Combination Of Chronic Kidney Disease Research Articles

Is there a “renal-pulmonary syndrome” in rheumatoid arthritis?

Objective: to compare the course of “rheumatoid disease” in multimorbid patients with and without interstitial lung disease (ILD).Material and methods. Two groups were formed of 1034 patients with active rheumatoid arthritis (RA) who met the 2010 ACR/EULAR criteria: one group with ILD identified by high-resolution computed tomography of the lungs (n=82) and another – without ILD (n=900). In all patients, estimated glomerular filtration rate (eGFR) was determined using the Cockroft–Gault formula. The presence and stage of chronic kidney disease (CKD) was assessed depending on the eGFR level: stage I CKD was diagnosed in eGFR <89 ml/min, stage II (subclinical) – 60<eGFR <89 ml/min, stage IIIa (clinical) – 45<eGFR<59 ml/min and IIIb – 30<eGFR<45 ml/min.Results and discussion. Arterial hypertension (p=0.004), cerebrovascular disease (p=0.0001), diabetes mellitus (p=0.04), obesity, psoriasis (p=0.009) and stage II–III CKD (p=0.04) were more frequently observed in the group with ILD.Conclusion. The combination of CKD and ILD frequently found in patients with RA and the known similarity and close interrelationship of the pathogenesis of these diseases, suggest a type of “renal-pulmonary syndrome” associated with a specific variant of RA.

РАСПРОСТРАНЕННОСТЬ НЕПРОПОРЦИОНАЛЬНО ВЫСОКОЙ МАССЫ МИОКАРДА ЛЕВОГО ЖЕЛУДОЧКА СРЕДИ ПАЦИЕНТОВ С РАЗЛИЧНЫМИ ЗАБОЛЕВАНИЯМИ

Abstract. Introduction. According to the inappropriate left ventricular mass concept proposed by G. de Simone et al. (1998), in some cases, an increment in the left ventricular myocardium mass occurs inadequately to the hemodynamic load of high blood pressure. Studying the prevalence and interrelation of disproportionately high left ventricular myocardia ВЕСТНИК СОВРЕМЕННОЙ КЛИНИЧЕСКОЙ МЕДИЦИНЫ 2023 Том 16, вып. 6 131ОБЗОРЫ mass continues to remain topical to the present, due to the increased risk of cardiovascular events among affected people, and at the same time independently of the presence of left ventricular hypertrophy. Aim. To analyze the scientific medical literature data obtained in studying the prevalence of disproportionately high left ventricular myocardial mass in patients with different diseases. Materials and Methods. We reviewed and analyzed the scientific results from national and foreign medical literature in electronic databases PubMed, Medline, and eLibrary over the years 1998- 2023. Results and Discussion. Research papers dealing with studying the prevalence of disproportionately high left ventricular myocardial mass mainly present patients with cardiovascular diseases. Prevalence of disproportionately high left ventricular myocardial mass in patients with arterial hypertension varies quite widely, from 9% to 82,4%; at the same time, gender and racial differences were found. It is also common in patients with coronary heart disease, aortic stenosis, chronic kidney disease, rheumatoid arthritis, type 2 diabetes mellitus, and primary aldosteronism. It turned out that the frequency of abnormally high left ventricular myocardial mass tends to increase in cases with a combination of chronic kidney disease and type 2 diabetes mellitus. Conclusions. To thoroughly study how disproportionately high left ventricular myocardial mass contributes to bad cardiovascular prognosis, further research is needed in this theme, including studying its prevalence in patients with different diseases, both isolated and combined.

Elevated Crude Mortality in Obese Chronic Kidney Disease Patients with Loss of Exercise Habit: A Cohort Study of the Japanese General Population.

Background The relationship between obesity and risk of death in chronic kidney disease (CKD) patients remains controversial. In addition, no clear evidence has been accumulated regarding whether or not exercise improves mortality in CKD patients. Materials and Methods The original cohort was based on a Japanese general population of 685,889 people from 40 to 74 years old who had undergone annual specific health checkups. The number of all-cause deaths during follow-up (mean, 4.7 years) in this study was 1,490. Information on walking and exercise habits was obtained by questionnaires. The study population was divided into 4 categories by the combination of CKD and obesity [body mass index (BMI) ≥25.0 kg/m2]. Changes in the BMI and walking and exercise habits were determined by results for the first year and following year. Results Obese CKD patients with weight gain (BMI increase by more than +1.0 kg/m2/year) showed a higher crude mortality (1.32%) than those with a stable BMI (within ±1.0 kg/m2/year; 0.69%). In the obese CKD population, mortality was higher with loss of exercise habits (0.96%) than in those continuously maintaining exercise habits (0.52%). The age- and sex-adjusted hazard ratio for all-cause death was 2.23 in the group with weight gain compared to the group with stable weight (p<0.01) and 2.08 in the group with loss of exercise habits compared to those who maintained exercise habits (p<0.01). Conclusions This observational cohort study suggested that loss of exercise habits as well as weight gain of more than 1 kg/m2/year might worsen all-cause mortality in the obese CKD population.

Impact of multimorbidity on mortality in heart failure with reduced ejection fraction: which comorbidities matter most? An analysis of PARADIGM-HF and ATMOSPHERE.

Multimorbidity, the coexistence of two or more chronic conditions, is synonymous with heart failure (HF). How risk related to comorbidities compares at individual and population levels is unknown. The aim of this study is to examine the risk related to comorbidities, alone and in combination, both at individual and population levels. Using two clinical trials in HF-the Prospective comparison of ARNI (Angiotensin Receptor-Neprilysin Inhibitor) with ACEI (Angiotensin-Converting Enzyme Inhibitor) to Determine Impact on Global Mortality and morbidity in HF trial (PARADIGM-HF) and the Aliskiren Trial to Minimize Outcomes in Patients with Heart Failure trials (ATMOSPHERE)-we identified the 10 most common comorbidities and examined 45 possible pairs. We calculated population attributable fractions (PAF) for all-cause death and relative excess risk due to interaction with Cox proportional hazard models. Of 15 066 patients in the study, 14 133 (93.7%) had at least one and 11 867 (78.8%) had at least two of the 10 most prevalent comorbidities. The greatest individual risk among pairs was associated with peripheral artery disease (PAD) in combination with stroke (hazard ratio [HR] 1.73; 95% confidence interval [CI] 1.28-2.33) and anaemia (HR 1.71; 95% CI 1.39-2.11). The combination of chronic kidney disease (CKD) and hypertension had the highest PAF (5.65%; 95% CI 3.66-7.61). Two pairs demonstrated significant synergistic interaction (atrial fibrillation with CKD and coronary artery disease, respectively) and one an antagonistic interaction (anaemia and obesity). In HF, the impact of multimorbidity differed at the individual patient and population level, depending on the prevalence of and the risk related to each comorbidity, and the interaction between individual comorbidities. Patients with coexistent PAD and stroke were at greatest individual risk whereas, from a population perspective, coexistent CKD and hypertension mattered most.

Statin Therapy After Myocardial Infarction in Patients With Renal Failure: The Longer, the Merrier!

Among the ongoing clinical challenges for cardiologists in the 21 th century, there is the necessity of being able to cope with multimorbidity and polypharmacy. Irrespectively, beneficial drugs should be continued long-term, to ensure mortality and morbidity benefits continue to be accrued. This is evidently the case for the use of statins to improve long-term outcomes in chronic kidney disease (CKD) patients with acute coronary syndromes (ACS), as the combination of CKD and ACS represents a veritable crucible of adverse risk factors. Furthermore, statins have pleiotropic effects, including anti-inflammatory, antioxidant and endothelial-protective effects. Even though these effects are debated in CKD patients, it is biologically plausible that statins may reduce the inflammatory burden and improve glomerular hemodynamics. Awaiting for further clinical studies, for instance focused on the identification of possible biomarkers of statins action on renal function, it is pivotal to maintain our CKD patients with history of ACS on lifesaving medications such as statins.

The significance of chronic kidney disease, heart failure and cardiovascular disease for mortality in type 1 diabetes: nationwide observational study

People with type 1 diabetes have a substantially increased risk of premature death. This nationwide, register-based cohort study evaluated the significance of risk factors and previous cardiovascular disease (CVD), heart failure and chronic kidney disease (CKD), for mortality in type 1 diabetes. Nationwide, longitudinal, register-based cohort study. Patients (n = 36,303) listed in the Swedish National Diabetes Register between January 1 2015 and December 31 2017 were included and followed until December 31, 2018. Data were retrieved from national health registries through each patient's unique identifier, to capture data on clinical characteristics, outcomes, or deaths, to describe mortality rates in risk groups. The mean follow-up time was 3.3 years, with 119,800 patient years of observation and 1127 deaths, corresponding to a crude overall mortality of 0.92% deaths/year. Statistically significant increased risk in multivariate analyzes was found in older age groups, in men, and in underweight or people with normal BMI, high HbA1c or blood pressure. A history of CVD, albuminuria and advanced stages of CKD was associated with an increased risk of mortality. Each combination of these conditions further increased the risk of mortality. These results emphasize the importance of risk factors and cardiovascular and renal diabetes complications. People with a combination of CKD, CVD, and heart failure, exhibit a markedly increased risk of dying prematurely. These findings provide strong arguments for optimized and individualized treatment of these groups of people with type 1 diabetes in clinical everyday life.

Reduction in risk of contrast-induced nephropathy in patients with chronic kidney disease and diabetes mellitus by enhanced external counterpulsation.

To evaluate the efficacy of enhanced external counterpulsation (EECP) in the prevention of contrast-induced nephropathy (CIN) in patients with combined chronic kidney disease (CKD) and diabetes mellitus (DM) by comparing the changes in renal function-related indicators in patients before and after coronary angiography (CAG) or percutaneous coronary intervention (PCI). There were 230 subjects consecutively included in the study. Of these, 30 cases with DM underwent rehydration therapy, and 200 cases underwent EECP therapy in addition to rehydration therapy, comprising 53 patients with DM and 147 patients without. All the patients were tested to measure the renal function indicators before and after CAG/PCI. The postoperative results of blood urea nitrogen (BUN), serum creatinine (Scr), estimated glomerular filtration rate (eGFR), B2 microglobulin, and high-sensitivity C-reactive protein in the three groups showed a statistically significant difference (P < 0.05). After EECP therapy, patients with DM showed a significant decrease in BUN (9.1 ± 4.2 vs. 7.2 ± 3.0, t = 3.899, P < 0.001) and a significant increase in eGFR (41.5 ± 12.7 vs. 44.0 ± 15.6, t = -2.031, P = 0.047), while the patients without DM showed a more significant difference (P < 0.001). Patients with DM showed a lower percentage of elevated Scr (66.7% vs. 43.4%, P = 0.042), a higher percentage of elevated eGFR (30.0% vs. 52.8%, P = 0.044), and a lower incidence of CIN (16.7% vs. 3.8%, P = 0.042) after EECP therapy. Treatment with EECP can reduce Scr in patients with combined CKD and DM post CAG/PCI, increase eGFR, and decrease the incidence of CIN.

Combined Effects of Chronic Kidney Disease and Nonalcoholic Fatty Liver Disease on the Risk of Cardiovascular Disease in Patients with Diabetes.

Background: We investigated the combined effect of chronic kidney disease (CKD) and nonalcoholic fatty liver disease (NAFLD) on the risk of cardiovascular disease (CVD) in patients with type 2 diabetes. Methods: Data were obtained from the Korean National Health Insurance Service. Patients with diabetes who participated in health screenings from 2009 to 2011 were included. The fatty liver index (FLI) was used as a surrogate marker for NAFLD. Results: During a mean follow-up of 6.9 years, 40,863 incidents of myocardial infarction (MI), 58,427 strokes, and 116,977 deaths were reported in 1,607,232 patients with type 2 diabetes. After adjusting for conventional risk factors, patients with CKD and NAFLD showed the highest risk of MI and stroke (hazard ratio (HR) = 1.49; 95% confidence interval (CI): 1.42–1.57 and stroke, HR = 1.48; 95% CI: 1.41–1.54, respectively) compared with those without either CKD or NAFLD. Both overall and cardiovascular mortality were highest in the CKD/NAFLD group compared with other groups (HR = 2.00; 95% CI: 1.94–2.06, and HR = 2.20; 95% CI: 2.07–2.35, respectively). Advanced liver fibrosis was significantly associated with an increased risk of CVD in patients with NAFLD. Proteinuria was significantly associated with incidence of CVD events in patients with CKD. Conclusions: The combination of CKD and NAFLD was associated with an increased risk of CVD and mortality in patients with type 2 diabetes. Close monitoring and appropriate management of CKD and NAFLD may be warranted to prevent CVD in these patients.

MO182: Safety Analysis of Anticoagulant Therapy in Stage 4 CKD in Combination with AF

Abstract BACKGROUND AND AIMS A renocardial comorbid condition with a combination of chronic kidney disease (CKD) and atrial fibrillation (AF) increases the risk of thromboembolic complications (TEC) and hemorrhagic events. As kidney function worsens, this risk only increases. Anticoagulant therapy is the standard for prevention of acute cerebrovascular accident (ACVA) in AF. Clinical data on the use of new oral anticoagulants (NOACs) in patients with advanced CKD and AF are very limited, which indicates the relevance of research. Analysis of safety and efficacy indicators of rivaroxaban in patients with stage 4 CKD in combination with AF. METHOD The study included 106 patients with a glomerular filtration rate (GFR) of 15–29 mL/min/1.73 m2 and AF. A total of 73 patients took rivaroxaban at a dose of 15 mg/day and 33 patients took warfarin, the dose of which was individually adjusted according to INR values. The average follow-up period was 18 months. Thromboembolic complications were the primary endpoint. The secondary endpoint is the development of haemorrhagic events (major and minor bleeding). RESULTS In the rivaroxaban group, the mean CHA2DS2 VASc score was 4.9, the HAS BLED score was 3.2, and in the warfarin group, 4.5 and 3.1, respectively. The incidence of stroke in the rivaroxaban group was observed in one patient (1.37%), and in the warfarin group in two patients (6.06%). The results of the study on the primary endpoint indicate that the indicators in both groups did not differ significantly (P = .24). The incidence of haemorrhagic events such as minor bleeding in the rivaroxaban group on the BARC scale was n = 31 (42.5%), and n = 24 (72.7%) in the warfarin group (P &amp;lt; .01). This indicator on the ISTH scale is n = 27 (36.9%) and n = 21 (63.6%), respectively. Major bleeding was observed in the rivaroxaban group n = 2 (2.74%), and in the warfarin group n = 2 (6.06%) on the BARC and ISTH scales (P = .31). Heamorrhagic events were significantly more frequent in the warfarin group compared with the rivaroxaban group. CONCLUSION The data obtained from this study indicate a favourable safety profile of NOAC (rivaroxaban) compared with a vitamin K antagonist in patients with stage 4 CKD in combination with AF.

Abstract 9177: Prognostic Value of Chronic Kidney Disease and Cardiac Sympathetic Dysfunction Assessed by 123 I-metaiodobenzylguanidine Scintigraphy for Lethal Arrhythmic Events in Chronic Heart Failure

Introduction: Clinical implication of chronic kidney disease (CKD) and cardiac sympathetic nerve activity (CSNA) for lethal arrhythmic events has not been fully elucidated in patients with chronic heart failure (CHF). Hypothesis: The combination of CKD and abnormal CSNA, assessed by 123 I-metaiodobenzylguanidine ( 123 I-MIBG) scintigraphy, may provide useful prognostic information for the incidence of lethal arrhythmic events. Methods: We studied 165 consecutive hospitalized CHF patients without dialysis. In a clinically stable condition, cardiac 123 I-MIBG scintigraphy was performed. CKD was defined as estimated glomerular filtration rate (eGFR) &lt;60 ml/min/1.73m 2 , and abnormal CSNA was defined as late heart to mediastinum ratio &lt;1.6. We then investigated the incidence of lethal arrhythmic events (sustained ventricular arrhythmia, appropriate implantable cardioverter-defibrillator therapy, or sudden cardiac death). Results: During a median follow-up of 5.3 years, lethal arrhythmic events were observed in 40 patients (24.2%). The patients were divided into 4 groups according to the presence of CKD and CSNA abnormality: non-CKD/ normal CSNA ( n = 52), CKD/ normal CSNA ( n = 39), non-CKD/ abnormal CSNA ( n = 33), and CKD/ abnormal CSNA ( n = 41).The Kaplan-Meier analysis showed that CKD/ abnormal CSNA had the highest event rate (log-rank p = 0.004). In addition, the multivariable Cox proportional hazard analysis after the adjustment of multiple confounders showed that CKD/ abnormal CSNA was an independent predictor for lethal arrhythmic events compared to non-CKD/ normal CSNA (HR, 4.667, p = 0.006). However, the other two groups did not show significant differences compared to non-CKD/ normal CSNA. Conclusions: The combination of CKD and abnormal CSNA, assessed by cardiac 123 I-MIBG scintigraphy, had a significant prognostic value for the incidence of lethal arrhythmic events in patients with CHF.

Predictive impacts of chronic kidney disease and cardiac sympathetic nervous activity on lethal arrhythmic events in chronic heart failure.

BackgroundThe clinical implications of chronic kidney disease (CKD) and cardiac sympathetic nervous activity (CSNA) regarding lethal arrhythmic events have not yet been fully elucidated in patients with chronic heart failure (CHF). We hypothesized that the combination of CKD and abnormal CSNA, assessed by 123I‐metaiodobenzylguanidine (123I‐MIBG) scintigraphy, may provide useful prognostic information for lethal arrhythmic events.MethodsWe studied 165 consecutive hospitalized CHF patients without dialysis. Cardiac 123I‐MIBG scintigraphy was performed in a clinically stable condition, and abnormal CSNA was defined as a late heart‐to‐mediastinum ratio of <1.6. CKD was defined as an estimated glomerular filtration rate of <60 ml/min/1.73 m2. We then investigated the incidence of lethal arrhythmic events (sustained ventricular tachyarrhythmia, appropriate implantable cardioverter‐defibrillator therapy, or sudden cardiac death).ResultsDuring a median follow‐up of 5.3 years, lethal arrhythmic events were observed in 40 patients (24.2%). The patients were divided into four groups according to the presence of CKD and CSNA abnormality: non‐CKD/normal CSNA (n = 52), CKD/normal CSNA (n = 39), non‐CKD/abnormal CSNA (n = 33), and CKD/abnormal CSNA (n = 41). Kaplan–Meier analysis showed that CKD/abnormal CSNA had the highest event rate (log‐rank p = .004). Additionally, the Cox proportional hazard analysis revealed that CKD/abnormal CSNA was a predictor for lethal arrhythmic events compared with non‐CKD/normal CSNA (hazard ratio, 5.368, p = .001). However, the other two groups did not show significant differences compared with the non‐CKD/normal CSNA group.ConclusionsThe combination of CKD and abnormal CSNA, assessed by 123I‐MIBG scintigraphy, had a high predictive value for lethal arrhythmic events in patients with CHF.

Cardiovascular risk factors early in the course of treatment in people with type 2 diabetes without established cardiovascular disease: A population-based observational retrospective cohort study.

AimsTo characterise the cardiovascular risk of people with type 2 diabetes without established cardiovascular disease but with risk factors, relative to those with established cardiovascular disease, to provide information on which patients could benefit from early use of glucose‐lowering therapies that also reduce cardiovascular risk.MethodsData from people with type 2 diabetes initiating second‐line glucose‐lowering medication were retrieved from the UK Clinical Practice Research Datalink GOLD database and linked with Hospital Episode Statistics and Office for National Statistics (2001–2016). Cox proportional hazards models were used to estimate relative risks of major adverse cardiovascular events within groups defined by the presence of selected risk factors in people without versus with established cardiovascular disease.ResultsOf 53,182 individuals, 19.4% had established cardiovascular disease (i.e. a prior cardiovascular event). Over 5–7 years’ follow‐up, the rate of major adverse cardiovascular events was 14.0 and 49.6 events/1000 person‐years without and with established cardiovascular disease, respectively (hazard ratio [HR] 0.28, 95% confidence interval [CI] 0.26, 0.29). Compared with a reference HR 1.0 for participants with established cardiovascular disease, estimated glomerular filtration rate <60 mL/min was the single factor associated with the highest risk of major adverse cardiovascular events (HR 0.75, 95% CI 0.70, 0.81) and mortality (HR 1.12, 95% CI 1.07, 1.18) in people with type 2 diabetes without established cardiovascular disease. The combination of chronic kidney disease with older age, smoking and/or dyslipidaemia was associated with a similarly high risk of cardiovascular events in people with type 2 diabetes and without cardiovascular disease compared with those having established cardiovascular disease.ConclusionsThese analyses provide important information to identify people who may benefit from primary prevention of cardiovascular disease. Modifiable cardiovascular risk factors should be controlled early in all individuals with type 2 diabetes (as well as in all individuals with cardiovascular disease).

L’importanza del vaccino anti Covid-19 nei pazienti affetti da malattia del rene policistico autosomico dominante dell’adulto (ADPKD)

The SARS-CoV-2 (Covid-19) infection affected about 106 million people worldwide and the total amount of casualties now sits at a staggering 2 millions.&#x0D; Chronic Kidney Disease (CKD) emerged as the first risk factor in worst patients, not considering old age. Kidney disease and acute kidney injury have been correlated with a higher chance of death. This combination of CKD and higher Covid-19 related mortality requires immediate response from a prevention point of view at first and then from a therapeutic one.&#x0D; There is not a clear relation between Covid-19 and ADPKD. What can be inferred is the following: Covid uses the ACE2 receptors on cell membranes to “lock on” its target. It is well-established in fact that the RAAS is more active in ADPKD patients and it may represent an additional risk factor for these patients.&#x0D; At the moment three Covid-19 vaccines have been approved, and two of them have been already administered, such as Pfizer BioNTech and Moderna, sharing the same mechanism. AstraZeneca released a third option. All of them are completely safe and reliable, each one with its own feature.&#x0D; Therefore, considering how delicate ADPKD patients are, vaccination is strongly recommended.

Age and comorbidities are crucial predictors of mortality in severe obstructive sleep apnoea syndrome

BackgroundObstructive sleep apnoea syndrome (OSAS) is a highly prevalent disorder. The prognostic role of comorbidity in patients with OSAS and their role for risk stratification remain poorly defined. MethodsWe studied 1,592 patients with severe OSAS diagnosed by polysomnography. The primary outcome was all-cause mortality. The standardized mortality ratio (SMR) was estimated as the ratio of observed deaths to expected number of deaths in the general population. The expected numbers of deaths were derived using mortality rates from the general Apulian population. The association of comorbidities with all-cause mortality was assessed using multivariable Cox regression analysis. Finally, recursive-partitioning analysis was applied to identify the combinations of comorbidities that were most influential for mortality and to cluster the patients into risk groups according to individual comorbidities ResultsDuring 11,721 person-years of follow-up, 390 deaths (3.33 deaths/100 person-years) occurred. The median follow-up was 7 (4–10) years. The SMR was 1.47 (95% confidence intervals 1.33–1.63). Age, sex, obesity, cardiovascular diseases (CVD), moderate-to-severe chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD) and malignancy were independently associated with mortality risk. Recursive-partitioning analysis allowed distinguishing three clinical phenotypes differentially associated with mortality risk. The combination of CKD with CVDs or with moderate-to-severe COPD conferred the highest risk. ConclusionsSevere OSAS is associated with increased risk for all-cause death. Age and comorbidity are crucial predictors of mortality in patients with severe OSAS. Clustering patients according to comorbidities allows identifying clinically meaningful phenotypes.

Impact of Chronic Kidney Disease and Platelet Reactivity on Clinical Outcomes Following Percutaneous Coronary Intervention.

We investigated the interaction between chronic kidney disease (CKD) and high platelet reactivity (HPR) in determining long-term clinical outcomes following elective PCI for stable coronary artery disease (CAD). A total of 500 patients treated with aspirin and clopidogrel were divided based on the presence of CKD (defined as glomerular filtration rate of < 60 ml/min/1.73 m2) and HPR (defined as a P2Y12 reaction unit value ≥ 240 at VerifyNow assay). Primary endpoint was the occurrence of major adverse clinical events (MACE) at 5 years. Patients with both CKD and HPR showed the highest estimates of MACE (25.6%, p = 0.005), all-cause death (17.9%, p = 0.004), and cardiac death (7.7%, p = 0.004). The combination of CKD and HPR was an independent predictor of MACE (HR 3.12, 95% CI 1.46-6.68, p = 0.003). In conclusion, the combination of CKD and HPR identifies a cohort of patients with the highest risk of MACE at 5 years.

Possibilities of using fosinopril in treatment of patients with chronic kidney disease in combination with cardiovascular diseases and diabetes mellitus

Chronic kidney disease is one of the most common diseases in general medical practice, due to their secondary damage to the kidneys in arterial hypertension, chronic heart failure, and diabetes mellitus. The coexistence of hypertension and diabetes increases the likelihood of developing chronic kidney failure tenfold. In turn, chronic kidney disease is an important independent risk factor for the development of cardiovascular complications, including fatal ones, due to the direct relationship of the pathogenetic mechanisms of cardiorenal relationships. Approaches to the treatment of chronic kidney disease should be aimed both at preventing the risks of developing renal dysfunction, and at treating existing pathology. The multifactorial nature of the disease and the complex etiopathogenetic relationships determine the need to optimize existing approaches to the treatment of chronic kidney disease in multimorbidity patients with concomitance cardiovascular diseases and diabetes mellitus. This is also due to the fact that, unlike other target organs, compensation for background disease does not always prevent further deterioration of kidney function. According to the recommendations of the main scientific communities, in such cases, it is advisable to start therapy with the most effective angiotensin-converting enzyme inhibitors that combine nephro-and cardioprotective effects and have a dual route of elimination from the body, which is especially important in multimorbidity, the aim to prevent polypharmacy, reduce the risk of drug interactions and, consequently, side effects. This article reviews the literature data indicating the high efficacy and safety of the angiotensin converting enzyme inhibitor fosinopril in patients with chronic kidney disease in combination with cardiovascular diseases and diabetes mellitus.

Major Adverse Renal and Cardiovascular Events following Intra-Arterial Contrast Media Administration in Hospitalized Patients with Comorbid Conditions

Introduction: Several clinical studies and meta-analyses have demonstrated lower incidence of adverse renal and cardiovascular outcomes associated with the use of iso-osmolar contrast media (IOCM) than low-osmolar contrast media (LOCM) in patients with variable risk profiles undergoing intra-arterial interventional procedures. However, the association of contrast-type and major adverse renal and cardiovascular events (MARCE) has not been studied via comprehensive and robust real-world data analyses in patients with comorbid conditions considered at risk for post-procedural acute kidney injury (AKI). The objective of this study was therefore to retrospectively assess the MARCE rates comparing IOCM with LOCM in at-risk patients receiving iodinated intra-arterial contrast media using a real-world inpatient data source. Methods: Patients who underwent a diagnostic or treatment procedure with intra-arterial IOCM or LOCM administration were identified using the Premier Healthcare Database. Patient subgroups including those with diabetes, heart failure, chronic kidney disease (CKD) stages 1–4, CKD 3–4, or diagnosis of chronic total occlusion (CTO) were formed. Subgroups with combinations of diabetes and CKD 3–4 with and without CTO were also investigated. We compared the primary endpoint of MARCE (composite of AKI, AKI requiring dialysis, acute myocardial infarction, stroke/transient ischemic attack, stent occlusion/thrombosis, or death) after IOCM versus LOCM administration via adjusted multivariable regression analyses. Results: A total of 536,013 inpatient visits met the primary inclusion and exclusion criteria (IOCM = 133,192; LOCM = 402,821). After multivariable modeling, the use of IOCM was associated with a significantly lower incidence of MARCE than LOCM in patients with CKD 1–4, CKD 3–4, diabetes, or heart failure, with greatest absolute risk reduction (ARR) of 2.4% (p < 0.0001) in CKD 3–4 patients (relative risk reduction [RRR] = 13.8%, number needed to treat [NNT] = 43). Additionally, ARR associated with IOCM increased to 3.5% (p < 0.0001) in patients with combined comorbidities of diabetes and CKD 3–4 (RRR = 19.1%, NNT = 29). Statistically significant risk reduction was also found for the use of IOCM among patients who underwent revascularization for CTO (ARR = 1.6% [p < 0.0001], RRR = 22.3%, NNT = 62). Conclusion: Intra-arterial administration using IOCM in at-risk patients is associated with lower rates of MARCE than the use of LOCM. This difference is especially apparent in patients with a combination of CKD 3–4 and diabetes and in patients with CTO, providing real-world data validation with meaningful NNT in favor of IOCM.

Dynamics of central hemodynamic parameters and cytokine levels in patients with chronic kidney disease and arterial hypertension during combination therapy

The effect of antihypertensive and hypolipidemic therapy with the use of a fixed combination of amlodipine, lisinopril and rosuvastatin on the parameters of cytokines (the level of the proinflammatory cytokine - interleukin-1β, anti-inflammatory cytokine - interleukin-10, ligand CD40 (CD40L)), central aortic pressure, arterial stiffness and the value of albuminuria in patients with stage 3 chronic kidney disease, both in combination with arterial hypertension (AH) of 1-2 degrees, and without it, and in patients with coronary artery disease in combination with AH. The results of the study allow to conclude that the proposed antihypertensive and hypolipidemic therapy significantly reduces the parameters of central hemodynamics and vascular stiffness, the levels of microalbuminuria (MAU) and blood creatinine in patients with stage 3 chronic kidney disease in combination with AH of 1-2 degrees, and significantly increases the values IL-10 in patients with hypertension and CKD.

Хроническая болезнь почек в сочетании с хронической обструктивной болезнью легких в условиях низкогорья: факторы развития риска, раннее выявление и клинико-функциональные особенности

Хроническая болезнь почек в сочетании с хронической обструктивной болезнью легких в условиях низкогорья: факторы развития риска, раннее выявление и клинико-функциональные особенности

A multimorbidity nurse practitioner-led clinic: Evaluation of health outcomes

BackgroundHealthcare services for people living with multiple chronic diseases have traditionally been organised around each condition, an approach which is neither resource-efficient nor convenient or effective for patients. The integrated nurse practitioner service reported here was developed to optimise patient experience and outcomes within a chronic disease self-management framework. AimTo evaluate patient outcomes following attendance at an integrated chronic disease nurse practitioner clinic for multimorbidity. MethodsA prospective service evaluation of adults with any combination of chronic kidney disease, diabetes and/or heart failure between June 2014 and December 2017. Demographic and clinical outcomes at entry and after 12 months of clinic attendance were collected from health records of all patients (n = 162); a subgroup also completed health-related quality of life and self-efficacy measures at entry and 12 months follow-up (n = 106). FindingsPatients attending the clinic had complex needs and poor health-related quality of life. Despite the complexity of their health problems, as a cohort blood pressure was well-controlled and self-efficacy for chronic disease management was relatively high. Over the first 12 months of integrated nurse practitioner care, there were large improvements in physical aspects of health-related quality of life and many patients achieved reductions in body mass index. Use of hospital inpatient and emergency services also decreased. DiscussionNurse practitioner-led services have the potential to reduce treatment burden and deliver integrated chronic disease management. ConclusionsThe multimorbidity clinic has improved health outcomes in this patient cohort and offers a model for enhanced primary care.