluate CKD progression in patients with resistant hypertension undergoing 2 diferent therapies: treatment with spironolactone or furosemide.MethodsWe included 30 patients (21 M, 9 W) with a mean age of 66.3 ± 9.1 years, eGFR 55.8 ± 16.5 ml/min/1.73 m², SBP 162.8 ± 8.2 and DBP 90.2 ± 6.2 mmHg: 15 patients received spironolactone and 15 furosemide and we followed up them a median of 32 months (28-41).ResultsThe mean annual eGFR decrease was -2.8 ± 5.4 ml/min/1.73 m². In spironolactone group was –2.1 ± 4.8 ml/min/1.73 m² and in furosemide group was -3.2 ± 5.6 ml/min/1.73 m², P<0.01. In patients received spironolactone, SBP decreased 23 ± 9 mmHg and in furosemide group decreased 16 ± 3 mmHg, P<.01. DBP decreased 10 ± 8 mmHg and 6 ± 2 mmHg, respectively (P<.01). Treatment with spironolactone reduced albuminuria from a serum albumin/creatine ratio of 210 (121-385) mg/g to 65 (45-120) mg/g at the end of follow-up, P<.01. There were no significant changes in the albumin/creatinine ratio in the furosemide group. The slower drop in kidney function was associated with lower SBP (P=.04), higher GFR (P=.01), lower albuminuria (P=.01), not diabetes mellitus (P=.01) and treatment with spironolactone (P=.02). Treatment with spironolactone (OR 2.13, IC 1.89-2.29) and lower albuminuria (OR 0.98, CI 0.97-0.99) maintain their independent predictive power in a multivariate model.ConclusionTreatment with spironolactone is more effective reducing BP and albuminuria in patients with resistant hypertension compared with furosemide and it is associated with a slower progression of CKD in the long term follow up.     

Severe acute kidney injury and multiple myeloma: Evaluation of kidney and patient prognostic factors

BackgroundPatients with multiple myeloma (MM) manifesting acute kidney injury (AKI) and who later recover renal function and independence from renal replacement therapy (RRT) are considered to have a better outcome. The aim of this work was to study the factors associated with renal function recovery (independence of hemodialysis) and longer survival in these patients.MethodsA retrospective single center study including patients with a diagnosis of MM and severe AKI, defined as stage 3 of the Kidney Disease: Improving Global Outcomes (KDIGO) criteria: 3.0 times baseline increase in serum creatinine (sCr) or increase in sCr to ≥ 4.0 mg/dL or initiation of RRT, was conducted. Data was registry-based and collected between January 2000 and December 2011. We examined demographic and laboratorial data, presenting clinical features, precipitating factors, need for RRT and chemotherapy. Death was considered the primary endpoint.ResultsLower serum β2-microglobulin was the only independent factor associated with recovery of renal function and independence of RRT (OR 0.95, 95% CI: 0.91–0.99, P = 0.02). The median survival after AKI was 10.7 ± 12.1 months. The factors associated with longer survival were independence of RRT (HR 2.21; 95% CI: 1.08–4.49; P = 0.02), lower CRP (HR 1.07; 95% CI: 1.03–1.12; P = 0.001) and younger age (HR 1.03; 95% CI: 1.01–1.06; P = 0.005).ConclusionsOur study suggests that MM patients with lower serum β2-microglobulin have a higher likelihood of recovering renal function after severe AKI. Independence of RRT, lower CRP and younger age are associated with longer survival.     

Association between neutrophil-to-lymphocyte ratio in the first seven days of sepsis and mortality

IntroductionThe neutrophil-to-lymphocyte ratio (NLR) in the diagnosis of sepsis has been found to be higher in non-survivors than in survivors, and that is associated with mortality. A higher NLR in non-survivors than in survivors has been reported in two studies during patient follow-up; however, NLR was not controlled for sepsis severity. Thus, the objective of this study was to determine whether there is an association between NLR in the first seven days and mortality controlling for sepsis severity.MethodsThis observational study, which included septic patients, was conducted in the Intensive Care Units of 3 Spanish hospitals. NLR was recorded on the first, fourth, and eighth day of sepsis. Multiple logistic regression analyses were carried out to determine the association between NLR during the first 7 days of sepsis diagnosis and mortality controlling for sepsis severity.ResultsThirty-day non-surviving patients (n = 68) compared to surviving patients (n = 135) showed higher NLR on the first (p < 0.001), fourth (p < 0.001), and eighth (p < 0.001) day of sepsis diagnosis. Multiple logistic regression analysis found an association between NLR at days first (p < 0.001), fourth (p = 0.004), and eighth (p = 0.01) of sepsis diagnosis and mortality controlling for SOFA and lactic acid in those days.ConclusionsThe new finding of our study was the association between NLR in the first seven days of sepsis and mortality controlling for sepsis severity.     

Lactate and other clinicolaboratory predictors for subtle myocardial dysfunction in pediatric intensive care unit

IntroductionThis study aimed to determine the incidence of admission subtle myocardial dysfunction (SMD) in critically ill children by measuring cardiac troponin I (cTnI) and to identify clinicolaboratory risk factors.MethodsAdmission systolic blood pressure (SBP) registration. Categorizing patients into 2 groups: sepsis and nonsepsis. Laboratory investigations including: Hemoglobin, urea, creatinine, alanine aminotransferase (ALT); aspartate transaminase (AST) and serum troponin I (cTnI) and lactate.ResultsSixty-three patients were enrolled. Eleven (17.5%) patients had SMD. All SMD patients were in severe sepsis or septic shock having significant characteristics: (1) cTnI (median 0.7 ng/mL, P < 0.000), lactate (median 5.5 mmol/L. P < 0.000). (2) Age (median 6mo, P < 0.04) (3) SBP (median 73 mm Hg. P < 0.001) (4) ALT and AST (median 259 IU/dl and 586 IU/dl, P < 0.000 for each). (5) BUN and Creatinine (median 29 mg/dl, P < 0.002, median 1.4 mg/dl, P < 0.01, respectively). (6) Hemoglobin (median 7.2 g/dl, P < 0.003). Lactate Level > 3.3 mmol/L(95% CI −.9 to −.25, P < 0.001) and high ALT (95% CI −.002 to .000, P < 0.001) are predictors of SMD. High Lactate had a sensitivity of 90.9%, specificity of 89.9% with positive predictive value of 83.3%, negative predictive value of 94.1% and accuracy of 90%. for SMD. Patients with SMD had significant mortality.ConclusionSubtle myocardial dysfunction is detected in infants with severe sepsis and septic shock. SMD should be suspected in those patients showing high ALT and Lactate level > 3.3 mmol/L.     

Association between nonalcoholic fatty liver disease and the incidence of cardiovascular and renal events

BackgroundRecent data suggest that the presence of non-alcoholic fatty liver disease (NAFLD) may be linked to increased cardiovascular and chronic kidney diseases. Here we assess whether NAFLD, as diagnosed by ultrasound, predicts the risk of incident cardiovascular and renal impairment events.MethodsA total of 1150 patients with normal or near normal liver and kidney functions, and without protienuria or histories of cardiovascular accident were included in this multicenter prospective observational cohort study. All patients were subjected to full clinical evaluation, laboratory investigation including estimation of the GFR and immunonephelometric evaluation for protienuria, and abdominal ultrasonography for diagnosis of NAFLD. The metabolic syndrome was defined according to the modified National Cholesterol Education Program (NCEP)–ATP criteria. All patients followed up periodically over three years for the incidence of cardiovascular (including coronary heart disease, ischemic stroke and cerebral hemorrhage) and renal impairment events.ResultsOnly 747 (62.25%) patients completed the follow-up examination and were included in the final analysis. 35.8% of them fulfilled the sonographic criteria of NAFLD. The frequency of cardiovascular accident and renal impairment was significantly higher in them: 136 patients (50.7%) vs. 110 (23%); P < 0.001 for cardiovascular events, 88 (32.8%) vs. 88 (18.4%), P < 0.001 for microalbuminuria; and 24 (8.9%) vs. 14 (2.9%), P < 0.001 for macroalbuminuria. Also, mean estimated glomerular filtration rate (eGFR) was significantly lower in patients with NAFLD (96 ± 23.28 vs. 111 ± 28.37; P < 0.001). Logistic regression analysis revealed that NAFLD was the best predictor for cardiovascular and renal impairment.ConclusionNAFLD is a good predictor of cardiovascular and renal diseases.     

Microalbuminuria,but not reduced eGFR,is associated with cardiovascular subclinical organ damage in type 2 diabetes

AimThis study explored the association between reduced estimated glomerular filtration rate (eGFR) and microalbuminuria vs. subclinical organ damage in patients with type 2 diabetes.MethodsData from middle-aged patients with type 2 diabetes (n = 706) treated in primary care were analyzed for microalbuminura, defined as a urinary albumin/creatinine ratio (uACR) ≥ 3.0 mmol/mol, and reduced eGFR, defined as < 60 mL/min/1.73 m², in relation to blood pressure, pulse wave velocity (PWV), left ventricular mass index (LVMI), and carotid intima–media thickness (IMT) and lumen diameter (LD).ResultsPatients with microalbuminuria had significantly higher 24-h ambulatory systolic blood pressure (ASBP) compared with subjects with uACR < 3 mg/mmol: 137 vs. 128 mmHg (P < 0.001). There were no differences in ASBP in patients with eGFR < 60 mL/min/1.73 m². However, patients with vs. without microalbuminuria had increased PWV (11.4 vs. 10.1 m/s; P < 0.001), LVMI (134.4 vs. 118.6 g/m²; P < 0.001), LD (7.01 ± 0.93 vs. 6.46 ± 0.74 mm; P < 0.001) and IMT (0.78 vs. 0.74 mm; P = 0.047), respectively. The associations between uACR vs. PWV and LVMI were more robust after adjusting for age, diabetes duration, ASBP, HbA_1c, LDL-cholesterol, and antihypertensive and lipid-lowering therapy compared with uACR vs. IMT. There were no statistically significant differences in PWV, LVMI or IMT between patients with reduced (< 60 mL/min/1.73 m²) vs. normal eGFR.ConclusionLevels of urinary albumin excretion, but not reduced eGFR, were associated with increased arterial stiffness, left ventricular mass and atherosclerosis in patients with type 2 diabetes.     

Performance of a selective screening strategy for diagnosis of hyperglycaemia in pregnancy as defined by IADPSG/WHO criteria

AimOur study evaluated the performance of a selective screening strategy for hyperglycaemia in pregnancy (HIP) based on the presence of risk factors (RFs; body mass index ≥ 25 kg/m², age ≥ 35 years, family history of diabetes, personal history of HIP or macrosomic infant) to diagnose HIP and to predict HIP-related events.MethodsWomen with no known diabetes who had undergone complete universal screening (early, before 22 weeks of gestation and, if normal, in the second part of pregnancy) at our department (2012–2016) were selected, resulting in four groups of women according to the presence of HIP and/or RFs, with a predefined composite endpoint (preeclampsia or large-for-gestational-age infant or shoulder dystocia).ResultsIncluded were 4518 women: 23.5% had HIP and 71.1% had at least one RF. The distribution among our four groups was: HIP−/RF− (n = 1144); HIP−/RF+ (n = 2313); HIP+/RF− (n = 163); and HIP+/RF+ (n = 898). HIP was more frequent when RFs were present rather than absent (33.1% vs 15.4%, respectively; P < 0.001). Incidence of the composite endpoint differed significantly (P < 0.0001) across groups [HIP−/RF− 6.3%; HIP−/RF+ 13.2%; HIP+/RF− 8.6%; and HIP+/RF+ 17.1% (HIP effect: P < 0.05; RF effect: P < 0.001; interaction HIP * RF: P = 0.94)] and significantly increased with the number of RFs (no RF: 6.3%, 1 RF: 10.8%, 2 RFs: 14.7%, 3 RFs: 28.0%, 4–5 RFs: 25.0%; P < 0.0001).ConclusionRFs are predictive of HIP, although 15.4% of women with HIP have no RFs. Also, irrespective of HIP status, RFs are predictive of HIP-related events, suggesting that overweight/obesity, the only modifiable RFs, could be targets of interventions to improve pregnancy prognosis.     

Circulating Bcl-2 concentrations and septic patient mortality

IntroductionThere are not data on blood B-cell lymphoma 2 (Bcl-2) concentrations (one of the antiapoptotic molecules of the Bcl-2 family in the intrinsic apoptosis pathway) in septic patients. Therefore, this study was carried with the aims to explore whether blood Bcl-2 concentrations at diagnosis of sepsis are different in survivor and non-survivor septic patients, are associated with mortality, and are useful for the mortality prediction.MethodsIntensive Care Units from 3 Spanish hospitals participated in this observational and prospective study with septic patients and serum Bcl-2 concentrations at diagnosis of sepsis were determined. Mortality at 30 days was as outcome variable.ResultsWe found that 30-day non-surviving patients (n = 81) showed lower serum Bcl-2 levels (p = 0.003) than surviving patients (n = 140). We found that serum concentrations of Bcl-2 < 4.4 ng/mL were associated with mortality (OR = 3.228; 95% CI = 1.406–7.415; p = 0.006) in the multiple logistic regression analysis, and that showed an area under the curve for mortality prediction of 62% (95% CI = 55–68%; p = 0.003).ConclusionsIn our study appears novel findings such as higher blood Bcl-2 concentrations in survivor than in non-survivor septic patients, the association between low blood Bcl-2 concentrations and mortality of septic patients, and the ability of blood Bcl-2 concentrations for the prediction of septic patient mortality.     

Low adiponectin levels at baseline and decreasing adiponectin levels over 10 years of follow-up predict risk of the metabolic syndrome

AimAdiponectin is the most abundant adipokine and may play a key role in the interplay between obesity, inflammation, insulin resistance and the metabolic syndrome (MetS). Thus, this large population-based cohort investigated whether adiponectin at baseline and/or a decrease in adiponectin during follow-up is associated prospectively with the risk of incident MetS.MethodsUsing a prospective study design, the development of MetS was examined in 1134 healthy participants from the community. Plasma adiponectin was measured at study entry and again after a median follow-up of 9.4 years (IQR: 9.2–9.7). During follow-up, 187 participants developed MetS, and 439 presented with at least two components of MetS.ResultsDuring follow-up, adiponectin decreased in participants who developed MetS, whereas adiponectin was increased in those who did not develop MetS (P < 0.001). Those with low adiponectin levels (quartile 1) at baseline had an increased risk of developing MetS (OR: 2.92, 2.08–6.97; P < 0.001) compared with those with high levels (quartile 4). After adjusting for confounding variables, low adiponectin levels at baseline remained independently associated with MetS (OR: 2.24, 1.11–4.52; P = 0.017). Similarly, participants with a decrease in adiponectin during follow-up also had an increased risk of MetS (OR: 2.96, 2.09–4.18; P < 0.001). This association persisted after multivariable adjustments, including for baseline adiponectin (OR: 4.37, 2.77–6.97; P < 0.001). Finally, adiponectin levels at follow-up were inversely associated with an increase in the number of components of MetS (P < 0.001); geometric mean adiponectin levels were 9.5 mg/L (95% CI: 9.0–10.0) for participants with no components vs 7.0 mg/L (95% CI: 6.3–7.9) for those with four to five components.Conclusions/interpretationLow plasma adiponectin levels at baseline and decreasing adiponectin levels during follow-up are both associated with an increased risk of MetS.     

Prognostic Significance of Acute Kidney Injury After Reperfused ST-Elevation Myocardial Infarction: Synergistic Acceleration of Renal Dysfunction and Left Ventricular Remodeling

BackgroundAcute kidney injury (AKI) after myocardial infarction is associated with poor clinical outcome. However, mechanisms of the adverse effect of AKI on clinical outcome after reperfused ST-elevation myocardial infarction (STEMI) have not been fully elucidated.Methods and ResultsWe examined 141 consecutive patients with reperfused first anterior STEMI. AKI was defined as an increase in serum creatinine of ≥0.3 mg/dL within 48 hours after admission. Patients with AKI had higher incidence of in-hospital cardiac death (P = .0004) and major adverse cardiac events (MACE, P = .020) during a mean of 39 ± 40 (range, 1 to 96) months than those without, in association with adverse left ventricular (LV) remodeling. White blood cell count on admission and peak C-reactive protein were higher in patients with than those without AKI. Plasma norepinephrine on admission, interleukin-6, brain natriuretic peptide, and malondialdehyde-modified low-density lipoprotein 2 weeks after STEMI were higher in patients with AKI than those without AKI. Cox proportional hazards model analysis revealed AKI was an independent predictor of MACE (hazard ratio = 2.38, P = .019).ConclusionsAKI was a strong predictor of MACE in association with adverse LV remodeling. Enhanced inflammatory response, oxidative stress, and neurohormonal activation may synergistically accelerate renal dysfunction and LV remodeling after STEMI.     

Chronic kidney disease predicts poor prognosis in patients with stable premature coronary artery disease

ObjectiveThis study was performed to determine the prevalence of chronic kidney disease (CKD) as well as its association with mid-term prognosis in patients with stable premature coronary artery disease (CAD) in a Chinese population.MethodsFive hundred and twelve patients from Jiangsu Province, China with stable, premature CAD were enrolled using an estimated glomerular filtration rate (eGFR) to determine the presence of CKD. The patients were then monitored over a two-year follow up during which major adverse cardiac events (MACEs) were recorded and analyzed.ResultsOne hundred and eighty-three patients (35.74%) were determined to have CKD. Having CKD was associated with a higher ratio of type 2 diabetes mellitus, multi-vessel disease, higher levels of fasting blood sugar and lower levels of left ventricular ejection fraction (all P < 0.05). Patients with CKD had significantly higher incidences of composite MACEs than the non-CKD group at the end of the two- (45.35% vs 30.72%, P = 0.001) but not one-year follow up (30.64% vs 25.32%, P = 0.209). Furthermore, as eGFR decreased, more MACEs occurred (all P < 0.05). Multivariate analysis confirmed that both CKD (P < 0.001) and multi-vessel disease (P < 0.001) are independent risk factors for MACEs.ConclusionChinese patients diagnosed with stable, premature CAD and CKD have more risk factors and worse two-year outcomes than those with only CAD.