Treatment of Chronic Heart Failure in Advanced Chronic Kidney Disease: The HAKA Multicenter Retrospective Real-World Study.

INTRODUCTION: Chronic heart failure (HF) has high rates of mortality and hospitalization in patients with advanced chronic kidney disease (aCKD). However, randomized clinical trials have systematically excluded aCKD population. We have investigated current HF therapy in patients receiving clinical care in specialized aCKD units. METHODS: The Heart And Kidney Audit (HAKA) was a cross-sectional and retrospective real-world study including outpatients with aCKD and HF from 29 Spanish centers. The objective was to evaluate how the treatment of HF in patients with aCKD complied with the recommendations of the European Society of Cardiology Guidelines for the diagnosis and treatment of HF, especially regarding the foundational drugs: renin-angiotensin system inhibitors (RASi), angiotensin receptor blocker/neprilysin inhibitors (ARNI), beta-blockers (BBs), mineralocorticoid receptor antagonists (MRAs), and sodium-glucose cotransporter-2 inhibitors (SGLT2i). RESULTS: Among 5,012 aCKD patients, 532 (13%) had a diagnosis of HF. Of them, 20% had reduced ejection fraction (HFrEF), 13% mildly reduced EF (HFmrEF), and 67% preserved EF (HFpEF). Only 9.3% of patients with HFrEF were receiving quadruple therapy with RASi/ARNI, BB, MRA, and SGLT2i, but the majority were not on the maximum recommended doses. None of the patients with HFrEF and CKD G5 received quadruple therapy. Among HFmrEF patients, approximately half and two-thirds were receiving RASi and/or BB, respectively, while less than 15% received ARNI, MRA, or SGLT2i. Less than 10% of patients with HFpEF were receiving SGLT2i. CONCLUSIONS: Under real-world conditions, HF in aCKD patients is sub-optimally treated. Increased awareness of current guidelines and pragmatic trials specifically enrolling these patients represent unmet medical needs.

How to Manage Kidney Transplant Recipients: Deciding Between Glomerular Filtration Rate-Estimating Equations, Creatinine Clearance and Albumin-Creatinine Ratio, or Albumin Excretion.

OBJECTIVES: Management of renal transplant recipients involves measuring glomerular filtration rate and albuminuria; however, data are conflicting on the use of estimating equations or creatinine clearance and albumin-creatinine ratio in early morning urine or albumin excretion in 24-hour urine. We aimed to determine the performance of creatinine clearance and 3 estimated creatinine-based formulas and compare the usefulness of albumin-creatinine ratio related to albumin excretion in kidney transplant patients. MATERIALS AND METHODS: This cross-sectional study examined 300 consecutive kidney transplant patients. Serum creatinine was measured with Cobas-8000 and albumin-creatinine ratio, and albumin excretion was measured with Cobas-C311 (Roche Diagnostics, Hitachi, Tokyo, Japan). We quantified bias and percent bias, Bland-Altman results, and concordances in the classification of chronic kidney disease between formulas and creatinine clearance. We also conducted linear regression analyses of all parameters and for cutoffs of 30 and 300 mg/24 hours and determined the ability of albumin-creatinine ratio to predict abnormal albumin excretion (receiver operator characteristic curve analysis). RESULTS: Bias (mL/min/1.73 m2), percent bias, and concordances between creatinine clearance and Cockcroft-Gault, Modification of Diet in Renal Disease, and Chronic Kidney Disease Epidemiology Colla-boration formulas in the classification of chronic kidney disease were as follows: 15.89, 20.91%, and 0.35; 20.52, 27.89%, and 0.21; and 18.24, 25.39%, and 0.27, respectively. Regression analyses showed a weak but significantly linear relationship for the cutoff values (P < .001). Receiver operator characteristic curve analyses showed areas under the curve of 0.957 and 0.997 at cutoffs of 30 and 300 mg/24 hours. In our patients, the cutoffs were 27 mg/g (88.38% sensitivity, 92.16% specificity) and 238 mg/g (80.00% sensitivity, 97.45% specificity). CONCLUSIONS: We suggest using estimating equations and albumin-creatinine ratio with caution. In routine management of patients with successive stable revisions, we recommended using the Cockcroft-Gault or Chronic Kidney Disease Epidemiology Collaboration formulas and albumin-creatinine ratio.

Vitamina D e hipertensión arterial / Vitamin D and hypertension

La deficiencia de vitamina D, definida como valores de 25-hidroxivitamina D < 20-30 ng/ml, es un problema prevalente en la población general. Además de relacionarse clásicamente con la enfermedad musculoesquelética, el déficit de vitamina D se ha relacionado con enfermedades autoinmunes, cáncer, enfermedades metabólicas y enfermedades cardiovasculares. La hipertensión arterial, como principal factor de riesgo cardiovascular, también se ha relacionado con el déficit de vitamina D, llevando a converger dos grandes problemas de salud prevalentes en la población mundial. Por tanto, este artículo revisa aquellos estudios más importantes que vinculan ambas patologías, los mecanismos descritos que las relacionan y la evidencia actual acerca del efecto que la suplementación de vitamina D podría tener sobre la hipertensión arterial (AU)

Low levels of vitamin D, defined as levels of 25-hydroxyvitamin D < 20-30 ng/ml, is a prevalent problem in the general population. Besides the classic relation with musculoskeletal disease, vitamin D has been also related to autoimmune diseases, cancer, metabolic diseases or cardiovascular diseases. High blood pressure, as the main cardiovascular risk factor, also has been related to vitamin D deficiency, constituting two prevalent worldwide health problems. Therefore, this article reviews the most important studies that combine both pathologies, the biological mechanism that relate them and the current evidence about the effect of vitamin D supplementation on hypertension (AU)

[Vitamin D and hypertension]. / Vitamina D e hipertensión arterial.

Low levels of vitamin D, defined as levels of 25-hydroxyvitamin D < 20-30 ng/ml, is a prevalent problem in the general population. Besides the classic relation with musculoskeletal disease, vitamin D has been also related to autoimmune diseases, cancer, metabolic diseases or cardiovascular diseases. High blood pressure, as the main cardiovascular risk factor, also has been related to vitamin D deficiency, constituting two prevalent worldwide health problems. Therefore, this article reviews the most important studies that combine both pathologies, the biological mechanism that relate them and the current evidence about the effect of vitamin D supplementation on hypertension.

Susceptibility for postmenopausal osteoporosis: interaction between genetic, hormonal and lifestyle factors.

Although previous studies have established the importance of genetic, hormonal and lifestyle factors separately, the integral role of these factors on bone mass in postmenopausal women is still controversial. We examined the association of the collagen 1-alpha-1 gene (COLIA1) and vitamin D receptor gene (VDR) polymorphisms, s-IGF-I, s-25OHD and lifestyle factors with bone mineral density (BMD) in postmenopausal women. We determined anthropometric parameters, lifestyle factors, serum levels of IGF-I and 25OHD, the COLIA1 Sp1 (Mscl) and VDR (Bsml, Taql) polymorphisms by PCR and BMD by dual X-ray absorptiometry in 141 ambulatory postmenopausal Spanish women. There were significant linear correlations between S-25OHD and BMD and between s-IGF-I and BMD. BMD was statistically higher in active subjects. Of the three different polymorphisms, only the COLIA1 Sp1 polymorphism was significantly associated with BMD. In the logistic regression model, the COLIA1 Sp1 polymorphism, S-25OHD, s-IGF-I and physical activity variables were independently associated with osteoporosis. Our study shows that COLIA1 Sp1 polymorphism, S-25OHD and s-IGF-I serum levels and physical activity are independently associated with BMD in postmenopausal Spanish women.

[Prevalence of vitamin D deficiency in populations at risk for osteoporosis: impact on bone integrity]. / Elevada prevalencia de déficit de vitamina D en poblaciones con riesgo de osteoporosis: un factor relevante en la integridad ósea.

BACKGROUND: Nowadays, severe deficiency of vitamin D is not a common finding in most developed countries. However, the prevalence of vitamin D insufficiency is relatively high and it can contribute to the descent of bone mass in osteoporosis risk populations. The objective of our study was to evaluate the prevalence of vitamin D insufficiency in postmenopausal women (PMW), patients with inflammatory bowel disease (IBD) and corticosteroid-dependent asthmatic patients (CAP) and to analyze its relationship with bone mineral density (BMD) and calciotropic hormones. PATIENTS AND METHOD: We studied 299 patients (PMW: 161; IBD: 61; CAP: 77). In all cases, serum levels of PTH and 25OHD were determined and the BMD (DXA, Hologic QDR1000) in lumbar spine (LS) and femoral neck (FN) was measured. RESULTS: Vitamin D insufficiency (25OHD < 15 ng/ml) was observed in 39.1% patients with PMW, 70.7% patients with IBD and 44.2% patients with CAP. 25OHD concentrations were lower in EII patients (p = 0.003) and PTH concentrations were higher in MPM (p < 0.001). We found a negative correlation between PTH and 25OHD in the overall group and this correlation persisted after considering each group separately. After adjusting for remaining variables, 25OHD was found to be significantly associated with BMD at lumbar spine and/or femoral neck in the three groups. CONCLUSIONS: In populations at risk of osteoporosis, there is a high prevalence of vitamin D insufficiency. This insufficiency has a significant effect on bone integrity.

Elevada prevalencia de déficit de vitamina D en poblaciones con riesgo de osteoporosis: un factor relevante en la integridad ósea / Prevalence of vitamin D deficiency in populations at risk for osteoporosis: impact on bone integrity

FUNDAMENTO: En la actualidad, la deficiencia grave de vitamina D es infrecuente en la mayoría de los países desarrollados. Sin embargo, la prevalencia del déficit subclínico de vitamina D (insuficiencia de vitamina D [IVD]) es más elevada y puede contribuir al descenso de la masa ósea en poblaciones con riesgo de osteoporosis. El objetivo de nuestro estudio fue evaluar la prevalencia de IVD en mujeres posmenopáusicas (MPM), pacientes diagnosticados de enfermedad inflamatoria intestinal (EII) y pacientes asmáticos en tratamiento con glucocorticoides (PAC) y analizar su relación con la densidad mineral ósea (DMO) y hormonas calciotropas. PACIENTES Y MÉTODO: Estudiamos a 299 sujetos (MPM 161; EII 61; PAC 77). En todos los casos determinamos los valores séricos de hormona paratiroidea (PTH), 25-hidroxivitamina D (25OHD) y la DMO (DXA, Hologic QDR1000) en columna lumbar y cuello femoral. RESULTADOS: La prevalencia de IVD (25OHD < 15 ng/ml) fue del 39,1 per cent en MPM, del 70,7 per cent en la EII y del 44,2 per cent en PAC. La 25OHD fue inferior en el grupo EII (p = 0,003) y la PTH fue superior en el grupo MPM (p < 0,001). Encontramos correlación negativa entre PTH y 25OHD en los 299 sujetos, que también fue significativa al estudiar a cada grupo por separado. Tras ajustar por el resto de las variables, la 25OHD se asoció significativamente a la masa ósea de la columna lumbar y/o el cuello femoral en los tres grupos estudiados. CONCLUSIONES: En poblaciones con riesgo de osteoporosis, el déficit de vitamina D tiene una elevada prevalencia y un efecto significativo en el deterioro de la integridad ósea (AU)

Utilidad de la densitometría ósea en la evaluación del hiperparatiroidismo primario / Usefulness of bone densitometry in the management of primary hyperparathyroidism

Fundamento: En la actualidad, el perfil clínico del hiperparatiroidismo primario se caracteriza por un predominio de las formas leves o asintomáticas. En este contexto, los efectos del hiperparatiroidismo primario sobre el metabolismo óseo adquieren una importancia creciente en la adopción de decisiones terapéuticas. Pacientes y métodos: Se estudió a 116 pacientes diagnosticados de hiperparatiroidismo primario, 95 mujeres (25 premenopáusicas, 70 posmenopáusicas) y 21 varones. En todos los casos, se evaluó la presencia de criterios de paratiroidectomía. En 71 casos, se determinó la densidad mineral ósea mediante densitometría dual de rayos X en la columna lumbar y el fémur proximal y se analizó la influencia de esta medida sobre la decisión de tratamiento quirúrgico. Resultados: Los pacientes con hiperparatiroidismo primario mostraron una significativa reducción de la densidad mineral ósea en todas las regiones analizadas (p < 0,001) y el 71,8 por ciento cumplía criterios densitométricos de osteoporosis. El criterio de paratiroidectomía más frecuente fue la presencia de manifestaciones clínicas específicas (51,7 por ciento) seguido de la disminución de la densidad mineral ósea en la columna lumbar (49,3 por ciento). La probabilidad de cumplir criterios para tratamiento quirúrgico fue significativamente mayor en los pacientes en que se realizó densitometría dual de rayos X (odds ratio: 3,09 [1,03-9,22]; p = 0,036). Conclusiones: En su forma de presentación actual, los pacientes con hiperparatiroidismo primario presentan una significativa disminución de masa ósea. La realización sistemática de densitometría ósea tiene una influencia decisiva en su tratamiento apropiado. (AU)