Association of chronic kidney disease with outcomes in chronic heart failure: a propensity-matched study

Background. Chronic kidney disease (CKD) is associated withincreased mortality in patients with heart failure (HF). However,its association with hospitalization in HF patients has notbeen well studied. Methods. Of 7788 patients in the Digitalis Investigation Grouptrial, 3527 had CKD, defined by an estimated glomerular filtrationrate (GFR) <60 ml/min/1.73 m² body surface area (BSA). Propensityscores for CKD were calculated using a multivariable logisticregression model and used to match 2399 pairs of patients withand without CKD. Matched Cox regression analyses were used toestimate association of CKD with outcomes. Results. All-cause hospitalization occurred in 1636 (rate, 4233/10 000person-years) and 1587 (rate, 3733/10 000 person-years)patients respectively, with and without CKD (matched hazardratio [HR] for CKD, 1.18, 95% confidence interval [CI], 1.08–1.29;P < 0.0001). Matched HR for cardiovascular and HF hospitalizationwere respectively 1.17 (95% CI, 1.06–1.28, P = 0.002)and 1.28 (95% CI, 1.13–1.45, P < 0.0001). Comparedto GFR 60 ml/min/1.73 m² BSA, HR for all-cause hospitalizationfor GFR 45–59 and <45 ml/min/1.73 m² BSA were respectively1.04 (95% CI, 0.94–1.16; P = 0.422) and 1.58 (95% CI,1.34–1.87; P < 0.0001). Similarly, HR for all-causedeath for GFR 45–59 and <45 ml/min/1.73 m² BSA wererespectively 1.03 (95% CI, 0.90–1.18; P = 0.651) and 1.70(95% CI, 1.40–2.07; P < 0.0001). Matched HR for deathdue to cardiovascular causes and progressive HF were respectively1.24 (95% CI, 1.09–1.40; P = 0.001) and 1.42 (95% CI,1.16–1.72; P = 0.001). Conclusion. CKD was associated with increased mortality andhospitalization in ambulatory patients with chronic HF, whichincreased progressively with worsening kidney function.     

Significant benefits after renal transplantation in patients with chronic heart failure and chronic kidney disease

Background: Chronic heart failure (CHF) and chronic kidney disease (CKD) are serious medical conditions with significant morbidity and mortality and often coexist. Because of perioperative risks in these patients, they may not be considered a candidate for renal transplantation (RTx).

Material and methods: We compare retrospectively RTx outcomes [graft/patient survival, rejection rates and adverse cardiac events] in study group [low left ventricular ejection fraction (LVEF) ≤45% by echocardiogram, n?=?63] and control group [normal LVEF ≥50%, n?=?537] from a developing country.

Results: The mean EF was 35?±?5.6 and 57?±?3% for the study and control groups, respectively (p?Conclusion: RTx may play a role in reversing LV systolic dysfunction. Once thought by many to be a contraindication for renal transplantation, this appears not to be the case. The outcomes between the 2 groups are comparable and transplant is an option for even low EF patients.     

Non-albuminuric renal disease among subjects with advanced stages of chronic kidney failure related to type 2 diabetes mellitus

Urinary albumin excretion has been consistently found to be normal in a significant number of subjects with early stages of diabetic kidney disease. This study was aimed to estimate the prevalence and characteristics of non-albuminuric chronic kidney disease associated with type 2 diabetes mellitus among subjects who reach advanced stages of renal failure. Study population was composed of incident patients with advanced chronic kidney disease (glomerular filtration rate <30?mL/min) related to type 2 diabetes in a tertiary hospital from Gran Canaria (Spain) during a period of 2 years. Subjects were classified as normoalbuminuric (urinary albumin-to-creatine ratio [UACR] <30?mg/g), microalbuminuric (UACR ≥30 and <300?mg/g), or proteinuric (UACR ≥300?mg/g). Of 78 eligible patients, 21.8% had normoalbuminuria, 20.5% had microalbuminuria, and 57.7% had proteinuria. Individuals with normoalbuminuria were mostly women and had a lower prevalence of smoking and polyneuropathy than subjects with microalbuminuria or proteinuria. They also presented greater measures of body mass index and waist circumference, higher values of total and LDL cholesterol, and lower values of HbA_1c and serum creatinine than subjects with microalbuminuria or proteinuria. Multivariate analysis demonstrated that female sex (positively) and HbA_1c and polyneuropathy (negatively) were independently associated with absence of albuminuria. In conclusion, around 20% of subjects with diabetes-related advanced chronic kidney disease, characteristically women, have normal urinary albumin excretion. HbA_1c and polyneuropathy are inversely related to this non-albuminuric form of nephropathy.     

不同剂量瑞舒伐他汀对老年慢性心力衰竭合并肾功能不全患者心、肾功能、N端前脑钠肽及胱抑素C的影响

目的:探究不同剂量瑞舒伐他汀对老年慢性心力衰竭合并肾功能不全患者N端前脑钠肽(NT-proBNP)、胱抑素C(Cys-C)及心、肾功能的影响。方法:选取我科127例老年慢性心力衰竭合并肾功能不全的患者,根据数字表法随机分为两组。对照组63例患者在常规治疗的基础上给予常规剂量瑞舒伐他汀,观察组64例患者在常规治疗的基础上...     

功能MRI评估2型糖尿病早期肾损害研究进展

糖尿病肾病（DKD）是糖尿病微血管并发症,亦为导致终末期肾脏病的主要原因。早期诊断、及时干预可有效控制DKD病情进展并改善预后。近年来,功能MRI （fMRI）逐渐用于定量评估2型糖尿病（T2DM）患者早期肾损害。本文就fMRI评估T2DM早期肾损害研究进展进行综述。     

Increased morbidity and mortality in patients with diabetes mellitus after kidney transplantation as compared with non-diabetic patients.

The results of renal transplantation in patients with juvenile-onset diabetes mellitus were compared to those of a well-matched control group of non-diabetic patients. All transplantations were performed between 1977 and 1988. In the diabetic group hypertension (72 versus 41%), coronary artery disease (17 versus 0%), and peripheral vascular disease (19 versus 0%) had been significantly more frequent pretransplantation. Fewer diabetic patients had previously been treated with dialysis therapy (69 versus 97%). Graft function measured by creatinine clearance after 1 year follow-up, and incidence of proteinuria were not significantly different. The overall graft survival was significantly worse in the diabetic group compared to the control group: 42 versus 69% after 60 months and 21 versus 62% after 90 months. This was caused by a significantly worse patient survival in the diabetic group after 105 months: 28 versus 78% in the control group. The graft survival following exclusion of the patients who died with a functioning graft did not differ significantly between the groups after 60 and 90 months: 62 and 31% in the diabetic group and 69 and 62% in the control group. The existence of any vascular disease before transplantation, especially pre-existing peripheral vascular disease, had a significant effect on mortality in diabetic patients (P = 0.0003). After transplantation, diabetic patients had significantly more cerebrovascular accidents (23 versus 3%), peripheral vascular disease (31 versus 3%), and number of infections (1.9 versus 1.2). Retransplantation was carried out in each group to the same extent, with the same success rate.     

Vascular response to vasoactive agents in dialysed patients with chronic renal failure with and without diabetes mellitus

Using a muscle bath technique the vascular response to KCl,noradrenaline, angiotensin II, acetylcholine, and sodium nitroprussidewere evaluated in 13 patients with diabetes mellitus (DM group)and 15 non-diabetic (non-DM group) chronic renal failure patientstreated with haemodialysis. There were no differences in age,duration of haemodialysis, blood pressure and the levels ofplasma renin activity, noradrenaline, and parathyroid hormonebetween groups. After informed consent was obtained, a smallpiece of forearm vein was resected during the blood access surgery.The ring preparation of the blood vessel was sustained in themuscle bath filled with Krebs-Henseleit solution and the isometrictension development was recorded. All drugs produced concentrationdependent responses in the ring preparations of both groups.Although there were no significant differences in E_max valuesfor KCl-and angiotensin-II-induced contractions between groups,the value for noradrenaline in the DM group was significantlyless than that in the non-DM group. Sodium nitroprusside completelyrelaxed the ring preparation precontracted by 10^–5 M noradrenaline.However, the response to acetylcholine in the DM group was significantlyweaker than that in the non-DM group. These results suggesta reduced vascular response to noradrenaline and acetylcholinein dialysed diabetic renal failure patients, which may relateto the autonomic nervous system dysfunction.     

2型糖尿病并发慢性肾脏病临床病理特点分析

目的 研究2型糖尿病并发慢性肾脏病（CKD）患者的肾脏损害类型及临床特点。 方法 回顾性分析155例伴显性白蛋白尿的2型糖尿病患者的肾脏损害病理类型及临床特点。根据病理表现分为典型糖尿病肾小球病（DG）组、不典型糖尿病相关肾脏病（ADRD）组、非糖尿病肾病组（NDRD）和DG并发NDRD组。 结果 DG占18.7%,ADRD占12.9%,NDRD占60.0%,DG并发NDRD占8.4%。DG的糖尿病病程较长,空腹血糖较高,糖尿病视网膜病变（DR）发生率较高,收缩压和平均动脉压较高,尿蛋白量较多,GFR下降更明显。ADRD组年龄较小,体质量指数和肥胖比例较高。NDRD组多可见肉眼血尿和急性肾功能下降,对诊断NDRD有一定预测价值的因素有不伴DR、糖尿病病程小于5年、肉眼血尿、急性肾功能下降、自身免疫性疾病证据和尿蛋白量≥3.5 g/24 h且eGFR≥60 ml/min。 结论 2型糖尿病并发CKD的肾脏病理表现多样,NDRD常见,且与ADRD和DG有差异。如2型糖尿病并发慢性肾脏病患者出现以下任何1项：2型糖尿病病程少于5年、不伴DR、肉眼血尿史、急性肾功能下降、尿蛋白量≥3.5 g/24 h但eGFR≥60ml/min、有导致肾损害的系统性疾病证据,应考虑肾活检明确病理诊断。     

Non diabetic renal disease in type 2 diabetes mellitus

AIM: The aim of this analysis of renal biopsies in people with type 2 diabetes was to know the prevalence and nature of non-diabetic renal disease (NDRD) and to note its correlation with the duration of diabetes, extent of proteinuria and presence or absence of retinopathy. METHODS: From January 2000 to December 2004, 160 people with type 2 diabetes with clinically suspected NDRD underwent renal biopsy reported by a single pathologist. The case records of these patients were retrospectively analysed. Based on the biopsy findings, patients were grouped as Group I, isolated NDRD; Group II, NDRD with underlying diabetic glomerulosclerosis; and Group III, isolated diabetic glomerulosclerosis. The relation of histology with clinical profile in each group was noted and statistically analysed using strata 6 software. RESULTS: Of the 160 patients studied, 118 were males and 42 were females (2.8:1). The average age was 51.35 years (30-79). Indications for renal biopsy included: nephrotic syndrome in 55 (34.37%), acute renal failure (ARF) in 49 (30.62%), rapidly progressive renal failure (RPRF) in 24 (15%), absent retinopathy in 19 (11.87%), haematuria in 10 (6.25%) and acute on chronic renal failure (CRF) in three (1.87%) patients. Group I included 68 patients (42.50%), Group II included 48 patients (30%) and Group III included 44 patients (27.50%). The mean duration of diabetes was 5.37, 10.12 and 6.86 years in Groups I, II and III respectively. The duration of diabetes was significantly less in Group I compared with Group II and III combined (5.37 vs 8.53; P < 0.001). Diabetic retinopathy was absent in 61 (38.13%) patients, of whom 41 (67.21%) had isolated NDRD. The most common NDRD were acute interstitial nephritis (18.1%), post infectious glomerulonephritis (17.24%), membranous nephropathy (11.20%) and focal segmental glomerulosclerosis (7.75%). CONCLUSIONS: Prevalence of NDRD (either isolated or superimposed on underlying diabetic glomerulosclerosis) is very high in appropriate clinical settings. The shorter duration of diabetes and the absence of retinopathy, especially when associated with nephrotic proteinuria, strongly predict NDRD.     

Obesity-related indices are associated with albuminuria and advanced kidney disease in type 2 diabetes mellitus

Obesity is an important risk factor for the development of diseases including diabetes, hypertension, and cardiovascular disease. However, few reports have investigated the relationships between these obesity-related indices and diabetic nephropathy. The aim of this study was to evaluate associations between obesity-related markers with albuminuria and advanced kidney disease in patients with type 2 diabetes mellitus (DM). Obesity-related indices including body mass index (BMI), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), body roundness index (BRI), conicity index (CI), lipid accumulation product (LAP), visceral adiposity index (VAI), body adiposity index (BAI), abdominal volume index (AVI), body shape index (BSI), and triglyceride glucose (TyG) index were measured. Albuminuria was defined as a urine albumin/creatinine ratio of ≥30 mg/g. Advanced kidney disease was defined as an estimated glomerular filtration rate (eGFR) <30 ml/min/1.73 m². A total of 1872 patients with type 2 DM (mean age 64.0 ± 11.3 years, 809 males and 1063 females) were enrolled. In multivariable analysis, 11 high obesity-related indices (BMI, WHR, WHtR, LAP, BRI, CI, VAI, BAI, AVI, ABSI, and TyG index) were significantly associated with albuminuria. In addition, high BMI, WHR, WHtR, LAP, BRI, CI, VAI, and AVI were significantly associated with eGFR <30 ml/min/1.73 m². The results of this study showed that various obesity-related indices were significantly associated with albuminuria and advanced kidney disease in patients with type 2 DM. Screening may be considered in public health programs to recognize and take appropriate steps to prevent subsequent complications.     

End-stage renal failure and cardiac mortality after heart transplantation

BACKGROUND: Coronary artery disease (CAD) is the leading cause of mortality after the first year of heart transplantation. End-stage renal failure (ESRF) is more frequent because of long-term survival. Impact of ESRF on cardiac mortality in heart transplant patients is unappreciated. The hypothesis of accelerated CAD in uremic patients has been suggested. METHODS: In Pitié La Salpêtrière hospital, 1211 heart transplants have been performed between 1982 and 2001. Thirty-three patients have reached ESRF. A case-control study was performed to identify risk factors responsible for ESRF and to appreciate the impact of ESRF on cardiac mortality. RESULTS: In cases at 6 months, serum creatinine tended to be higher (159 +/- 31 micromol/L vs. 141 +/- 44 micromol/L, p = 0.06) and cyclosporine (CSA) dosage (mg/kg) was significantly lower (5.4 +/- 1.8 mg/kg vs. 7.7 +/- 2.7 mg/ kg, p = 0.002). Mean triglyceride level after transplantation until dialysis was significantly lower in cases (2.18 +/- 0.82 mmol/L vs. 1.48 +/- 0.62 mmol/L, p = 0.002). In cases and controls, cardiac mortality was responsible for 67% (10 of 15) and 38% (three of eight) of all deaths, respectively. High triglyceride level (> or = 2 mmol/L) was associated with cardiac mortality [p < 0.03, hazard ratio (HR) = 3.89]. Kaplan Meier cardiac free survival rates were significantly lower in cases than in controls (p < 0.03). CONCLUSION: These data suggest that CSA nephrotoxicity could result from individually determined susceptibility and that hypertriglyceridemia may have a negative impact on renal function and cardiac mortality. The risk of cardiac mortality is increased in heart transplant patients with ESRF. The hypothesis of accelerated atherosclerosis in ESRF patients after heart transplantation leading to higher cardiac mortality incidence needs further study.     

Impact of diabetic and pre-diabetic state on development of contrast-induced nephropathy in patients with chronic kidney disease.

BACKGROUND: The aim of the present study was to assess the influence of diabetic and pre-diabetic state on the development of contrast-induced nephropathy (CIN) in chronic kidney disease patients undergoing coronary angiography. METHODS: A total of 421 patients with Cockcroft clearance between 15 and 60 ml/min were divided into three groups [diabetes mellitus (DM), n = 137; pre-diabetes (pre-DM), n = 140; and normal fasting glucose (NFG), n = 144]. CIN was defined as an increase of > or =25% in creatinine over baseline within 48 h of angiography, DM as glucose > or =126 mg/dl, pre-DM as glucose between 100 and 125 mg/dl and NFG as glucose <100 mg/dl. RESULTS: CIN occurred in 20% of the DM [relative risk (RR) 3.6, P = 0.001], 11.4% of the pre-DM (RR 2.1, P = 0.314) and 5.5% of the NFG group. The decrease of glomerular filtration rate (GFR) was higher in DM and pre-DM (P = 0.001 and P = 0.002, respectively). GFR < or =30 ml/min (RR 19.22), multivessel involvement (RR 7.59), hyperuricaemia (RR 3.95), use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blocker (RR 2.70) and DM (RR 2.34) were predictors of CIN. Length of hospital stay was 2.45 +/- 1.45 day in DM, 2.27 +/- 0.68 day in pre-DM and 1.97 +/- 0.45 day in NFG (P < 0.001, DM vs NFG and P = 0.032, pre-DM vs NFG). The rate of major adverse cardiac events was 8.7% in DM, 5% in pre-DM and 2.1% in NFG (P = 0.042, DM vs NFG). Haemodialysis was required in 3.6% of DM and 0.7% in pre-DM (P = 0.036, DM vs NFG), and the total number of haemodialysis sessions during 3 months was higher in DM and pre-DM (P < 0.001). Serum glucose > or =124 mg/dl was the best cut-off point for prediction of CIN. CONCLUSION: Our data support that patients with DM are at a higher risk of developing CIN, but patients with pre-DM are not at as high a risk for developing CIN as diabetes patients.     

Role of sodium-glucose co-transporter-2 inhibitors in the management of heart failure in patients with diabetes mellitus

Heart failure(HF) is a major complication of diabetes mellitus(DM). Patients with DM have considerably higher risk for HF than non-diabetic subjects and HF is also more severe in the former. Given the rising prevalence of DM, the management of HF in diabetic patients has become the focus of increased attention. In this context, the findings of several randomized, placebo-controlled trials that evaluated the effects of sodium-glucose co-transporter-2 inhibitors on the risk of hospitalization for HF in patients with type 2 DM represent a paradigm shift in the management of HF. These agents consistently reduced the risk of hospitalization for HF both in patients with and in those without HF.These benefits appear to be partly independent from glucose-lowering and have also been reported in patients without DM. However, there are more limited data regarding the benefit of sodium-glucose co-transporter-2 inhibitors in patients with HF and preserved left ventricular ejection fraction, which is the commonest type of HF in diabetic patients.     

Comparative mortality from cardiovascular disease in patients with chrome renal failure

Patients with chronic renal failure show an excess mortalityfrom cardiovascular disease (CVD). Over a 4-year period (1983–1986)we have prospectively studied 305 patients (177 men, 128 women)from a geographically constrained population entering a renalreplacement therapy (RRT) programme. The development of newcardiovascular events and patient survival have been documentedup to the end of 1990. We have determined the incidence of CVDamongst the patients compared to the general population of theregion and assessed the predictive value for future cardiovascularevents of risk factors present at the start of RRT. One hundred and fourteen patients experienced a new cardiovascularevent. One hundred and fifteen patients died, 89 from CVD. Stratificationby age and sex identified diabetes, previous coronary heartdisease, and cardiomegaly to be significantly associated withan increased risk of a cardiovascular event, and diabetes, previouscoronary heart disease, and accelerated hypertension to be significantlyassociated with an increased risk of cardiovascular death. Mortalityfrom CVD was 10.1 times that of the corresponding general population,and was increased 44 times for patients with diabetes. Durationof RRT did not influence mortality rates. This excessive early mortality has significant implica tionsfor RRT programmes and further research is necessary to identifyindividuals at risk and the modi fiable risk factors that couldreceive targeted interven tional therapy.     

Role of vitamin D in diabetes mellitus and chronic kidney disease

Approximately 30%-50% of people are recognized to have low levels of vitamin D,and insufficiency and deficiency of vitamin D are recognized as global health problems worldwide.Although the presence of hypovitamin D increases the risk of rickets and fractures,low vitamin D levels are also associated with hypertension,cancer,and cardiovascular disease.In addition,diabetes mellitus(DM) and chronic kidney disease(CKD) are also related to vitamin D levels.Vitamin D deficiency has been linked to onset and progression of DM.Although in patients with DM the relationship between vitamin D and insulin secretion,insulin resistance,and β-cell dysfunction are pointed out,evidence regarding vitamin D levels and DM is contradictory,and well controlled studies are needed.In addition,vitamin D influences the renin-angiotensin system,inflammation,and mineral bone disease,which may be associated with the cause and progression CKD.There is increasing evidence that vitamin D deficiency may be a risk factor for DM and CKD;however,it remains uncertain whether vitamin D deficiency also predisposes to death from DM and CKD.Although at this time,supplementation with vitamin D has not been shown to improve glycemic control or prevent incident DM,clinical trials with sufficient sample size,study periods,and optimal doses of vitamin D supplementation are still needed.This review focuses on the mechanism of vitamin D insufficiency and deficiency in DM or CKD,and discusses the current evidence regarding supplementation with vitamin D in patients with these diseases.     

Predictors of mortality in adult patients with congestive heart failure receiving nesiritide--retrospective analysis showing a potential adverse interaction between nesiritide and acute renal dysfunction.

BACKGROUND: A recent meta-analysis has suggested that nesiritide (NES), a new agent for the treatment of congestive heart failure (CHF), is associated with an increased risk of short-term mortality. METHODS: We retrospectively examined this issue among 1407 consecutive elderly CHF patients by Pearson's chi-squared test, and determined independent risk factors for 60-day mortality by multivariate analysis in a cohort of 682 patients for whom we had sufficient clinical and laboratory data. RESULTS: Univariate analysis revealed that NES usage was associated with increased mortality (n=1407, 10 vs 6%, P=0.011; n=682, 19 vs 12.5%, P=0.046). However, by forward stepwise regression analysis, NES usage did not survive as an independent predictor of mortality. The following variables were independent predictors of mortality: development of acute renal failure (ARF) defined as an increase of serum creatinine (SCr) >or= 0.5 mg/dl; lack of beta-adrenergic blockade; increased admission blood urea nitrogen; digoxin use; and increased admission brain natriuretic peptide. When patients were stratified according to NES usage, ARF emerged as an independent risk factor for mortality only among patients who received NES. Strikingly, among CHF patients who developed ARF (n=102), NES usage emerged as the only independent predictor of mortality (P=0.006, OR=3.73, 95% CI 1.45-9.56). CONCLUSION: We conclude that, while NES per se is not independently associated with an increased risk for mortality, the development of ARF in association with NES use may confer an increased risk of mortality.