Hepatocardiorenal syndrome in liver cirrhosis:Recognition of a new entity?

Emerging evidence and perspectives have pointed towards the heart playing an important role in hepatorenal syndrome(HRS),outside of conventional understanding that liver cirrhosis is traditionally considered the sole origin of a cascade of pathophysiological mechanisms directly affecting the kidneys in this context.In the absence of established heart disease,cirrhotic cardiomyopathy may occur more frequently in those with liver cirrhosis and kidney disease.It is a specific form of cardiac dysfunction characterized by blunted contractile responsiveness to stress stimuli and altered diastolic relaxation with electrophysiological abnormalities.Despite the clinical description of these potential cardiac-related complications of the liver,the role of the heart has traditionally been an overlooked aspect of circulatory dysfunction in HRS.Yet from a physiological sense,temporality(prior onset)of cardiorenal interactions in HRS and positive effects stemming from portosystemic shunting demonstrated an important role of the heart in the development and progression of kidney dysfunction in cirrhotic patients.In this review,we discuss current concepts surrounding how the heart may influence the development and progression of HRS,and the role of systemic inflammation and endothelial dysfunction causing circulatory dysfunction within this setting.The temporality of heart and kidney dysfunction in HRS will be discussed.For a subgroup of patients who receive portosystemic shunting,the dynamics of cardiorenal interactions following treatment is reviewed.Continued research to determine the unknowns in this topic is anticipated,hopefully to further clarify the intricacies surrounding the liver-heart-kidney connection and improve strategies for management.

Prognostic Factors in Cardiorenal Syndrome Type 1: Retrospective Observational and Analytical Study

Introduction: Type 1 cardiorenal syndrome (CRS 1) is characterized by acute impairment of cardiac function leading to acute renal dysfunction. CRS1 is present in 25% of patients admitted for heart failure. The objective of our study is to analyze the epidemiological, clinical, therapeutic profile and the risk and prognostic factors of these patients. Materials and Methods: We identified 120 patients with cardiorenal syndrome (CRS) over a one-year period to determine the prevalence and risk factors for developing CRS 1. We analyzed the clinical, biological, and evolutionary profiles of patients with CRS 1 and determined the risk factors for the occurrence of acute kidney injury (AKI) as well as the mortality factors in these patients. Résultats: The average age of our patients with CRS1 is 58 ± 9 years, with a sex ratio of 1.4. The average eGFR of our patients is 35 ± 6.5 ml/min/1.73m2. Diabetes was found in 17% of our patients and hypertension in 14%. The etiology of cardiac impairment is predominantly acute coronary syndrome (ACS), followed by rhythm disorders. Renally, all our patients have acute kidney injury (AKI), with 86% having functional acute renal failure and 14% having acute tubular necrosis. Therapeutically, 50% of our patients are on diuretics, 42% receive beta-blocker treatment, and RAAS blockers are used in 29% of cases. Renal replacement therapy (RRT) sessions were required in 13.8% of cases. In univariate analysis, male gender, tachyarrhythmia, and hypertension are associated with the early onset of acute kidney injury (AKI). The use of diuretics, anemia, and low left ventricular ejection fraction (LVEF) are linked to a higher risk of developing CRS 1 (p = 0.021, p = 0.037, p = 0.010 respectively). In multivariate analysis, advanced age is significantly associated with increased mortality risk in CRS 1 patients (p = 0.030), while beta-blocker use is considered a protective factor (p = 0.014). Conclusion: Our study identifies several key factors associated with outcomes in type 1 CRS. Male gender, tachyarrhythmia, and hypertension are linked to early-onset AKI. The use of diuretics and the presence of anemia increase the risk of developing CRS1. Advanced age is significantly associated with higher mortality rates. Conversely, the use of beta-blockers appears to be protective in this patient population. .

Peritoneal dialysis for chronic cardiorenal syndrome:Lessons learned from ultrafiltration trials

The current models of cardiorenal syndrome(CRS) are mainly based on a cardiocentric approach; they assume that worsening renal function is an adverse consequence of the decline in cardiac function rather than a separate and independent pathologic phenomenon. If this assumption were true,then mechanical extraction of fluid(i.e.,ultrafiltration therapy) would be expected to portend positive impact on renal hemodynamics and function through improvement in cardio-circulatory physiology and reduction in neurohormonal activation. However,currently available ultrafiltration trials,whether in acute heart failure(AHF) or in CRS,have so far failed to show any improvement in renal function; they have reported no impact or even observed adverse renal outcomes in this setting. Moreover,the presence or absence of renal dysfunction seems to affect the overall safety and efficacy of ultrafiltration therapy in AHF. This manuscript briefly reviews cardiorenal physiology in AHF and concludes that therapeutic options for CRS should not only target cardio-circulatory status of the patients,but they need to also have the ability of addressing the adverse homeostatic consequences of the associated decline in renal function. Peritoneal dialysis(PD) can be such an option for the chronic cases of CRS as it has been shown to provide efficient intracorporeal ultrafiltration and sodium extraction in volume overloaded patients while concurrently correcting the metabolic consequences of diminished renal function. Currently available trials on PD in heart failure have shown the safety and efficacy of this therapeutic modality for patients with chronic CRS and suggest that it could represent a pathophysiologically and conceptually relevant option in this setting.

Fluid overload as a major target in management of cardiorenal syndrome:Implications for the practice of peritoneal dialysis

Congestion is an integral component of cardiorenal syn-drome and portends an adverse impact on the outcomes. Recent studies suggest that congestion has the ability ofmodulating the interactions between the kidney and the heart in this setting. Peritoneal dialysis （PD） is a home-based therapeutic modality that is not only offered to patients with end-stage renal disease to provide solute clearance and ultrafltration, but it has also been used in patients with refractory heart failure and fuid overload to help optimize volume status. Several uncontrolled studies and case series have so far evaluated the role of PD in management of hypervolemia for patients with heart failure. They have generally reported favorable results in this setting. However, the data on the outcomes of patients with end-stage renal disease and concomitant heart failure is mixed, and the proposed theoretical advantages of PD might not translate into improvedclinical endpoints. Congestion is prevalent in this patient population and has a signifcant effect on their survival. As studies suggest that a significant subset of patients with end-stage renal disease who receive PD therapy are hypervolemic, suboptimal management of congestion could at least in part explain these conficting results. PD is a highly fexible therapeutic modality and the choice oftechniques, regimens, and solutions can affect its ability for optimization of fluid status. This article provides an overview of the currently available data on the role and clinical relevance of congestion in patients with cardiorenal syndrome and reviews potential options to enhance decongestion in these patients.

Impact of erythropoietin therapy on cardiorenal syndrome:A systematic review with meta-analysis

BACKGROUND Heart and kidney dysfunction frequently coexist in patients with acute heart failure due to the overlap between these two organ systems.Cardiorenal syndrome(CRS)results from pathology occurring in the heart and kidneys along with the consequences of dysfunction in one organ contributing to dysfunction in the other and vice versa.AIM To evaluate the use of erythropoietin(EPO)in patients with CRS and its effects on hemoglobin(Hb),major cardiovascular(CV)events,and hospitalization rates.METHODS On February 24,2022,searches were conducted using PubMed,MEDLINE,and EMBASE,and 148 articles were identified.A total of nine studies were considered in this systematic review.We assessed the included articles based on the National Heart,Lung,and Blood Institute quality assessment tools for controlled intervention and observational cohort or cross-sectional studies.An assessment of bias risk was conducted on the chosen studies,and data relevant to our review was extracted.RESULTS The systematic review of these studies concluded that most existing literature indicates that EPO improves baseline Hb levels and decreases myocardial remodeling and left ventricular dysfunction without reducing CV mortality.In addition,the effect of EPO on the hospitalization rate of patients with CRS needs to be further studied since this relationship is unknown.Future studies,such as randomized controlled clinical trials and prospective cohort studies,should be conducted to enhance the literature on the potential of EPO therapy in patients with CRS.CONCLUSION Our systematic review suggests that EPO therapy may have a significant role in managing CRS.The review highlights the potential benefits of EPO in improving baseline Hb levels,reducing the risk of major CV events,improving cardiac remodeling,myocardial function,New York Heart Association class,and B-type natriuretic peptide levels.However,the effect of EPO treatment on hospitalization remains unclear and needs further exploration.

Evidence based review of management of cardiorenal syndrome type 1

Cardiorenal syndrome(CRS)type 1 is the development of acute kidney injury in patients with acute decompensated heart failure.CRS often results in prolonged hospitalization,a higher rate of rehospitalization,high morbidity,and high mortality.The pathophysiology of CRS is complex and involves hemodynamic changes,neurohormonal activation,hypothalamic-pituitary stress reaction,inflammation,and infection.However,there is limited evidence or guideline in managing CRS type 1,and the established therapeutic strategies mainly target the symptomatic relief of heart failure.This review will discuss the strategies in the management of CRS type 1.Six clinical studies have been included in this review that include different treatment strategies such as nesiritide,dopamine,levosimendan,tolvaptan,dobutamine,and ultrafiltration.Treatment strategies for CRS type 1 are derived based on the current literature.Early recognition and treatment of CRS can improve the outcomes of the patients significantly.

Range of adiposity and cardiorenal syndrome

Obesity and obesity-related co-morbidities,diabetes mellitus,and hypertension are among the fastest-growing risk factors of heart failure and kidney disease worldwide.Obesity,which is not a unitary concept,or a static process,ranges from alterations in distribution to the amount of adiposity.Visceral adiposity,which includes intraabdominal visceral fat mass and ectopic fat deposition such as hepatic,cardiac,or renal,was robustly associated with a greater risk for cardiorenal morbidity than subcutaneous adiposity.In addition,morbid obesity has also demonstrated a negative effect on cardiac and renal functioning.The mechanisms by which adipose tissue is linked with the cardiorenal syndrome(CRS)are hemodynamic and mechanical changes,as well neurohumoral pathways such as insulin resistance,endothelial dysfunction,nitric oxide bioavailability,renin-angiotensin-aldosterone,oxidative stress,sympathetic nervous systems,natriuretic peptides,adipokines and inflammation.Adiposity and other associated co-morbidities induce adverse cardiac remodeling and interstitial fibrosis.Heart failure with preserved ejection fraction has been associated with obesity-related functional and structural abnormalities.Obesity might also impair kidney function through hyperfiltration,increased glomerular capillary wall tension,and podocyte dysfunction,which leads to tubulointerstitial fibrosis and loss of nephrons and,finally,chronic kidney disease.The development of new treatments with renal and cardiac effects in the context of type 2 diabetes,which improves mortality outcome,has highlighted the importance of CRS and its prevalence.Increased body fat triggers cellular,neurohumoral and metabolic pathways,which create a phenotype of the CRS with specific cellular and biochemical biomarkers.Obesity has become a single cardiorenal umbrella or type of cardiorenal metabolic syndrome.This review article provides a clinical overview of the available data on the relationship between a range of adiposity and CRS,the support for obesity as a single cardiorenal umbrella,and the most relevant studies on the recent therapeutic approaches.

Hypertension, type Ⅳ cardiorenal syndrome and chronic kidney disease: Pathophysiological and therapeutical approach

Hypertension represent one of the most important comorbid factors in chronic kidney disease(CKD) patients and its prevalence increases from 65% to 95% according to glomerular filtration rate decline. CKD patients need to maintain their blood pressure levels into 130/80 mm Hg according to most recent guidelines. Despite of many therapeutic agents, achievement of ideal blood pressure levels remains so far from the ideal ones. Hypertensive disease represent most important risk factor to develop a type Ⅳ cardiorenal syndrome, while prevalence of end stage renal disease is still raising and it represents worldwide epidemiological challenge. Correct management of hypertensive disease can obtain better control on CKD progression.

Renal Profile of Patients with Cardiorenal Syndrome: Nephrology and Cardiology Department Experience of the University Hospital IBN SINA of Rabat

Introduction: Cardio-renal syndrome (CRS) is a complex pathophysiological entity affecting the heart and kidneys in which acute or chronic dysfunction of one organ can induce acute or chronic dysfunction of the other organ. Five types of CRS have been described. Methods: The study explored the prevalence and types of Cardiorenal Syndrome (CRS) at CHU Ibn Sina in Rabat. Over a year, 120 CRS patients were assessed, excluding those with end-stage chronic renal failure. We analyzed the epidemiological, clinical, therapeutic and evolutionary profile of these patients. Results: The average age of our patients is 67.8 ± 12 years, with extremes ranging from 39 years to 92 years. The sex ratio is 1.35. The different types of CRS types (1, 2, 4 and 5) were noted respectively in 28.4%, 20.8%, 5%, 45.8%, however, we did not note patients having CRS type 3. On the renal level, we noted acute renal failure (ARF) in 51.6% of patients, of whom 61.3% had functional ARF and 38.7% presented with acute tubular necrosis. Chronic renal failure (CRF) is found in 48.4% of cases, of which 39% are at stage III and 61% are at stage IV. The etiology of CKD is dominated by hypertensive nephropathy (72.4%) followed by diabetic nephropathy (60.3%). Therapeutically diuretics are administered in 51% of our patients. We used hemodialysis in 9.1% of patients who are resistant to diuretics. Vasoactive drugs are used in 9.5% of our patients. Mortality risk factors for patients with CRS are significantly related to advanced age, long hospital stay, type 1 CRS, re-hospitalization, acute pulmonary edema (APE), use of hemodialysis, right heart failure (RHF), valvulopathy and hemodynamic instability (OR = 1.15, p = 0.01;OR = 4.5, p = 0.03;OR = 5.2, p = 0.019;p Conclusion: CRS type 5 was most common, with hypertension and diabetes being primary causes of Chronic Kidney Disease. Mortality factors were linked to acute pulmonary edema, hemodialysis, right heart failure, valvulopathy, and re-hospitalization.

PCI术与CKD患者CRS发病率的相关研究

目的探讨经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)对慢性肾脏疾病(chronic kidney disease,CKD)患者1型心肾综合征(cardiorenal syndrome,CRS)发病率的影响。方法发生急性心肌梗死(acute myocardial infarction,AMI)的84例CKD患者,根据住院期间是否发生急性肾损伤(acute kidney injury,AKI)分为1型CRS组和无CRS组,对两组患者PCI治疗情况、造影剂用量、血清尿素氮、血清肌酐和死亡率进行统计学分析。结果 84名CKD合并AMI患者有37例发生1型CRS(44%),1型CRS组患者与无CRS组患者PCI治疗比例(48.6%vs 53.2%,P>0.05),造影剂用量(130±48 ml vs 148±55 ml,P>0.05)均无统计学差异,43例行PCI治疗的患者手术前后血清肌酐值变化无显著差异(140.8±40.4 vs 141.2±63.7 umol/l,P>0.05),其中22名患者PCI术后血肌酐显著下降(153.9±39.7 vs 105.9±22.9 umol/l,P<0.01)。结论本组资料提示PCI术未增加CKD患者1型CRS发病率。

益气温阳活血利水方对CRS患者炎性反应的影响

目的:探讨炎性反应与心肾综合征(CRS)发病的相关性,观察益气温阳活血利水方对CRS患者炎性反应的影响。方法:选取2014年1月至2015年7月入住我院心内科、肾内科及ICU的患者共243例,最终纳入研究232例,根据心肾功能水平将入选患者分为对照组(A组59例),单纯心衰组(B组61例),单纯肾衰组(C组62例),CRS(D组61例)。对各组受试者入院24h及应用益气温阳活血利水方满疗程后空腹抽取静脉血,分别测定患者治疗前后白介素-6(IL-6)、细胞间粘附因子-1(sICAM-1)、肿瘤坏死因子α(TNF-α)、血清淀粉样蛋白A(SAA)水平,均采用分光比色法。对照组、单纯心衰组及单纯肾衰组采用西医对症治疗,CRS组在西医治疗基础上加用益气温阳活血利水方治疗,4组疗程均为20d,疗程结束后对比4组患者炎性反应改善情况。结果:B组、C组、D组治疗前IL-6、sICAM-1、TNF-α、SAA水平均高于A组,D组治疗前IL-6、sICAM-1、TNF-α、SAA水平均高于A组、B组及C组,差异有统计学意义(P<0.05)。B组、C组、D组治疗后IL-6、sICAM-1、TNF-α、SAA水平均有所降低,D组治疗后IL-6、sICAM-1、TNF-α、SAA水平降低幅度均大于B组、C组,差异均有统计学意义(P<0.05);A组治疗前后IL-6、sICAM-1、TNF-α、SAA水平比较无明显改变,差异均无统计学意义(P<0.05)。结论:炎性反应与CRS发病密切相关,益气温阳活血利水方能够改善CRS患者炎性反应。

Impact of Baseline LDL-C and Lp(a) Elevation on Coronary Revascularization in Patients with Acute Coronary Syndrome One-Year after First Percutaneous Coronary Intervention

Objective: The aim of this study was to investigate the effect of Lipoprotein-a [Lp(a)] on Coronary Revascularizaton (CR) on one year follow up in patients with Acute Coronary Syndrome (ACS) after the first Percutaneous Coronary Intervention (PCI). Method: A retrospective study was designed. A total of 475 patients that underwent their first PCI treatment due to ACS between January 2016 and December 2017 were recruited and followed for one year at the Zhongda Hospital, China. The clinical end point after first PCI was prevalence of Major Adverse Cardiovascular Events (MACE) including nonfatal Myocardial Infarction (MI), cardiovascular death, ischemic stroke and Coronary Revascularization (CR). According to the cut point of Lp(a), participants were divided into low Lp(a) subgroup (Lp(a) mg/L) and high Lp(a) subgroup (Lp(a) ≥ 300 mg/L). Furthermore, based on baseline Low Density Lipoprotein Cholesterol (LDL-C) level, participants were divided into low LDL-C (LDL-C mmol/L) and high LDL-C (LDL-C ≥ 1.8 mmol/L) subgroups. Results: The number of prevalence of CR was higher with elevated serum Lp(a) in both low LDL-C subgroup and high LDL-C subgroup, and was significantly different in both the low LDL-C subgroup and high LDL-C subgroup (p = 0.009 and p = 0.006, respectively). Multivariate Cox-hazard regression analysis for CR showed increase in serum LDL-C and Lp(a) increased prevalence of CR by 1.514 and 1.002 folds respectively. Furthermore, Kaplan-Meier cumulative survival curves showed that increased prevalence of CR within one year after first PCI in patients with high Lp(a) [log rank p = 0.000]. Conclusion: Baseline increase of serum LDL-C and Lp(a) significantly increases the prevalence of CR after first PCI within one year. It indicates that after PCI treatment, in patient with serum LDL-C and Lp(a) elevation, treatment with high-dose statin therapy or PCSK9 inhibitors may alleviate the adverse effects imposed by Lp(a) elevation.

microRNA-141与HMGB1通路在不同程度心肾综合征中的表达及临床意义

目的研究心肾综合征(cardiorenal syndrome, CRS)患者外周血中microRNA-141(miR-141)与重组人高迁移率族蛋白B1(HMGB1)通路的表达,探讨其与CRS发生、发展之间的关系。方法收集2017年1月至2018年12月入住东营市胜利油田中心医院重症医学科的CRS患者80例及同期体检中心40例健康志愿者外周血标本,按照2010年改善全球肾脏病预后组织/急性透析质量倡议(KDIGO/ADQI)共识将患者分为急性心肾综合征(CRS Ⅰ型)和慢性心肾综合征(CRS Ⅱ型)各40例。检测血清B型钠尿肽前体(NT-proBNP)、超敏C反应蛋白(hs-CRP)、血肌酐(SCr)、左室射血分数(LVEF)、二尖瓣口舒张早期峰值血流速度(E峰)、舒张晚期峰值血流速度(A峰),计算E/A比值。运用RT-PCR法及Western blot法检测外周血标本中miR-141、HMGB1、 Beclin-1及自噬标志物(LC3)蛋白的表达情况并进行对比。结果 CRS I型患者常规指标NT-proBNP、hs-CRP、SCr、LVEF、E/A比值均高于CRSⅡ型患者,差异有统计学意义(P<0.05);RT-PCR结果显示,miR-141表达量在正常组、CRSⅠ组及CRSⅡ组分别为(1.64±0.17)、(0.58±0.12)及(1.21±0.28),两个研究组表达均低于正常组,且CRS Ⅰ组表达最低(P<0.05);HMGB1-mRNA在正常组、CRSⅠ组及CRSⅡ组中表达水平分别为(0.81±0.31)、(2.23±0.35)及(1.61±0.42),两个研究组表达均高于正常组,且CRSⅠ组表达最高(P<0.05);Western blot结果显示, HMGB1、Beclin-1和LC3在CRSⅠ型中的表达量分别为(1.69±0.21)、(1.89±0.35)、(1.94±0.28),均高于CRSⅡ型(1.31±0.29)、(1.39±0.29)、(1.34±0.31),差异有统计学意义(P<0.05),且两组表达均高于正常组(0.61±0.23)、(0.64±0.12)、(0.51±0.22),差异均有统计学意义(P<0.05)。结论 miR-141在CRSⅠ型患者血清中表达下降,与miR-141通过影响HMGB1的水平从而影响自噬水平,进而导致CRS的发生、发展有关,故miR-141可能为CRS潜在的治疗靶点。

芪苈强心胶囊联合阿托伐他汀治疗2型心肾综合征疗效及对血清hs-CRP、D-D、ET-1的影响

目的观察芪苈强心胶囊联合阿托伐他汀治疗2型心肾综合征(CRS)的疗效及对血清超敏C反应蛋白(hs-CRP)、D-二聚体(D-D)、内皮素-1(ET-1)的影响。方法将98例2型CRS患者随机分为观察组49例和对照组49例,2组均给予强心、利尿、扩管等常规治疗,对照组在常规治疗基础上给予阿托伐他汀钙治疗,观察组在对照组治疗基础上给予芪苈强心胶囊口服,疗程均为12周。观察2组治疗前后心功能(心脏结构功能、心电图)、肾功能、肾动脉血流指标及血清hs-CRP、D-D、ET-1水平变化情况。结果 2组治疗后左室射血分数(LVEF),左室舒张末期内径(LVEDD),N-末端脑钠肽前体(NT-pro BNP)水平,心电图中心室率、QRS波时限、QT间期(QTc),血肌酐(SCr)水平,肾小球滤过率(GFR),血清胱抑素C水平,肾动脉内径(D),肾动脉收缩期峰值血流速度(Vmax),肾动脉阻力指数(RI)较治疗前均明显改善(P均<0.05),且观察组改善情况显著优于对照组(P均<0.05);2组治疗后血清hs-CRP、D-D、ET-1水平均明显降低(P均<0.05),观察组上述指标均显著低于对照组(P均<0.05)。结论芪苈强心胶囊联合阿托伐他汀治疗2型CRS疗效确切,能够显著改善患者的心、肾功能,其机制可能与抑制炎性反应、改善高凝状态以及血管内皮功能有关。

SARS的胸部CR和CT动态改变

目的 :研究SARS胸部CR和CT的动态改变。材料和方法 :回顾性分析和研究 47例SARS一系列胸部CR和CT资料。结果 :47例均有异常发现。起病 1～ 3天 ,异常发现包括单发小圆形磨玻璃密度影 2 0例 ,小结节 2 1例 ,单发大结节 3例和局部磨玻璃斑片影 3例。 74.5 % ( 3 5 /4 7)位于单侧肺 ,63 .8% ( 3 0 /4 7)分布于中下肺野 ,63 .8% ( 3 0 /4 7)位于中外带。发病后 1周病变迅速进展 ,范围扩大 2 7例 ,病变增大或双侧侵犯 10例 ,在磨玻璃密度影内出现结节或带条影 10例。发病后 2～ 3周 ,病变继续增大 10例 ,肺实变 8例和肺不张 3例 ,但 2 6例病变开始吸收。出院后 2周 ,6例胸部CR示残留条索或斑片影 ,但其中 1例 2周后再胸部CR复查显示残留索条影完全吸收。结论 :SARS的胸部CR和CT的动态改变能反映其病理改变 ,并为临床诊疗提供重要和可靠的信息。

Cardiorenal syndrome： pathophysiological mechanism, preclinical models, novel contributors and potential therapies

Objective To review the current knowledge about the pathophysiological mechanisms,preclinical models,novel contributors and potential therapies of cardiorenal syndrome.Data sources The literature concerning cardioranal syndrome in this review was collected from PubMed published in English up to January 2014.Study selection Original articles and critical reviews related to cardiorenal syndrome were selected and carefully analyzed.Results Cardiorenal syndrome is a condition characterized by kidney and heart failure where failure of one organ worsens the function of the other thus further accelerating the progressive failure of both organs.The pathophysiology of cardiorenal syndrome is not fully understood,but may be caused by a complex combination of neurohormonal system activation,endothelial dysfunction,proteinuria,oxidative stress,uremic toxins and other factors.Managing cardiorenal syndrome is still a major therapeutic challenge in clinical practice because many of the drugs used to control heart failure can worsen renal function,and vice versa.Non-dialyzable uremic toxins,such as indoxyl sulfate,causing detrimental effects on the heart and kidney as well as stimulation of inflammatory responses,may be an effective therapeutic target for cardiorenal syndrome.Conclusions Suitable disease models of cardiorenal syndrome are urgently needed to investigate the pathophysiology and effective therapeutic approaches to the condition.Non-dialyzable protein-bound uremic toxins that may have cardiac and renal effects may provide therapeutic benefit to cardiorenal syndrome patients.

尿KIM-1在Ⅰ型心肾综合征患者选择CRRT治疗时机中的应用价值

目的:探讨尿肾损伤分子-1(KIM-1)在Ⅰ型心肾综合征(CRS)患者早期选择连续性肾脏替代治疗(CRRT)治疗中的参考价值。方法:选择温州市人民医院2015年07月~2018年07月收治的Ⅰ型CRS患者,确诊后24 h内收集患者尿液标本,用酶联免疫吸附测定法(ELISA法)检测尿KIM-1水平,同时统计确诊Ⅰ型CRS之后72 h内接受CRRT的机率;根据患者72 h内是否需要接受连续性肾脏替代治疗(CRRT),分为非CRRT组和CRRT组,对两组进行对比分析;通过ROC曲线下面积评价尿液KIM-1浓度在预测Ⅰ型CRS患者需CRRT的价值。结果:总共收集132例Ⅰ型CRS患者,男性占44.7%,年龄21岁~96岁,平均(68.2±16.6)岁,57例患者最后接受CRRT治疗;2组患者在年龄、24 h呋塞米用量、NT-pro BNP、尿KIM-1浓度上在统计学上差异有统计学意义(P<0.05);尿KIM-1预测患者需CRRT治疗的ROC曲线下面积为0.803(95%CI:0.719~0.886,P<0.01);根据ROC曲线,将尿KIM-1早期预测Ⅰ型CRS患者需CRRT的切点值定为20.85 pg/ml.cr左右,此时预测的敏感度、特异度、约登指数和准确性分别是70.2%、86.7%、0.569和78.8%,阳性预测值和阴性预测值分别为79.5%和78.3%。结论:尿KIM-1水平在早期预测Ⅰ型CRS患者需CRRT治疗有一定的应用价值。

Gingerol improves cardiac function in rats with cardiorenal syndrome via inhibiting fibrosis

Background Cardiorenal syndrome(CRS)is a clinical syndrome with a complex mechanism,and there is currently no specific treatment.Gingerol was confirmed to possess anti-inflammatory,antioxidant and cardiotonic properties as cardiovascular pharmacological effects.However,in vivo studies have yet to prove that it can improve cardiac function and inhibit fibrosis in rats with cardiorenal syndrome.Methods In this study,34 male Sprague-Dawley(SD)rats were randomly divided into control(n=9),model(n=12)and gingerol groups(n=13).The model and the gingerol groups underwent ligation of the left anterior descending coronary artery and 5/6 subtotal nephrectomy to construct a type 2 cardiorenal syndrome rat model.The rats in gingerol group were injected intraperitoneally with 50 mg/kg gingerol.The same amount of saline was administered to both the control and the model groups.Following 4 weeks of treatment,the rat cardiac function and myocardial fibrosis were evaluated by cardiac ultrasound and blood biochemistry.Results Biochemical results showed that the brain natriuretic peptide(BNP)levels of gingerol group decreased(P<0.05).Cardiac ultrasound revealed that gingerol improved cardiac systolic function and ventricular remodeling(P<0.05).The systolic function of the model group was significantly decreased compared with the control group.Masson staining confirmed that the fibrosis area in the model group was significantly augmented than that in the control group,while the area of fibrosis in the gingerol group was diminished compared to the model group(P<0.01).Moreover,immunofluorescence showed that compared with the control group,the expression of collagen 1,TGF-β1 andα-SMA was significantly increased in the model group,and both collagen deposition and the expression of collagen I,TGF-β1 andα-SMA decreased in gingerol group.Immunohistochemistry revealed that the expression of collagen 1 andα-SMA was significantly increased in the model group compared with the control group,while it was decreased in gingerol group(P<0.05).Conclusions Gingerol can improve the cardiac function and cardiac fibrosis in rats with cardiorenal syndrome.

1例心源性脑梗死后出血转化合并心肾综合征病人应用无创呼吸机治疗的护理

总结1例心源性脑梗死后出血转化合并心肾综合征病人应用无创呼吸机治疗的护理经验。护理要点:无创呼吸机辅助通气治疗的护理、液体及营养支持管理、静脉血栓的预防及处理、预防和控制感染、联合康复科制订渐进式康复方案、出院指导与随访。经过21 d的精心治疗和护理,病人病情稳定,顺利转回当地医院继续康复治疗。

AMI患者并发CRS1危险因素及预测模型构建

目的探讨急性心肌梗死(AMI)患者并发1型心肾综合征(CRS1)的危险因素并构建预测模型,旨在为后续临床防治方案制定及选择提供更多参考。方法回顾性纳入2016年1月-2022年1月于我院住院治疗AMI患者共964例,根据住院期间是否并发CRS1分组[未并发CRS1组(n=840)、并发CRS1组(n=124)],并在倾向性匹配后比较两组临床特征资料,采用多因素Logistic回归模型评价AMI患者并发CRS1的独立危险因素并构建预测模型,描绘ROC曲线分析相关独立危险因素及预测模型预测AMI并发CRS1的效能。结果964例AMI患者住院期间并发CRS1共124例,发生率为12.86%;倾向性匹配后未并发CRS1组、并发CRS1组均为110例。倾向性匹配后并发CRS1组心肌肌钙蛋白Ⅰ(cTnⅠ)峰值、N末端B型利钠肽原及白细胞计数水平均高于未并发CRS1组(P<0.05);并发CRS1组估算肾小球滤过率、白蛋白及血红蛋白水平均低于未并发CRS1组(P<0.05);Logistic多因素回归分析显示,基线eGFR下降、NT-proBNP升高、cTnⅠ峰值升高及WBC升高均是独立危险因素。预测模型预测AMI并发CRS1的ROC曲线下面积值为0.955(95%CI:0.926~0.984),特异度为0.936,敏感度为0.918。结论AMI患者如基线估算肾小球滤过率下降、N末端B型利钠肽原升高、cTnⅠ峰值升高及白细胞计数升高则在住院期间更易发生CRS1;基于上述指标构建的临床模型在预测CRS1发生方面具有良好的效能。