ABSTRACT
Background
Hyperkalemia is common among patients with chronic kidney disease (CKD) but there is scarce information on differential risk factors and outcomes for men and women. For instance, ...smoking has been suggested to be a risk factor for hyperkalemia, but specific analysis of the sex-specific impact of smoking on hyperkalemia in CKD is lacking.
Methods
We studied serum potassium levels in 2891 participants from the NEFRONA cohort: 483 controls (47% women) and 2408 CKD patients (38% women) without prior cardiovascular disease (CVD), assessing whether smoking is a risk factor for hyperkalemia, and if hyperkalemia is associated with outcomes separately for men and women.
Results
Median potassium levels and prevalence of hypo and hyperkalemia were higher in CKD participants than in controls. Serum potassium levels were higher and hyperkalemia and severe hyperkalemia more prevalent in men than in women with non-dialysis CKD (G3–G5). The highest prevalence of hyperkalemia for each gender was found in CKD G4-G5 and hemodialysis patients for men (46%) and in hemodialysis (54%) for women. Gender-specific etiological multivariate analysis identified current smoking as a risk factor for hyperkalemia only in men. Hyperkalemia was independently associated with stopping RAASi, an outcome which was more common in women. Hyperkalemia was also associated to higher risk of cardiovascular events within 4 years in men. In conclusion, hyperkalemia is common among men and women with CKD, but the prevalence, risk factors and outcomes may differ by gender. Specifically, current smoking is a driver of hyperkalemia in men.
Graphical Abstract
Graphical Abstract
Chronic kidney disease (CKD) is associated with an elevated risk of all-cause mortality, with cardiovascular death being extensively investigated. However, non-cardiovascular mortality represents the ...biggest percentage, showing an evident increase in recent years. Klotho is a gene highly expressed in the kidney, with a clear influence on lifespan. Low levels of Klotho have been linked to CKD progression and adverse outcomes. Single nucleotide polymorphisms (SNPs) of the Klotho gene have been associated with several diseases, but studies investigating the association of Klotho SNPs with non-cardiovascular death in CKD populations are lacking.
The main aim of this study was to assess whether 11 Klotho SNPs were associated with non-cardiovascular death in a subpopulation of the National Observatory of Atherosclerosis in Nephrology (NEFRONA) study (
= 2185 CKD patients).
After 48 months of follow-up, 62 cardiovascular deaths and 108 non-cardiovascular deaths were recorded. We identified a high non-cardiovascular death risk combination of SNPs corresponding to individuals carrying the most frequent allele (G) at rs562020, the rare allele (C) at rs2283368 and homozygotes for the rare allele (G) at rs2320762 (rs562020 GG/AG + rs2283368 CC/CT + rs2320762 GG). Among the patients with the three SNPs genotyped (
= 1016), 75 (7.4%) showed this combination. Furthermore, 95 (9.3%) patients showed a low-risk combination carrying all the opposite genotypes (rs562020 AA + rs2283368 TT + rs2320762 GT/TT). All the other combinations
= 846 (83.3%) were considered as normal risk. Using competing risk regression analysis, we confirmed that the proposed combinations are independently associated with a higher {hazard ratio HR 3.28 confidence interval (CI) 1.51-7.12} and lower HR 6 × 10
(95% CI 3.3 × 10
-1.1 × 10
) risk of suffering a non-cardiovascular death in the CKD population of the NEFRONA cohort compared with patients with the normal-risk combination.
Determination of three SNPs of the Klotho gene could help in the prediction of non-cardiovascular death in CKD.
Abstract
Background
Chronic kidney disease (CKD) patients show an increased burden of atherosclerosis and high risk of cardiovascular events (CVEs). There are several biomarkers described as being ...associated with CVEs, but their combined effectiveness in cardiovascular risk stratification in CKD has not been tested. The objective of this work is to analyse the combined ability of 19 biomarkers associated with atheromatous disease in predicting CVEs after 4 years of follow-up in a subcohort of the NEFRONA study in individuals with different stages of CKD without previous CVEs.
Methods
Nineteen putative biomarkers were quantified in 1366 patients (73 CVEs) and their ability to predict CVEs was ranked by random survival forest (RSF) analysis. The factors associated with CVEs were tested in Fine and Gray (FG) regression models, with non-cardiovascular death and kidney transplant as competing events.
Results
RSF analysis detected several biomarkers as relevant for predicting CVEs. Inclusion of those biomarkers in an FG model showed that high levels of osteopontin, osteoprotegerin, matrix metalloproteinase-9 and vascular endothelial growth factor increased the risk for CVEs, but only marginally improved the discrimination obtained with classical clinical parameters: concordance index 0.744 (95% confidence interval 0.609–0.878) versus 0.723 (0.592–0.854), respectively. However, in individuals with diabetes treated with antihypertensives and lipid-lowering drugs, the determination of these biomarkers could help to improve cardiovascular risk estimates.
Conclusions
We conclude that the determination of four biomarkers in the serum of CKD patients could improve cardiovascular risk prediction in high-risk individuals.
The increase in telemedicine in the mental health field has led to psychometric instruments changing from paper-and-pencil administration to an electronic format. A study is performed to determine if ...both formats are equivalent for well-known questionnaires such as GHQ-12, WHO-5, and PHQ-9.
Forty-seven volunteers completed GHQ-12, WHO-5 and PHQ-9 questionnaires in paper-and-pencil format, and in the following 24h they completed their electronic versions via the web site www.memind.net. An electronic-Likert format was used by 24 participants, and 23 used an electronic-slider format. Internal consistency was measured by α-Cronbach index and omega coefficient, and test-retest was measured by the intraclass correlation coefficient (ICC). Agreement between individual items was compared using Weighted Kappa coefficients, and dimensional structure between formats using the Comparative Fit Index (CFI).
Internal consistency was higher than 0.8 for GHQ-12 and WHO-5. The ICC ranged between 0.655 for PHQ-9 paper-and-pencil/electronic-slider and 0.901 for GHQ-12 paper-and-pencil/electronic- slider. Agreement for individual items in paper-and-pencil and electronic-Likert versions was variable, ranging from low agreement in PHQ-1 (weighted κ=0.143; P=.384) to high agreement in PHQ-5 (weighted κ=0.769; P=.000). The CFI results showed an adequate equivalence between formats.
Except for the PHQ-9 electronic-Likert, questionnaires keep their structure in electronic formats. Discrepancies were found in items agreement. This study supports previous works indicating that the change from paper-and-pencil to electronic formats is not an immediate process, and needs a proper adaptation.
Transcatheter mitral valve repair (TMVR) with MitraClip is a therapeutic option for high surgical risk patients with severe mitral regurgitation (MR). The main objective of this study was to analyze ...differences in outcomes in patients with severe MR according to the cause of MR.
Observational, multicenter, and prospective study with consecutive patient inclusion. The primary endpoint was the combination of all-cause mortality and new readmissions due to heart failure after 1 year. We compared clinical and procedural characteristics and the event rate for each MR group. We performed a multivariate analysis to identify predictive variables for the primary endpoint.
A total of 558 patients were included: 364 (65.2%) with functional etiology, 111 (19.9%) degenerative and 83 (14.9%) mixed. The mean age was 72.8±11.1 years and 70.3% of the sample were men. There were 95 (17%) events in the overall sample. No significant differences were found in the 3 groups in the number of primary outcome events: 11 (11.3%) in degenerative MR, 71 (21.3%) in functional MR, and 13 (18.1%) in mixed MR (P=.101). Independent predictors were functional class (P=.029), previous surgical revascularization (P=.031), EuroSCORE II (P=.003), diabetes mellitus (P=.037), and left ventricular ejection fraction (P=.015).
This study confirms the safety and efficacy of TMVR with MitraClip irrespective of MR etiology in real-life data and shows the main factors related to prognosis during the first year of follow up.
La reparación de la válvula mitral transcatéter (RVMT) con el sistema MitraClip es un tratamiento para los pacientes con insuficiencia mitral (IM) grave de alto riesgo quirúrgico. El objetivo principal fue analizar los resultados del RVMT en pacientes con IM grave, según la etiología.
Estudio observacional, prospectivo y multicéntrico con inclusión de pacientes consecutivos. El objetivo primario fue el combinado de mortalidad por todas las causas y reingresos hospitalarios por insuficiencia cardiaca al año. Se compararon las características clínicas y del procedimiento y los eventos para cada grupo de IM. Se realizó un análisis multivariable para determinar las variables asociadas con el objetivo primario.
Se incluyó a 558 pacientes; 364 (65,2%) tenían etiología funcional; 111 (19,9%), degenerativa, y 83 (14,9%), mixta. La media de edad fue 72,8±11,1 años y eran varones el 70,3%. Respecto al objetivo primario, hubo 95 (17%) eventos en toda la serie. No hubo diferencias significativas entre los 3 grupos en el número de eventos del objetivo primario: 11 (11,3%) en la IM degenerativa, 71 (21,3%) en la funcional y 13 (18,1%) en la mixta (p=0,101). Los predictores independientes fueron la clase funcional (p=0,029), la revascularización quirúrgica previa (p=0,031), el EuroSCORE II (p=0,003), la diabetes mellitus (p=0,037) y la fracción de eyección del ventrículo izquierdo (p=0,015).
Este trabajo confirma con datos de la práctica clínica la seguridad y la eficacia de la RVMT independientemente de la etiología de la IM y se documentan los principales factores asociados con el pronóstico durante el primer año de seguimiento.
La reparación de la válvula mitral transcatéter (RVMT) con el sistema MitraClip es un tratamiento para los pacientes con insuficiencia mitral (IM) grave de alto riesgo quirúrgico. El objetivo ...principal fue analizar los resultados del RVMT en pacientes con IM grave, según la etiología.
Estudio observacional, prospectivo y multicéntrico con inclusión de pacientes consecutivos. El objetivo primario fue el combinado de mortalidad por todas las causas y reingresos hospitalarios por insuficiencia cardiaca al año. Se compararon las características clínicas y del procedimiento y los eventos para cada grupo de IM. Se realizó un análisis multivariable para determinar las variables asociadas con el objetivo primario.
Se incluyó a 558 pacientes; 364 (65,2%) tenían etiología funcional; 111 (19,9%), degenerativa, y 83 (14,9%), mixta. La media de edad fue 72,8±11,1 años y eran varones el 70,3%. Respecto al objetivo primario, hubo 95 (17%) eventos en toda la serie. No hubo diferencias significativas entre los 3 grupos en el número de eventos del objetivo primario: 11 (11,3%) en la IM degenerativa, 71 (21,3%) en la funcional y 13 (18,1%) en la mixta (p=0,101). Los predictores independientes fueron la clase funcional (p=0,029), la revascularización quirúrgica previa (p=0,031), el EuroSCORE II (p=0,003), la diabetes mellitus (p=0,037) y la fracción de eyección del ventrículo izquierdo (p=0,015).
Este trabajo confirma con datos de la práctica clínica la seguridad y la eficacia de la RVMT independientemente de la etiología de la IM y se documentan los principales factores asociados con el pronóstico durante el primer año de seguimiento.
Transcatheter mitral valve repair (TMVR) with MitraClip is a therapeutic option for high surgical risk patients with severe mitral regurgitation (MR). The main objective of this study was to analyze differences in outcomes in patients with severe MR according to the cause of MR.
Observational, multicenter, and prospective study with consecutive patient inclusion. The primary endpoint was the combination of all-cause mortality and new readmissions due to heart failure after 1 year. We compared clinical and procedural characteristics and the event rate for each MR group. We performed a multivariate analysis to identify predictive variables for the primary endpoint.
A total of 558 patients were included: 364 (65.2%) with functional etiology, 111 (19.9%) degenerative and 83 (14.9%) mixed. The mean age was 72.8±11.1 years and 70.3% of the sample were men. There were 95 (17%) events in the overall sample. No significant differences were found in the 3 groups in the number of primary outcome events: 11 (11.3%) in degenerative MR, 71 (21.3%) in functional MR, and 13 (18.1%) in mixed MR (P=.101). Independent predictors were functional class (P=.029), previous surgical revascularization (P=.031), EuroSCORE II (P=.003), diabetes mellitus (P=.037), and left ventricular ejection fraction (P=.015).
This study confirms the safety and efficacy of TMVR with MitraClip irrespective of MR etiology in real-life data and shows the main factors related to prognosis during the first year of follow up.
Determinar el efecto de un tratamiento en estudios observacionales es problemático por las diferencias existentes entre tratados y no tratados. Un método propuesto para controlar estas diferencias es ...calcular la probabilidad condicionada por covariables de recibir el tratamiento,
Propensity Score (PS). Presentamos una aplicación de este método analizando la asociación entre reperfusión y letalidad a 28 días en pacientes con infarto agudo de miocardio (IAM).
Se presenta cómo calcular la PS de recibir reperfusión y las diferentes estrategias para analizar posteriormente su asociación con la letalidad mediante mode-los de regresión y apareamiento. Utilizamos datos de un registro poblacional de IAM realizado en España entre 1997 y 1998 que incluyó 6.307 IAM.
Se calculó la PS de reperfusión en 5.622 pacientes. En el análisis multivariado la reperfusión se asoció con menor letalidad (
odds ratio OR = 0,59; intervalo de confianza IC del 95%, 0,46-0,77); al ajustar además por la PS de reperfusión esta asociación no fue significativa (OR
=
0,76; IC del 95%, 0,57-1,01). En el subgrupo de pacientes apareados, tratados y no tratados con PS de reperfusión similar (n
=
3.138), este tratamiento no se asoció con letalidad (OR
=
0,95; IC del 95%, 0,72-1,26). Controlando el impacto de los casos con datos insuficientes en la PS de reperfusión, ésta se asoció con menor letalidad (OR
=
0,66; IC del 95%, 0,55-0,80).
El cálculo de la PS es un método para controlar las diferencias entre los grupos tratado y no tratado. Tiene limitaciones cuando el apareamiento es incompleto o hay datos insuficientes en la PS calculada. Los resultados del ejemplo presentado indican que la reperfusión reduce la letalidad del IAM.
Analysis of the effect of treatment in observational studies is complex due to differences between treated and nontreated patients. Calculating the probability of receiving treatment conditioned on relevant covariates (propensity score PS) has been proposed as a method to control for these differences. We report an application of PS to assess the association between reperfusion treatment and 28-day case fatality in patients with acute myocardial infarction (AMI).
We describe the procedure used to calculate PS for receiving reperfusion treatment, and different strategies to analyze the association between PS and case fatality with regression modeling and matching. Data were from a population-based registry of 6307 patients with AMI in Spain during 1997-98.
The PS for reperfusion was calculated in 5622 patients. In the multivariate analysis, reperfusion was associated with lower case fatality (OR
=
0.59; 95% confidence interval 95% CI: 0.46-0.77). When PS was included as a covariate, this association became nonsignificant (OR
=
0.76; 95% CI: 0.57-1.01). In the subgroup of matched patients with a similar PS (n
=
3138), treatment was not associated with case fatality (OR
=
0.95; 95% CI: 0.72-1.26). When the influence of cases with missing data on PS was controlled for, reperfusion treatment was associated with lower fatality (OR
=
0.66; 95% CI: 0.55-0.80).
Calculating propensity score is a method that controls for differences between treated and nontreated patients. This score has limitations when matching is incomplete and when data are missing.Results of the present example suggest that reperfusion treatment reduces AMI case fatality.
El renacimiento de Dimensión Humana Pertusa Martínez, Salvador; Vázquez Díaz, José R.
Atención primaria,
11/2007, Letnik:
39, Številka:
11
Journal Article
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