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• W2080932081 abstract "To the Editor: Chronic kidney disease (CKD) has become increasingly prevalent in recent years, especially in elderly adults, and it has been estimated that approximately 50% of American people aged 70 and older have been diagnosed with CKD.1 Moreover, impaired kidney function is associated with all-cause and cardiovascular mortality in the oldest adults.2 Cardiorenal syndrome (CRS) is a heart and kidney disorder in which the acute or chronic dysfunction of one can induce an acute or chronic dysfunction of the other3 (Figure 1). This syndrome is divided into five types in relation to the interaction between the two organs, that is, because of hemodynamic and neurohumoral factors.4 In a previous study, the clinical features of CRS were described in a cohort of patients discharged from an internal medicine unit, with Type 1 appearing to be the most frequent one.5 Thus, the aim of the current study was to evaluate the prognosis of different types of CRS after adequate follow-up. The original population was described in a previous article.5 It consisted of 438 Caucasians, selected from among 2,998 individuals consecutively discharged from a 30-bed medical ward from June 2007 to December 2009 and diagnosed with Type 1 to 5 CRS according to the Acute Dialysis Quality Initiative criteria.3 Age, sex, smoking, diabetes mellitus history, congestive heart failure (CHF), ischemic heart disease, peripheral vascular disease, and cerebrovascular disease were analyzed. Serum creatinine levels assays were performed using the Jaffe method (Hitachi Modular, Roche Diagnostics, Mannheim, Germany). Renal function was also assessed as estimated glomerular filtration rate (eGFR) evaluated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula.6 All-cause mortality was the final end-point, and mean follow-up was 2.4 ± 1.4 years. Cox analysis was performed to detect which factors were independently associated with all-cause mortality. Data for survival analysis were obtained for 85.4% of the starting population (n = 374, 51.9% male). Mean age was 79.5 ± 7.8, mean serum creatinine was 2.0 ± 1.1 mg/dL, and eGFR was 31 ± 12 mL/min per 1.73 m2. One hundred forty-four deaths (38.7%) were recorded. The percentage of participants of each CRS type and the number who died and survived were: Type 1, 44.9%, 93 and 74 (P = .045); Type 2, 23.2%, 64 and 22 (P = .004); Type 3, 21.5%, 50 and 30 (P = .80); Type 4, 7.5%, 18 and 10 (P = .73); Type 5, 3.5%, 5 and 8 (P = .008). Survival curves of different types of CRS (P = .003) are shown in Figure 1. Cox regression analysis showed that all-cause mortality was independently associated with age (hazard risk (HR) = 1.049, 95% confidence interval (CI) = 1.023–1.075, P < .001) and eGFR (HR = 0.972, 95% CI = 0.957–0.988, P < .001). In older persons, renal function cannot appropriately be measured using serum creatinine, and eGFR is strongly suggested. It has been shown that the Cockcroft-Gault formula may be preferred in hospitalized older adults, because even if it slightly underestimates creatinine clearance, the Modification Diet in Renal Disease (MDRD) strongly overestimates it.7 It was decided to use the CKD-EPI equation in the current study because not all of the participants had poor renal function, and the MDRD formula works well when eGFR is less than 60 mL/min per 1.73 m2, and the Cockcroft-Gault formula measures creatinine clearance and not GFR.6 Considerable attention has recently been paid to renal disease in older adults, and new predictive tools have been proposed.8 In individuals aged 65 and older with an eGFR of less than 30 mL/min per 1.73 m2, the development of end-stage renal disease has been independently associated with age, CHF, systolic blood pressure, eGFR, and potassium and albumin levels.8 Therefore, it appears that CHF negatively affects the progression of renal dysfunction. One study9 assessed the efficacy of therapy on CRS, comparing a group of individuals randomly assigned to a stepped pharmacological-therapy algorithm with a comparable group of individuals randomly assigned to ultrafiltration and concluded that ultrafiltration was associated with a higher rate of adverse events during admission. Nevertheless, to the best of the knowledge of the authors of this letter, studies on long-term mortality in older persons with CRS are limited. Even if different types of CRS appear to exhibit different survival curves, at least in the group of elderly adults with heart and renal dysfunction in the current study, the main risk factors for all-cause mortality remain age and severity of renal failure. Future clinical trials in heart failure should take into consideration and include a representative number of elderly adults with impaired renal function, because significant improvement of clinical and hemodynamic parameters may be obtained with appropriate therapy.10 Supported in part by a research grant “Fondo Ateneo Ricerca—FAR,” University of Ferrara, Italy. Conflict of Interest: None. Author Contributions: All authors participated actively in study concept and design; acquisition, analysis, and interpretation of data; and preparation and review of manuscript. Fabbian: original idea, acquisition of data, patient care, statistical analysis, preparation of manuscript, final critical supervision. De Giorgi: acquisition of data, patient care, literature search, drafting manuscript, statistical analysis. Pala: acquisition of data, patient care, literature search, drafting manuscript. Mallozzi Menegatti: acquisition of data, patient care, literature search, drafting manuscript. Manfredini: original idea, acquisition of data, patient care, literature search, preparation of manuscript, final critical supervision. Sponsor's Role: None." @default.
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• W2080932081 date "2013-11-01" @default.
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• W2080932081 title "All-Cause Mortality in Elderly Adults Diagnosed with Cardiorenal Syndrome After an Internal Medicine Unit Admission" @default.
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• W2080932081 doi "https://doi.org/10.1111/jgs.12525" @default.
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