Bård Waldum

Renal Function in Outpatients With Chronic Heart Failure

BACKGROUND Impaired renal function confers an adverse prognosis in patients with heart failure (HF). The aims of the present study were to identify factors associated with and predictive of impaired renal function and to assess the relationship between estimated glomerular filtration rate (eGFR) and all-cause mortality in outpatients with HF. METHODS AND RESULTS Baseline data on 3605 patients (median age 73 years, 70.1% men) from 24 outpatient HF clinics in Norway were analyzed. Median follow-up time was 9 months. Renal dysfunction (eGFR < 60 mL/min) was present in 44.9%. The population was randomized into equal-sized model-building and validation samples to enhance model stability. eGFR was an independent predictor of all-cause mortality (HR 0.94 per 5 mL/min increase, P = .001). Use of spironolactone (P = .002), higher blood pressure (P < .001), and lower hemoglobin levels (P = .002) were predictors of impaired renal function. Increasing doses of loop diuretics were strongly associated with eGFR at baseline (P < .001), but only tended to predict worsening renal function during follow-up (P = .08). CONCLUSIONS Clinically significant reduction in renal function was prevalent in outpatients with HF, and was a strong predictor of all-cause mortality. Use of loop diuretics and spironolactone should be carefully evaluated as these agents may adversely affect renal function.

The Cardiorenal Syndrome: What the Cardiologist Needs to Know

Interactions between the heart and the kidneys are increasingly acknowledged among both cardiologists and nephrologists. The term cardiorenal syndrome now applies to the bidirectional nature of how disease in one organ system affects the function of the other organ system. Cardiovascular disease is a major threat to patients with chronic kidney disease, while renal dysfunction is prevalent in patients with cardiac disease and is a significant predictor of prognosis in cardiac patients. Still, renal patients with cardiac disease have largely been excluded from the clinical trials that have been the basis of modern cardiologic treatment. In this review, the current understanding of the pathophysiological mechanisms involved in the cardiorenal syndrome and potential therapeutic implications will be summarized from a nephrologists point of view. Probably, fragile cardiorenal patients will benefit from an enhanced collaboration between cardiologists and nephrologists to secure the best treatment given under safe conditions.

Baseline anemia is not a predictor of all-cause mortality in outpatients with advanced heart failure or severe renal dysfunction. Results from the Norwegian Heart Failure Registry.

OBJECTIVES The aim of this study was to evaluate the prognostic impact of anemia in outpatients with chronic heart failure attending specialized heart failure clinics and specifically to investigate its prognostic utility in patients with severe renal dysfunction or advanced heart failure. BACKGROUND Anemia is an independent prognostic marker in patients with heart failure. The effect of anemia on mortality decreases with increasing creatinine levels. METHODS Multivariate Cox regression analyses were used to investigate the prognostic effect of anemia in 4,144 patients with heart failure from 21 outpatient heart failure clinics in Norway. Severe renal failure was defined as estimated glomerular filtration rate ≤45 ml/min/1.73 m(2) and advanced heart failure as New York Heart Association functional classes IIIb and IV. RESULTS Baseline anemia was present in 24% and was a strong predictor of all-cause mortality (adjusted hazard ratio [HR]: 1.30, 95% CI: 1.09 to 1.56, p = 0.004). Baseline anemia did not predict mortality in the 752 patients with severe renal dysfunction (adjusted HR: 1.08, 95 % CI: 0.77 to 1.51, p = 0.662) and the 528 patients with advanced heart failure (adjusted HR: 0.87, 95% CI: 0.56 to 1.34, p = 0.542). In the 1,743 patients who attended subsequent visits, sustained anemia independently predicted worse prognosis (adjusted HR: 1.47, 95% CI: 1.10 to 1.94, p = 0.008), whereas transient and new-onset anemia did not. CONCLUSIONS According to our study, baseline anemia was not an independent predictor of all-cause mortality in outpatients with heart failure and accompanied severe renal dysfunction or advanced heart disease. Sustained anemia after optimizing heart failure treatment might imply worse prognosis independently of renal function and New York Heart Association functional class.

Clinical ResearchHeart FailureBaseline Anemia Is Not a Predictor of All-Cause Mortality in Outpatients With Advanced Heart Failure or Severe Renal Dysfunction: Results From the Norwegian Heart Failure Registry

OBJECTIVES The aim of this study was to evaluate the prognostic impact of anemia in outpatients with chronic heart failure attending specialized heart failure clinics and specifically to investigate its prognostic utility in patients with severe renal dysfunction or advanced heart failure. BACKGROUND Anemia is an independent prognostic marker in patients with heart failure. The effect of anemia on mortality decreases with increasing creatinine levels. METHODS Multivariate Cox regression analyses were used to investigate the prognostic effect of anemia in 4,144 patients with heart failure from 21 outpatient heart failure clinics in Norway. Severe renal failure was defined as estimated glomerular filtration rate ≤45 ml/min/1.73 m(2) and advanced heart failure as New York Heart Association functional classes IIIb and IV. RESULTS Baseline anemia was present in 24% and was a strong predictor of all-cause mortality (adjusted hazard ratio [HR]: 1.30, 95% CI: 1.09 to 1.56, p = 0.004). Baseline anemia did not predict mortality in the 752 patients with severe renal dysfunction (adjusted HR: 1.08, 95 % CI: 0.77 to 1.51, p = 0.662) and the 528 patients with advanced heart failure (adjusted HR: 0.87, 95% CI: 0.56 to 1.34, p = 0.542). In the 1,743 patients who attended subsequent visits, sustained anemia independently predicted worse prognosis (adjusted HR: 1.47, 95% CI: 1.10 to 1.94, p = 0.008), whereas transient and new-onset anemia did not. CONCLUSIONS According to our study, baseline anemia was not an independent predictor of all-cause mortality in outpatients with heart failure and accompanied severe renal dysfunction or advanced heart disease. Sustained anemia after optimizing heart failure treatment might imply worse prognosis independently of renal function and New York Heart Association functional class.

Hypertension in women: latest findings and clinical implications:

Cardiovascular disease claims more women’s lives than any other disease. Hypertension is an important risk factor for cardiovascular disease in women but is often underestimated and undiagnosed and there is an ongoing misperception that women are at a lower risk of cardiovascular disease than men. The attainment of clinical blood pressure goals can markedly reduce cardiovascular morbidity and mortality, yet approximately two-thirds of treated hypertensive women have uncontrolled blood pressure. Furthermore, there are special risk factors that are unique for women that needs acknowledgement in order to help prevent the great number of hypertension-related events in women. Guidelines for treatment of hypertension are similar for men and women. More studies on the interaction between gender and response to antihypertensive drugs would be of interest.

Self-perceived quality of sleep and mortality in Norwegian dialysis patients

Sleep complaints are prevalent and associated with poor health‐related quality of life (HRQoL), depression and possibly mortality in dialysis patients. This study aimed to explore possible associations between sleep quality, daytime sleepiness and mortality in dialysis patients. In this study, 301 dialysis patients were followed up to 4.3 years. HRQoL was evaluated at baseline with the Kidney Disease and Quality of Life—Short Form (KDQoL‐SF), depression with Beck Depression Inventory (BDI), sleep quality with Pittsburgh Sleep Quality Index and daytime sleepiness with Epworth Sleepiness Scale. The single item “on a scale from 0–10, how would you evaluate your sleep?” in the sleep subscale in KDQoL‐SF was used to identify poor (0–5) and good sleepers (6–10). A total of 160 patients (53.3%) were characterized as poor sleepers. They were younger (r = 0.241, P < 0.001), had more depression (BDI: 8.72 ± 6.79 vs. 13.60 ± 8.04, P < 0.001), a higher consumption of hypnotics and antidepressants and reduced HRQoL (Mental Component Summary score: 45.4 ± 11.0 vs. 50.0 ± 10.4, P < 0.001. Physical Component Summary score: 35.0 ± 9.9 vs. 38.5 ± 10.5, P = 0.004). In multivariate analyses, poor sleepers had nearly a twofold increase in mortality risk (hazard ratio [HR] 1.92, confidence interval [CI] 1.10‐3.35, P = 0.022). Daytime sleepiness was not related to mortality (HR 1.01, CI 0.95‐1.08, P = 0.751). Sleep complaints predicted increased mortality risk in dialysis patients and should therefore be routinely assessed. Further studies are needed to find suitable treatment options for poor sleep in dialysis patients as it may affect both HRQoL and survival.

Sleep complaints, depression and quality of life in Norwegian dialysis patients.

BACKGROUND This study explores sleep problems in dialysis patients and the associations to health-related quality of life (HRQoL) and depression. A comparison between different validated sleep questionnaires was done in order to find an appropriate diagnostic tool in clinical practice. METHODS In a cross-sectional study of 301 prevalent dialysis patients, sleep problems were elaborated with Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS). Poor sleep was defined as PSQI score > 5 and daytime sleepiness as ESS > 10. HRQoL, including quality of sleep, was evaluated with the Kidney Disease and Quality of Life - Short Form (KDQoL-SF), and physical (PCS) and mental component summary scores (MCS) were computed. Depression was assessed with Beck Depression Inventory (BDI). RESULTS Poor sleep and excessive daytime sleepiness was found in 74.3% and 22.2%, respectively. Depression was common (29.5%) and associated with reduced sleep quality (ρ = 0.49, p < 0.001). Poor sleepers had significantly lower MCS (51.8 ± 9.6 vs. 46.6 ± 10.6, p = 0.001) and PCS (41.8 ± 9.6 vs. 35.2 ± 10.0, p < 0.001) compared to good sleepers. PSQI scores were independently associated with PCS (p = 0.001), but not MCS (p = 0.468) in multivariate analyses. The sleep subscale from KDQoL-SF was strongly correlated to PSQI (r = -0.75, p < 0.001). CONCLUSIONS As sleep complaints, daytime sleepiness and depression were prevalent, all dialysis patients should routinely be screened for self-perceived sleep problems with a simple Questionnaire.

Health related quality of life in patients in dialysis after renal graft loss and effect of gender

BackgroundAn increasing number of dialysis patients have returned to dialysis after renal graft loss, and the transition in disease state could likely be associated with reduced health related quality of life (HRQOL). Furthermore, gender differences in HRQOL have been observed in dialysis and kidney transplanted patients, but whether transition in disease state affects HRQOL differently in respect to gender is not known. The aims of this study were to compare HRQOL in dialysis patients with graft loss to transplant naïve dialysis patients, and to explore possible gender differences.MethodsIn a cross-sectional study, HRQOL was measured in 301 prevalent dialysis patients using the Kidney Disease and Quality of Life Short Form version 1.3. Adjusted comparisons were made between dialysis patients with previous graft loss and the transplant naïve patients. Multiple linear regression analyses were performed with HRQOL as outcome variables. Interaction analyses using product terms were performed between gender and graft loss. HRQOL was analysed separately in both genders.ResultsPatients with renal graft loss (n = 50) did not experience lower HRQOL than transplant naïve patients after multiple adjustments. Among patients with graft loss, women (n = 23) reported lower HRQOL than men (n = 27) in the items physical function (40 vs. 80, p = 0.006), and effect of kidney disease (49 vs. 67, p = 0.017). Women with graft loss reported impaired kidney-specific HRQOL compared to transplant naïve women (n = 79) in the items effect of kidney disease (50 vs. 72, p = 0.002) and cognitive function (80 vs. 93, p = 0.006), and this observation persisted after multiple adjustments. Such differences were not apparent in the male counterparts.ConclusionsPatients who resumed dialysis after renal graft loss did not have lower HRQOL than dialysis patients not previously transplanted. However, losing graft function was associated with reduced HRQOL in females, and important interactions were identified between graft loss and gender. This needs to be further explored in prospective studies.

Prognostic utility of B-type natriuretic peptides in patients with heart failure and renal dysfunction

Background Renal dysfunction is considered a confounding variable in the interpretation of B-type natriuretic peptides (BNPs) and their amino-terminal fragments (NT-ProBNP) in patients with heart failure (HF). Our aim was to investigate the prognostic utility of BNPs and NT-proBNP in HF outpatients with renal dysfunction, and compare the prognostic significance of the corresponding BNP/NT-ProBNP levels in patients with and without renal dysfunction. Methods A total of 2076 patients from 13 HF clinics in the Norwegian Heart Failure Registry were investigated. The BNP/NT-ProBNP levels were categorized centre-wise into four groups using the quartile limits found in patients with preserved renal function. Patients with renal dysfunction, i.e. glomerular filtration rate (GFR) ≤60 mL/min/1.73 m2, were then assigned to BNP groups 1–4 centre-wise according to their level of natriuretic peptides. Results Renal dysfunction was present in 37.5% of the patients, of whom the majority (59.1%) had levels of natriuretic peptide in the highest BNP group. Patients with renal dysfunction and BNP levels in the lower three BNP groups had similar 2-year survival as patients without renal dysfunction and comparable BNP levels [crude hazard ratio (HR) 1.25, 95% CI 0.82–1.89, P = 0.302, multiple adjusted HR 0.85, 95% CI 0.54–1.33, P = 0.457]. Beyond 2 years of follow-up, renal dysfunction predicted all-cause mortality irrespective of the level of natriuretic peptides at the start of follow-up. Conclusion In HF outpatients, the BNP/NT-ProBNP level predicted 2-year mortality irrespective of renal function and provided important prognostic information on patients with renal dysfunction.