Risk factors associated with the progression of acute kidney injury to chronic kidney disease in pediatric allogeneic hematopoietic cell transplantation (AlloHCT) recipients are not well described. ...We retrospectively investigated the risk factors for the progression to CKD in 275 AlloHCT recipients. AKI and CKD grading was defined according to the Kidney Disease Improving Global Outcomes classification. PRI90 was defined as persistent renal insufficiency (estimated GFR < 90 ml/min/1.73 m
) 90 days after the first episode of AKI. The median age was 9.1 years. Incidence of stages 1, 2, and 3 AKI were 43%, 41%, and 15%, respectively. 86.1% met our study criteria for PRI90. Of the 236 PRI90 patients, 213 and 152 patients were evaluable for CKD at 1 and 3 years, respectively. The incidence of CKD at 1 and 3 years was 63.1% and 62.9%, respectively. On multivariable analysis, estimated GFR at initial episode of AKI (<80 ml/min/1.73 m
) and estimated GFR (<70 ml/min/1.73 m
) at PRI90 was a risk factor associated with CKD development and both risk factors were associated with significantly lower overall survival. To conclude, eGFR at the time of AKI and PRI90 may be considered for screening pediatric AlloHCT recipients at risk for the progression to CKD.
Aims
Global longitudinal strain (GLS) assessed by speckle‐tracking echocardiography has been proposed as a parameter able to reflect early changes in left ventricular systolic function at a stage ...when left ventricular ejection fraction (LVEF) is still normal. This study aimed at assessing prevalence and prognostic value of left ventricular systolic dysfunction (LVSD) assessed by echocardiographic speckle‐tracking GLS in a community‐based cohort.
Methods and Results
Participants from the community‐based prospective Northern Manhattan Study underwent two‐dimensional transthoracic echocardiography as part of the Cardiovascular Abnormalities and Brain Lesions study. Left ventricular systolic function was assessed by LVEF and speckle‐tracking GLS. Subjects were followed annually (mean = 4.8 ± 1.5 years) and incident vascular events (ischaemic stroke, myocardial infarction, and vascular death) were reviewed and adjudicated. Of the 708 study participants, 114 (16.1%) had abnormal GLS but normal LVEF (GLS‐LVSD), 30 (4.2%) had abnormal LVEF (LVEF‐LVSD), and 564 (79.7%) had normal GLS and LVEF (no‐LVSD). In multivariate analysis, risk of events was significantly greater in GLS‐LVSD adjusted hazard ratio (HR) = 2.39, 95% confidence interval (CI) = 1.20–4.77 and in LVEF‐LVSD (adjusted HR = 3.51, 95% CI = 1.25–9.88) compared with no‐LVSD. Among participants with normal LVEF, lower GLS was significantly associated with events (adjusted HR/unit decrease = 1.15, 95% CI = 1.03–1.28) whereas LVEF was not (adjusted HR/unit decrease = 1.01, 95% CI = 0.94–1.07). The GLS prognostic value was incremental to risk factors and LVEF both in the overall population (chi‐square change = 7.406, P = 0.006) and in participants with normal LVEF (chi‐square change = 6.357, P = 0.012).
Conclusion
In a community‐based cohort, GLS‐LVSD was four times more frequent than LVEF‐LVSD. GLS‐LVSD was a powerful and independent predictor of cardiovascular events. Left ventricular function assessment by GLS may improve cardiovascular risk stratification in subjects with normal LVEF.
Patent Foramen Ovale and the Risk of Ischemic Stroke in a Multiethnic Population Marco R. Di Tullio, Ralph L. Sacco, Robert R. Sciacca, Zhezhen Jin, Shunichi Homma The ischemic stroke risk associated ...with a patent foramen ovale (PFO) was evaluated in a multiethnic cohort of 1,100 stroke-free subjects. Transthoracic echocardiography with contrast injection was used for the detection of PRO. During a mean follow-up of 79.7 ± 28.0 months, PFO was not found to be significantly associated with ischemic stroke after adjustment for demographics and other stroke risk factors (hazard ratio 1.64, 95% confidence interval 0.87 to 3.09). The coexistence of PFO with atrial septal aneurysm did not increase the stroke risk. Therefore, the PFO-related stroke risk in the general population appears low. Subgroups of subjects at increased risk may exist.
The purpose of this study was to assess the independent effect of increased body size on left ventricular (LV) diastolic function.
Obese and overweight persons are at increased risk of heart failure. ...Left ventricular diastolic dysfunction is an asymptomatic condition associated with future heart failure. It is unclear whether obesity and overweight are independently associated with LV diastolic dysfunction.
The LV diastolic function was evaluated in 950 participants from the CABL (Cardiovascular Abnormalities and Brain Lesions) study by traditional and tissue Doppler imaging. Peak early transmitral diastolic flow velocity (E), late transmitral diastolic flow velocity (A), and early diastolic mitral annulus velocity (E') were measured, and E/A and E/E' were calculated. The study sample was divided into 3 groups: normal weight (body mass index BMI <25.0 kg/m(2)), overweight (BMI 25.0 to 29.9 kg/m(2)), and obese (BMI ≥30 kg/m(2)).
In multivariate analyses, BMI was independently associated with higher E, A, and E/E', an indicator of LV filling pressure (all p ≤ 0.01). Overweight and obese had lower E' (both p < 0.01) and higher E/E' (both p < 0.01) than normal weight participants. The E/A was lower in obese subjects than in normal weight subjects (p < 0.01). The risk of diastolic dysfunction was significantly higher in overweight subjects (adjusted odds ratio: 1.52, 95% confidence interval: 1.04 to 2.22) and obese subjects (adjusted odds ratio: 1.60, 95% confidence interval: 1.06 to 2.41) compared to normal weight subjects.
Increased BMI was associated with worse LV diastolic function independent of LV mass and associated risk factors. The increased risk of LV diastolic dysfunction in both overweight and obese persons may partially account for the increased risk of heart failure associated with both conditions.
Chronic inflammation has been associated with colorectal cancer. Prediagnostic levels of C-reactive protein (CRP), a highly sensitive marker of inflammation, have been weakly associated with ...increased colorectal cancer incidence, but few data are available examining its relationship with colorectal cancer mortality.
In the Third National Health and Nutrition Examination Survey (NHANES III), 65% of the 15,924 adult participants had CRP levels ≤0.21 mg/dL. Using this as the reference group, we calculated hazard ratios (HR) for higher CRP categories and colorectal cancer mortality, and compared them with HRs for other mortality causes.
Over a median follow-up period of 14.2 years, there were 92 deaths from colorectal cancer. Compared with the reference group, multivariable adjusted HRs for colorectal cancer mortality were 2.66 95% confidence interval (CI), 1.36-5.20 for CRP levels 0.22-0.50 mg/dL; 3.40 (95% CI, 1.48-7.77) for levels 0.51-1.00 mg/dL; and 3.96 (95% CI, 1.64-9.52) for levels >1.00 mg/dL. Estimates for colorectal cancer mortality did not change appreciably after excluding deaths within the first 3 years or by limiting follow-up to 5 or 10 years.
In a large representative study of U.S. adults, we observed strong dose-response associations between CRP levels and colorectal cancer mortality.
Further evaluation of CRP may help identify high-risk groups for colorectal cancer screening and those who might benefit most from prophylactic anti-inflammatory therapy.
Left atrial (LA) maximum volume (LAV(max)) is an indicator of left ventricular (LV) diastolic function. However, LAV(max) is also influenced by systolic events, whereas the LA minimum volume ...(LAV(min)) is directly exposed to LV pressure. The authors hypothesised that LAV(min) may be a better correlate of LV diastolic function than LAV(max).
Cross-sectional.
University hospital.
357 participants from a community-based cohort study.
LA volumes and reservoir function, measured as total LA emptying volume (LAEV) and LA emptying fraction (LAEF), were assessed by real-time three-dimensional echocardiography. LV diastolic function was assessed by trans-mitral early (E) and late (A) Doppler velocities and mitral early diastolic velocity by tissue-Doppler (e'). LV systolic function was assessed by LV ejection fraction (LVEF) and global longitudinal strain (GLS) by speckle-tracking.
LAV(min) significantly increased with worsening diastolic dysfunction (p<0.001), whereas the increase in LAV(max) was less pronounced (p=0.07). LAEV and LAEF decreased with worsening diastolic dysfunction (both p<0.001). In linear regressions, LAV(min) and LAV(max) were significant predictors of E/e', with higher parameter estimates for LAV(min). In multivariate models, LAV(min) resulted strongly associated with E/e' (β=0.45, p<0.001), whereas LAV(max) was not (β=-0.16, p=0.08). LA reservoir function was better associated with GLS than LVEF. In multivariate analyses, GLS was significantly associated with LAV(max) (β=-0.15, p=0.002), LAEV (β=-0.37, p<0.001) and LAEF (β=-0.28, p<0.001) but not with LAV(min).
LAV(min) is a better correlate of LV diastolic function than LAV(max). The impact of LV longitudinal systolic function on LA reservoir function might explain the weaker relation between LAV(max) and LV diastolic function.
Increased arterial stiffness and wave reflection have been reported in heart failure with normal ejection fraction (HFNEF) and in asymptomatic left ventricular (LV) diastolic dysfunction, a precursor ...of HFNEF. It is unclear whether women, who have higher frequency of HFNEF, are more vulnerable than men to the deleterious effects of arterial stiffness on LV diastolic function. We investigated, in a large community-based cohort, whether sex differences exist in the relationship among arterial stiffness, wave reflection, and LV diastolic function. Arterial stiffness and wave reflection were assessed in 983 participants from the Cardiovascular Abnormalities and Brain Lesions study using applanation tonometry. The central pulse pressure/stroke volume index, total arterial compliance, pulse pressure amplification, and augmentation index were used as parameters of arterial stiffness and wave reflection. LV diastolic function was evaluated by 2-dimensional echocardiography and tissue-Doppler imaging. Arterial stiffness and wave reflection were greater in women compared with men, independent of body size and heart rate (all P<0.01), and showed inverse relationships with parameters of diastolic function in both sexes. Further adjustment for cardiovascular risk factors attenuated these relationships; however, a higher central pulse pressure/stroke volume index predicted LV diastolic dysfunction in women (odds ratio, 1.54; 95% confidence intervals, 1.03 to 2.30) and men (odds ratio, 2.09; 95% confidence interval, 1.30 to 3.39), independent of other risk factors. In conclusion, in our community-based cohort study, higher arterial stiffness was associated with worse LV diastolic function in men and women. Womenʼs higher arterial stiffness, independent of body size, may contribute to their greater susceptibility to develop HFNEF.
The accelerated failure time model or accelerated life model relates the logarithm of the failure time linearly to the covariates. The parameters in the model provides a direct interpretation. In ...this paper, we review some newly developed practically useful estimation and inference methods for the model in the analysis of right censored data.
The impact of AGVHD on healthcare utilization and cost is not well described. In this retrospective single center cohort study of 240 pediatric patients, we analyzed cost, healthcare utilization and ...patient outcomes for the first year post-alloHCT. Costs were estimated from charges recorded in the Pediatric Health Information System database and the hospital's accounting system. The overall incidence of grade I-IV aGVHD was 40.4%. The incidence of grade I, grade II, and grade III-IV aGVHD was 6.6%, 16.2%, and 17.5%, respectively. The overall incidence of steroid refractory (SR)-aGVHD was 10.8%. The median number of days of hospitalization in the first year post-alloHCT was significantly higher for patients with aGVHD vs. no aGVHD: 113 days (range: 35-354 days) vs. 63 days (range: 25-298 days), p < 0.001. Patients with SR-aGVHD had increased hospitalization compared with the patients with steroid responsive aGVHD (152.8 ± 66.6days vs. 111.3 ± 59.3 days, p = 0.004), with associated increased alloHCT cost of ~$200,000. On multivariable analysis of risk factor for alloHCT cost, aGVHD, was associated with significantly higher cost ($141,094 SE = 31247, p < 0.001). In summary, aGVHD and SR-aGVHD is associated with prolonged hospitalization and higher cost and inferior survival among children. Better aGVHD prevention strategies are desperately needed. Despite significant advances, lack of effective salvage regimens for SR-aGVHD remains a major concern.
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