Nephrology Partnership for Advancing Technology in Healthcare (N-PATH) Erasmus+ project: The Renal Expert in Vascular Access (REVAC) module.

The Renal Expert in Vascular Access (REVAC) is one of the four modules of the Nephrology Partnership for Advancing Technology in Healthcare (N-PATH) project, the first European-wide advanced training course in diagnostics and interventional nephrology, funded by Erasmus+ Knowledge Alliance, a European Commission program. The N-PATH primary goal was to train 40 young European nephrologists in both theoretical knowledge and practical skills related to interventional nephrology. The REVAC module focused on the crucial aspects of vascular access (VA) care in nephrology practice, as a complementary training path to the actual residency program. The aim was to provide nephrology fellows with comprehensive knowledge and skills related to VA management. The methodology was based on face-to-face meetings and online learning, modern facilities, experienced tutors, cutting edge simulators, augmented reality tools by means of a multidisciplinary international faculty and hands-on-courses. A feedback survey reported the experience of fellows who attended the REVAC module, confirming the positive impact on their ongoing nephrology training. We are confident that this project will revitalize their nephrology careers and will help training the next generation of nephrologists; they will be able to manage VA needs with the help of multi-disciplinary teams to safely optimize the care of hemodialysis patients.

Increased Cardiovascular Risk in Young Patients with CKD and the Role of Lipid-Lowering Therapy.

PURPOSE OF REVIEW: Chronic kidney disease (CKD) is associated with a significantly increased risk of cardiovascular disease (CVD). This review summarizes known risk factors, pathophysiological mechanisms, and current therapeutic possibilities, focusing on lipid-lowering therapy in CKD. RECENT FINDINGS: Novel data on lipid-lowering therapy in CKD mainly stem from clinical trials and clinical studies. In addition to traditional CVD risk factors, patients with CKD often present with non-traditional risk factors that include, e.g., anemia, proteinuria, or calcium-phosphate imbalance. Dyslipidemia remains an important contributing CVD risk factor in CKD, although the mechanisms involved differ from the general population. While statins are the most commonly used lipid-lowering therapy in CKD patients, some statins may require dose reduction. Importantly, statins showed diminished beneficial effect on cardiovascular events in patients with severe CKD and hypercholesterolemia despite high CVD risk and effective reduction of LDL cholesterol. Ezetimibe enables the reduction of the dose of statins and their putative toxicity and, in combination with statins, reduces CVD endpoints in CKD patients. The use of novel drugs such as PCSK9 inhibitors is safe in CKD, but their potential to reduce cardiovascular events in CKD needs to be elucidated in future studies.

Heart failure with preserved ejection fraction is the most frequent but commonly overlooked phenotype in patients on chronic hemodialysis.

Introduction: Heart failure (HF) is a serious complication of end-stage kidney disease (ESKD). However, most data come from retrospective studies that included patients on chronic hemodialysis at the time of its initiation. These patients are frequently overhydrated, which significantly influences the echocardiogram findings. The primary aim of this study was to analyze the prevalence of heart failure and its phenotypes. The secondary aims were (1) to describe the potential of N-terminal pro-brain natriuretic peptide (NTproBNP) for HF diagnosis in ESKD patients on hemodialysis, (2) to analyze the frequency of abnormal left ventricular geometry, and (3) to describe the differences between various HF phenotypes in this population. Methods: We included all patients on chronic hemodialysis for at least 3 months from five hemodialysis units who were willing to participate, had no living kidney transplant donor, and had a life expectancy longer than 6 months at the time of inclusion. Detailed echocardiography together with hemodynamic calculations, dialysis arteriovenous fistula flow volume calculation, and basic lab analysis were performed in conditions of clinical stability. Excess of severe overhydration was excluded by clinical examination and by employing bioimpedance. Results: A total of 214 patients aged 66.4 ± 14.6 years were included. HF was diagnosed in 57% of them. Among patients with HF, HF with preserved ejection fraction (HFpEF) was, by far, the most common phenotype and occurred in 35%, while HF with reduced ejection fraction (HFrEF) occurred only in 7%, HF with mildly reduced ejection fraction (HFmrEF) in 7%, and high-output HF in 9%. Patients with HFpEF differed from patients with no HF significantly in the following: they were older (62 ± 14 vs. 70 ± 14, p = 0.002) and had a higher left ventricular mass index [96(36) vs. 108(45), p = 0.015], higher left atrial index [33(12) vs. 44(16), p < 0.0001], and higher estimated central venous pressure [5(4) vs. 6(8), p = 0.004] and pulmonary artery systolic pressure [31(9) vs. 40(23), p = 0.006] but slightly lower tricuspid annular plane systolic excursion (TAPSE): 22 ± 5 vs. 24 ± 5, p = 0.04. NTproBNP had low sensitivity and specificity for diagnosing HF or HFpEF: with the use of the cutoff value of 8,296 ng/L, the sensitivity of HF diagnosis was only 52% while the specificity was 79%. However, NTproBNP levels were significantly related to echocardiographic variables, most significantly to the indexed left atrial volume (R = 0.56, p < 10-5) and to the estimated systolic pulmonary arterial pressure (R = 0.50, p < 10-5). Conclusions: HFpEF was by far the most common heart failure phenotype in patients on chronic hemodialysis and was followed by high-output HF. Patients suffering from HFpEF were older and had not only typical echocardiographic changes but also higher hydration that mirrored increased filling pressures of both ventricles than in those of patients without HF.

Significant differences between two commonly used bioimpedance methods in hemodialysis patients.

INTRODUCTION: Bioimpedance methods are currently used abundantly in patients on chronic hemodialysis. In this population, their most important role is to determine the level of fluid volume, respectively its intra- and extracellular components. There are several bioimpedance devices on the market. In this project, we compared two frequently used devices: Body Composition Monitor and InBody S10. MATERIALS AND METHODS: We invited patients on chronic hemodialysis who are being treated in our institution. Inclusion criteria were: clinically stable condition, lack of artificial joints, pacemakers, or other implanted metal objects. The examinations were performed just prior to hemodialysis by both methods 5 minutes apart. Patients were examined in the supine position after 15 minutes at rest to stabilize body fluids. Studied parameters were those that are obtainable by both methods: total body water (TBW) (L), extracellular water (ECW) (L) and intracellular water (ICW) (kg), lean tissue mass (LTM) (L), and fat tissue mass (kg). RESULTS: We included 14 participants (aged 64.4 ± 18.0 years). Statistically and clinically significant differences between data from compared devices were observed for all variables. Inbody S10 overestimated TBW by 2.58 ± 2.73 L and ICW by 4.56 ± 2.27 L in comparison to BCM. The highest difference (27%) was measured for LTM and ICW 22%. LTM, fat, and ECW were higher when measured by BCM (LTM by 8.54 ± 6.43 kg, p < 0.001; fat by 3.41 ± 4.22, p = 0.01; ECW by 2.01 ± 0.89 L, p < 0.001). CONCLUSION: The differences between tested devices were significant not only statistically, but also clinically. These two devices cannot be used interchangeably for dry weight setting of hemodialysis patients.

Endovascular Arteriovenous Fistula Creation-Review of Current Experience.

Functioning vascular access is an essential element for life-saving hemodialysis therapy. A surgically-created arteriovenous fistula has been considered the best option for many years. Recently, two manufacturers developed systems for percutaneous/endovascular creation of an arteriovenous fistula (WavelinQ and Ellipsys). We provide a review of the available experience with these systems and discuss advantages and disadvantages.

Arteriovenous Hemodialysis Access Stenosis Diagnosed by Duplex Doppler Ultrasonography: A Review.

Arteriovenous fistula (AVF) is currently the hemodialysis access with the longest life expectations for the patients. However, even the AVF is at risk for many complications, especially the development of stenosis. The latter can not only lead to inadequate hemodialysis but also lead to AVF thrombosis. Duplex Doppler ultrasonography is a very precise method, in the hands of experienced professionals, for the diagnosis of AVF complications. In this review, we summarize the ultrasound diagnostic criteria of significant stenoses and their indication for procedural therapy.

Historical ferrous slag induces modern environmental problems in the Moravian Karst (Czech Republic).

Ferrous slag produced by a historic smelter is washed from a slagheap and transported by a creek through a cave system. Slag filling cave spaces, abrasion of cave walls / calcite speleothems, and contamination of the aquatic environment with heavy metals and other toxic components are concerns. We characterize the slag in its deposition site, map its transport through the cave system, characterize the effect of slag transport, and evaluate the risks to both cave and aqueous environments. The study was based on chemical and phase analysis supported laboratory experiments and geochemical modeling. The slag in the slagheap was dominated by amorphous glass phase (66 to 99 wt%) with mean composition of 49.8 ± 2.8 wt% SiO2, 29.9 ± 1.6 wt% CaO, 13.4 ± 1.2 wt% Al2O3, 2.7 ± 0.3 wt% K2O, and 1.2 ± 0.1 wt% MgO. Minerals such as melilite, plagioclase, anorthite, and wollastonite / pseudowollastonite with lower amounts of quartz, cristobalite, and calcite were detected. Slag enriches the cave environment with Se, As, W, Y, U, Be, Cs, Sc, Cd, Hf, Ba, Th, Cr, Zr, Zn, and V. However, only Zr, V, Co, and As exceed the specified limits for soils (US EPA and EU limits). The dissolution lifetime of a 1 mm3 volume of slag was estimated to be 27,000 years, whereas the mean residence time of the slag in the cave is much shorter, defined by a flood frequency of ca. 47 years. Consequently, the extent of slag weathering and contamination of cave environment by slag weathering products is small under given conditions. However, slag enriched in U and Th can increase radon production as a result of alpha decay. The slag has an abrasive effect on surrounding rocks and disintegrated slag can contaminate calcite speleothems.

CZecking heart failure in patients with advanced chronic kidney disease (Czech HF-CKD): Study protocol.

BACKGROUND: Heart failure (HF) is a frequent cause of morbidity and mortality of end-stage kidney disease (ESKD) patients on hemodialysis. It is not easy to distinguish HF from water overload. The traditional HF definition has low sensitivity and specificity in this population. Moreover, many patients on hemodialysis have exercise limitations unrelated to HF. Therefore, we postulated two new HF definitions ((1) Modified definition of the Acute Dialysis Quality Improvement working group; (2) Hemodynamic definition based on the calculation of the effective cardiac output). We hypothesize that the newer definitions will better identify patients with higher number of endpoints and with more advanced structural heart disease. METHODS: Cohort, observational, longitudinal study with recording predefined endpoints. Patients (n = 300) treated by hemodialysis in six collaborating centers will be examined centrally in a tertiary cardiovascular center every 6-12 months lifelong or till kidney transplantation by detailed expert echocardiography with the calculation of cardiac output, arteriovenous dialysis fistula flow volume calculation, bio-impedance, and basic laboratory analysis including NTproBNP. Effective cardiac output will be measured as the difference between measured total cardiac output and arteriovenous fistula flow volume and systemic vascular resistance will be also assessed non-invasively. In case of water overload during examination, dry weight adjustment will be recommended, and the patient invited for another examination within 6 weeks. A composite major endpoint will consist of (1) Cardiovascular death; (2) HF worsening/new diagnosis of; (3) Non-fatal myocardial infarction or stroke. The two newer HF definitions will be compared with the traditional one in terms of time to major endpoint analysis. DISCUSSION: This trial will differ from others by: (1) detailed repeated hemodynamic assessment including arteriovenous access flow and (2) by careful assessment of adequate hydration to avoid confusion between HF and water overload.

Skin autofluorescence corresponds to microvascular reactivity in diabetes mellitus.

Advanced glycation accelerated by chronic hyperglycaemia contributes to the development of diabetic vascular complications throughout several mechanisms. One of these mechanisms is supposed to be impaired microvascular reactivity, that precedes significant vascular changes. The aim of this study was to find an association between advanced glycation, the soluble receptor for AGEs (sRAGE), and microvascular reactivity (MVR) in diabetes. Skin autofluorescence (SAF), which reflects advanced glycation, was assessed by AGE-Reader, MVR was measured by laser Doppler fluxmetry and evaluated together with sRAGE in 43 patients with diabetes (25 Type 1 and 18 Type 2) and 26 healthy controls of comparable age. SAF was significantly higher in patients with diabetes compared to controls (2.4 ± 0.5 vs. 2.0 ± 0.5 AU; p < 0.01). Patients with diabetes with SAF > 2.3 AU presented significantly worse MVR in both post-occlusive reactive hyperaemia (PORH) on the finger and forearm, and thermal hyperaemia (TH), compared to patients with SAF < 2.3 AU. SAF was age dependent in both diabetes (r = 0.41, p < 0.01) and controls (r = 0.45, p < 0.05). There was no association between SAF and diabetes control expressed by glycated haemoglobin. A significant relationship was observed between SAF and sRAGE in diabetes (r = 0.56, p < 0.001), but not in controls. A significant inverse association was found between SAF and MVR on the forearm in diabetes (PORH: r = -0.42, p < 0.01; TH: r = -0.46, p < 0.005). Both advanced glycation expressed by higher SAF or sRAGE and impaired MVR are involved in the pathogenesis of vascular complications in diabetes, and we confirm a strong interplay of these processes in this scenario.

New Porcine Model of Arteriovenous Fistula Documents Increased Coronary Blood Flow at the Cost of Brain Perfusion.

Background: Arteriovenous fistulas (AVF) represent a low resistant circuit. It is known that their opening leads to decreased systemic vascular resistance, increased cardiac output and other hemodynamic changes. Possible competition of AVF and perfusion of other organs has been observed before, however the specific impact of AVF has not been elucidated yet. Previous animal models studied long-term changes associated with a surgically created high flow AVF. The aim of this study was to create a simple AVF model for the analysis of acute hemodynamic changes. Methods: Domestic female pigs weighing 62.6 ± 5.2 kg were used. All the experiments were held under general anesthesia. The AVF was created using high-diameter ECMO cannulas inserted into femoral artery and vein. Continuous hemodynamic monitoring was performed throughout the protocol. Near-infrared spectroscopy sensors, flow probes and flow wires were inserted to study brain and heart perfusion. Results: AVF blood flow was 2.1 ± 0.5 L/min, which represented around 23% of cardiac output. We observed increase in cardiac output (from 7.02 ± 2.35 L/min to 9.19 ± 2.99 L/min, p = 0.0001) driven dominantly by increased heart rate, increased pulmonary artery pressure, and associated right ventricular work. Coronary artery flow velocity rose. On the contrary, carotid artery flow and brain and muscle tissue oxygenation measured by NIRS decreased significantly. Conclusions: Our new non-surgical AVF model is reproducible and demonstrated an acute decrease of brain and muscle perfusion.

Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Immediate Invasive Assessment and Treatment on Functional Neurologic Outcome in Refractory Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial.

Importance: Out-of-hospital cardiac arrest (OHCA) has poor outcome. Whether intra-arrest transport, extracorporeal cardiopulmonary resuscitation (ECPR), and immediate invasive assessment and treatment (invasive strategy) is beneficial in this setting remains uncertain. Objective: To determine whether an early invasive approach in adults with refractory OHCA improves neurologically favorable survival. Design, Setting, and Participants: Single-center, randomized clinical trial in Prague, Czech Republic, of adults with a witnessed OHCA of presumed cardiac origin without return of spontaneous circulation. A total of 256 participants, of a planned sample size of 285, were enrolled between March 2013 and October 2020. Patients were observed until death or day 180 (last patient follow-up ended on March 30, 2021). Interventions: In the invasive strategy group (n = 124), mechanical compression was initiated, followed by intra-arrest transport to a cardiac center for ECPR and immediate invasive assessment and treatment. Regular advanced cardiac life support was continued on-site in the standard strategy group (n = 132). Main Outcomes and Measures: The primary outcome was survival with a good neurologic outcome (defined as Cerebral Performance Category [CPC] 1-2) at 180 days after randomization. Secondary outcomes included neurologic recovery at 30 days (defined as CPC 1-2 at any time within the first 30 days) and cardiac recovery at 30 days (defined as no need for pharmacological or mechanical cardiac support for at least 24 hours). Results: The trial was stopped at the recommendation of the data and safety monitoring board when prespecified criteria for futility were met. Among 256 patients (median age, 58 years; 44 [17%] women), 256 (100%) completed the trial. In the main analysis, 39 patients (31.5%) in the invasive strategy group and 29 (22.0%) in the standard strategy group survived to 180 days with good neurologic outcome (odds ratio [OR], 1.63 [95% CI, 0.93 to 2.85]; difference, 9.5% [95% CI, -1.3% to 20.1%]; P = .09). At 30 days, neurologic recovery had occurred in 38 patients (30.6%) in the invasive strategy group and in 24 (18.2%) in the standard strategy group (OR, 1.99 [95% CI, 1.11 to 3.57]; difference, 12.4% [95% CI, 1.9% to 22.7%]; P = .02), and cardiac recovery had occurred in 54 (43.5%) and 45 (34.1%) patients, respectively (OR, 1.49 [95% CI, 0.91 to 2.47]; difference, 9.4% [95% CI, -2.5% to 21%]; P = .12). Bleeding occurred more frequently in the invasive strategy vs standard strategy group (31% vs 15%, respectively). Conclusions and Relevance: Among patients with refractory out-of-hospital cardiac arrest, the bundle of early intra-arrest transport, ECPR, and invasive assessment and treatment did not significantly improve survival with neurologically favorable outcome at 180 days compared with standard resuscitation. However, the trial was possibly underpowered to detect a clinically relevant difference. Trial Registration: ClinicalTrials.gov Identifier: NCT01511666.

Effect of Roller Pump Pulse in the Arterial Needle Area during Hemodialysis.

Vascular access is a lifeline for hemodialysis patients. Its lifetime is affected by many hemodynamic factors such as pressure, flow regime and wall shear stress. During hemodialysis, changes in hemodynamic parameters occur due to the flow from needles inserted into the vascular system. Primarily, there is a change in shear stress that affects the vascular wall. Pathological effects of high or low WSS are known. The effect of jet from a venous needle on hemodynamics parameters was studied, but the influence of the arterial needle on hemodynamics parameters is not sufficiently studied. To understand its possible effects, we performed in vivo and in vitro studies. Methods. In vivo experiment: The existence of flow reversal around the suction needle was visualized in a group of 12 randomly selected patients using ultrasound velocity profiling (Doppler ultrasonography) during hemodialysis. In vitro experiment: The flow field was measured using the stereo particle image velocimetry method (stereo PIV). Two regimes were studied. In the first regime, the fluid in the extracorporeal circuit was pumped by a peristaltic pump. In the second regime, the continuous pump was used in the extracorporeal circuit. The conditions were set to resemble those in vascular access during a hemodialysis session. Flow volume was set to 600 mL/min for vascular access and 200 mL/min for the extracorporeal circuit. Results. The main finding of this study was that the wall in the region of the arterial needle was stressed by backflow through the arterial needle. Since this was a variable, low-shear stress loading, it was one of the risk factors for the development of stenosis. Cyclic flow reversal was apparent in all of the included hemodialysis patients. The stereo PIV in vitro experiment revealed the oscillating character of wall shear stress (WSS) inside the model. High shear stress was documented upstream of the injection point of the arterial needle. An area of very low WSS was detected right behind the injection point during a pulse of the peristaltic pump. The minimal and maximal values of the WSS during a pulse of the peristaltic pump in the observed area were -0.7 Pa and 6 Pa, respectively. The distribution of wall shear stress with the continual pump used in the extracorporeal circuit was similar to the distribution during a pulse of the peristaltic one. However, the WSS values were continual; the WSS did not oscillate. WSS ranged between 4.8 Pa and 1.0 Pa.

The role of Doppler ultrasonography in vascular access surveillance-controversies continue.

Chronic hemodialysis therapy required regular entry into the patient's blood stream with adequate flow. The use of arteriovenous fistulas and grafts is linked with lower morbidity and mortality than the use of catheters. However, these types of accesses are frequently affected by stenoses, which decrease the flow and lead to both inadequate dialysis and access thrombosis. The idea of duplex Doppler ultrasound surveillance is based on the presumption that in-time diagnosis of an asymptomatic significant stenosis and its treatment prolongs access patency. Details of performed trials are conflicting, and current guidelines do not support ultrasound surveillance. This review article summarizes the trials performed and focuses on the reasons of conflicting results. We stress the need of precise standardized criteria of significant access stenosis and the weakness of the metaanalyses performed.

Role of Doppler ultrasonography in the evaluation of hemodialysis arteriovenous access maturation and influencing factors.

The goal of vascular access creation is to achieve a functioning arteriovenous fistula (AVF) or arteriovenous graft (AVG). An autologous fistula has been shown to be superior to AVG or to central venous catheters (CVCs) with lowest rate of re-intervention, but vessel obstruction or immaturity accounts for 20 % to 54% of cases with primary failure of AVF. This review is focused on the factors influencing maturation; indication and timing of preoperative mapping/creation of vascular access; ultrasound parameters for creation AVF/AVG; early postoperative complications following creation of a vascular access; ultrasound determinants of fistula maturation and endovascular intervention in vascular access with maturation failure. However, vascular accesses that fail to develop, have a high incidence of correctable abnormalities, and these need to be promptly recognized by ultrasonography and managed effectively if a high success rate is to be expected. We review approaches to promoting fistula maturation and duplex ultrasonography (DUS) of evaluating vascular access maturation.

Current role of ultrasound in hemodialysis access evaluation.

Physical examination (PE) is considered the backbone before vascular access (VA) placement, during maturation period and for follow-up. However, it may be inadequate in identifying suitable vasculature, mainly in comorbid patients, or in detecting complications. This review highlights the advantages of ultrasound imaging to manage VA before placement, during maturation and follow-up. Furthermore, it analyses the future perspectives in evaluating early and late VA complications thank to the availability of multiparametric platforms, point of care of ultrasound, and portable/wireless systems. Technical improvements and low-cost systems should favor the widespread ultrasound-based VA surveillance programs. This significant turning point needs an adequate training of nephrologists and dialysis nurses and the standardization of exams, parameters, and procedures.

Reduction of arteriovenous access blood flow leads to biventricular unloading in haemodialysis patients.

AIMS: Patients on chronic haemodialysis have a wide range of changes in cardiac function and structure, including left ventricular hypertrophy, dilation and diastolic dysfunction or pulmonary hypertension. All these changes were linked to increased mortality in previous studies. High-flow arteriovenous fistulas (AVF) are supposed to be a factor contributing to their development. This study investigated the early effect of surgical AVF blood flow (Qa) reduction on these changes in patients with or without heart failure changes. METHODS AND RESULTS: Forty-two patients in chronic haemodialysis programme with high-flow AVF (Qa over 1500 mL/min), indicated for surgery for ≥1 of the following indications: 1.manifest heart failure; 2.hand ischemia; 3.advanced structural heart changes detected by echocardiography. The patients underwent echocardiography on selection visit, before blood flow reducing surgery and six weeks thereafter. The Qa reduction led to decrease of left ventricular mass (p = 0.02), end-diastolic volume (p = 0.008), end-diastolic diameter (p = 0.003) and left atrial volume (p = 0.0006). Diastolic function improved. Similarly, right ventricular diameter and right atrial volume decreased (p = 0.000001 and 0.00009, respectively) together with the decrease of estimated pulmonary artery systolic pressure. 81% of patients suffered from pulmonary hypertension prior to surgery, only 36% thereafter. CONCLUSION: The surgical restriction of the hyperkinetic circulation leads to several improvements of heart structure and function, which was linked to higher mortality in other studies. The beneficial effect of Qa reduction is present even in patients without symptoms of heart failure. The contribution of AVF must be considered with structural or functional heart changes.

The effect of high-flow arteriovenous fistulas on systemic haemodynamics and brain oxygenation.

AIMS: High-flow arteriovenous fistula (AVF) for haemodialysis leads to profound haemodynamic changes and sometimes to heart failure (HF). Cardiac output (CO) is divided between the AVF and body tissues. The term effective CO (COef) represents the difference between CO and AVF flow volume (Qa) and better characterizes the altered haemodynamics that may result in organ hypoxia. We investigated the effects of Qa reduction on systemic haemodynamics and on brain oxygenation. METHODS AND RESULTS: This is a single-centre interventional study. Twenty-six patients on chronic haemodialysis with high Qa (>1500 mL/min) were indicated for surgical Qa reduction for HF symptoms and/or signs of structural heart disease on echocardiography. The included patients underwent three sets of examinations: at 4 months and then 2 days prior and 6 weeks post-surgical procedure. Clinical status, echocardiographical haemodynamic assessment, Qa, and brain oximetry were recorded. All parameters remained stable from selection to inclusion. After the procedure, Qa decreased from 3.0 ± 1.4 to 1.3 ± 0.5 L/min, P < 0.00001, CO from 7.8 ± 1.9 to 6.6 ± 1.5 L/min, P = 0.0002, but COef increased from 4.6 ± 1.4 to 5.3 ± 1.4 L/min, P = 0.036. Brain tissue oxygen saturation increased from 56 ± 11% to 60 ± 9%, P = 0.001. CONCLUSIONS: Qa reduction led to increased COef. This was explained by a decreased proportion of CO running through the AVF in patients with Qa > 2.0 L/min. These observations were mirrored by higher brain oxygenation and might explain HF symptoms and improved haemodynamics even in asymptomatic high Qa patients.

Expert consensus on the importance of iron deficiency and the possibility of its correction in patients with heart failure.

Anemia and iron deficiency are common non-cardiovascular comorbidities of heart failure. The prevalence of iron deficiency is up to 55 % of patients with chronic heart failure and up to 80 % subjects with acute heart failure including acute decompensated heart failure, independently on anemia. The European Society of Cardiology Heart Failure Guidelines 2021 recommend intravenous iron replacement in patients with heart failure and iron deficiency to improve symptoms, stress tolerance and quality of life in chronic heart failure and to reduce risk of subsequent hospitalization after acute decompenstation.