Abnormal liver function tests in acute heart failure: relationship with clinical characteristics and outcome in the PROTECT study

Aims: Episodes of acute heart failure (AHF) unfavourably affect multiple organs, which may have an adverse impact on the outcomes. We investigated the prevalence and clinical consequences of abnormal liver function tests (LFTs) in AHF patients enrolled in the PROTECT study. Methods and results: The LFTs comprised serial assessment of aspartate aminotransferase (AST), alanine aminotransferase (ALT) and albumin at baseline and during follow-up (daily until discharge, on days 7 and 14). The prevalence of abnormal LFTs (above upper limit of normal for AST and ALT or below lower limit of normal for albumin) was: at baseline AST 20%, ALT 12%, albumin 40%; and at day 14: AST 15%, ALT 9%, albumin 26%. Abnormal LFTs at baseline were associated with a higher risk of in-hospital death with odds ratios [95% confidence interval (CI)] of 3.5 (1.7–7.3) for AST, 3.9 (1.8–8.4) for ALT, and 2.8 (1.3–5.9) for albumin (all P < 0.01). Abnormal baseline and discharge LFTs had an unfavourable impact on 180-day mortality with hazard ratios (95% CI) for baseline AST, ALT, and albumin of 1.3 (1.0–1.7), 1.1 (1.0–1.2), 1.4 (1.1–1.8), respectively, and 1.5 (1.1–2.0), 1.5 (1.0–2.2), and 1.6 (1.2–2.1), for discharge AST, ALT, albumin, respectively (all P < 0.05). Analysis of LFTs trajectories (calculated as changes in LFTs over time) revealed that increasing AST and ALT on day 3 as well as decreasing albumin on day 4 were independent prognosticators of 180-day outcome (all P < 0.05). Conclusions: Abnormal LFTs are frequent in AHF at baseline and during hospital stay and predict worse outcomes. Whether this association is causal and what are the underlying mechanisms involved require further study

Diagnosis and Management of Heart Failure

Heart failure prevalence continues to rise globally. Regardless of the underlying etiology, heart failure remains a progressive disease, largely irreversible and end-stage heart failure requires transplantation. Book focuses on the challenges and recent advances of diagnosis, treatment and prevention of heart failure with or without associated comorbidities. We hope that readers will appreciate the wide breadth of topics and clinical utility of the articles and reviews included to this book collection

Investigating the Cardiovascular Effects of 12-months Home Based Nocturnal Haemodialysis versus. Conventional Haemodialysis Treatment: a Non-randomised Controlled Pilot Study

Living with CKD dramatically impacts an individual’s quality of life, often mandating frequent life-saving treatment in the form of haemodialysis; with its significant negative impact on cardiovascular morbidity and mortality. The cost to the individual and the NHS is substantial, with the UK ESRD population increasing by 8% year on year. The overall aim of this research was to examine the effect of nocturnal haemodialysis; an extended-hours therapy on plasma markers of oxidative stress and inflammation and compare cardiovascular outcomes with those attributed to conventional haemodialysis. The primary aim was to compare the effect of nocturnal haemodialysis on myocardial strain, as assessed by LV GLS using STE and cardiac biomarkers. The principal secondary aim was to assess the effect of nocturnal dialysis on the rate of increase of coronary calcification as a marker of coronary disease burden as assessed by CACS. In line with previous research, notably the landmark Alberta trial, FHN and FHNN trials, this thesis demonstrated an improvement in blood pressure control, serum phosphate and reduction in polypharmacy. The nocturnal group saw an improvement in LV GLS (p=0.04967) from a more significantly impaired baseline, a non-significant reduction in LVMi and no significant increase in CACS (6%). Contrasted with the conventional group where a 71.2% increase in CACS was observed (p=0.043). With regards to changes in systemic inflammation, a reduction in inflammatory marker IL-6 (p=0.04) was seen in the nocturnal group. Higher serum hepcidin levels were observed in CAC progressors than those with regression of CAC (p=0.045), where significant correlation of baseline hepcidin with relative CACS (p=0.037, r=0.9) was observed. This thesis provides new and detailed information on the assessment of cardiovascular disease in dialysis using LV GLS and CACS. Extended hours treatment with nocturnal haemodialysis significantly decreased progression of CAC compared with conventional haemodialysis. Progression appeared to be more dependent on levels of inflammation than deranged bone mineralisation with hepcidin the best predictor of an improvement in GLS and CAC progression. This information will add to the evidence-base and further enable clinicians to make person-centred therapy decisions for their ESRD patients

Pharmacocinétique de population du candesartan chez des patients atteints d’insuffisance cardiaque chronique

Contexte: L’insuffisance cardiaque (IC) est un syndrome clinique complexe regroupant un large spectre de mécanismes pathologiques qui peuvent altérer le fonctionnement de multiples organes, affectant ainsi la pharmacocinétique (PK) des médicaments. La modélisation pharmacocinétique de population (Pop-PK) consiste à appliquer des modèles non linéaires à effets mixtes dans le but de décrire l’exposition au traitement et quantifier la variabilité au niveau des paramètres PK. Objectif: Ce travail vise à évaluer par approche populationnelle la PK du candesartan en IC et à déterminer les covariables décrivant d’une façon statistiquement et cliniquement significative la variabilité au niveau de la clairance. Méthodes: Les données d’une étude pharmacogénomique ouverte, multicentrique et prospective ont été récupérées pour amorcer notre analyse. Le processus de modélisation et les simulations nécessaires sont réalisés à l’aide du logiciel NONMEM (Nonlinear Mixed Effects Modeling). Les covariables préliminaires ont été sélectionnées par des tests statistiques tels que la régression linéaire et l’ANOVA. Enfin, l’élaboration du modèle final est effectuée en utilisant le processus de sélection séquentielle « forward/backward ». Résultats: Un total de 281 patients caucasiens ont été inclus pour développer le modèle Pop-PK. Les données du candesartan ont été caractérisées par un modèle à un compartiment avec absorption de premier ordre et temps de latence. Le poids, l'âge, la fraction N-terminale du pro-peptide natriurétique de type b (NT_proBNP), le débit de filtration glomérulaire (DFG), le diabète, l'utilisation du furosémide et le sexe étaient les covariables sélectionnées préliminairement pour la clairance apparente (CL/F). Le modèle final développé pour la clairance apparente est représenté par l'équation suivante : CL/F (L/h) = 8.63*(Poids/82.45)0.963 * (DFG/74)0.56 * (0.682) Diabète * EXP0.138 Les simulations ont révélé qu'une diminution importante de la clairance orale (diminution de plus que 25 %) est obtenue en combinant les facteurs significatifs retenus dans le modèle final (patients ayant un faible poids corporel avec une insuffisance rénale modérée à sévère et patients diabétiques avec une insuffisance rénale faible à modérée). Nous avons constaté que les patients ayant ces combinaisons dans notre base de données présentaient des concentrations comparables à celles des autres patients malgré qu’ils aient toléré de plus faibles doses pendant la titration. Conclusion: La modélisation PK de population a servi comme une approche efficace pour caractériser la PK du candesartan en IC et pour identifier une sous-population à risque d’une exposition élevée. Le poids, le DFG et le diabète sont des prédicteurs indépendants de la clairance du candesartan en IC. Considérant ces facteurs, une approche plus individualisée de l'administration du candesartan est nécessaire chez les patients atteints d’IC.Context: Heart failure (HF) is a clinical condition that causes pathological changes all over the body affecting hence the pharmacokinetic of drugs. Population pharmacokinetic modeling (Pop-PK) consists in applying non-linear mixed-effects models to characterize treatment exposure and quantify PK parameters variability. Objective: The aim of this study was to investigate the pharmacokinetic (PK) of candesartan in HF patients while examining statistically and clinically significant covariates on estimated clearance using population pharmacokinetics (Pop-PK) modeling approach. Methods: Data from a prospective, multicenter, open label, pharmacogenomic study were available for this analysis. Modeling and simulations were conducted using Nonlinear Mixed-Effect Modeling software NONMEM. Preliminary selection of covariates was accomplished with statistical tests (linear regression and ANOVA). Final model development was performed using forward/backward selection approach on the preliminarily selected covariates. Results: A total of 281 Caucasian patients were included to develop the Pop-PK model. Candesartan data were characterized by a 1 compartment model with first order absorption and lag time. Weight, age, N-terminal pro b-type natriuretic peptide (NT_proBNP), estimated glomerular filtration rate (eGFR), diabetes, use of furosemide and sex were the preliminarily selected covariates for apparent clearance (CL/F). The final model developed for apparent clearance is represented by the following equation: CL/F (L/h) = 8.63*(Weight/82.45)0.963 * (eGFR/74)0.56 * (0.682) Diabetes * EXP0.138 Simulations revealed that an important decrease in oral clearance (decrease of more than 25%) is obtained with the combination of the significant factors retained in the final model (patients having low weight with moderately to severely impaired renal function and diabetic with mildly to moderately impaired renal function). Patients having these combinations in our database were found to achieve comparable concentrations to the rest of patients despite tolerating only lower doses. Conclusion: Population pharmacokinetic modeling provided an effective approach to characterize the PK of candesartan in HF and to identify a subpopulation at potential risk of high exposure. Weight, eGFR and diabetes are independent predictors of candesartan clearance in patients with HF. Considering these factors, a more individualized approach of candesartan dosing is needed in HF patients

Anthracycline-induced cardiotoxicity, a pathophysiology based approach for early detection and protective strategies

In this thesis the development of a pathophysiology-based method for the early evaluation of anthracycline-induced cardiotoxicity was described. We evaluated a comprehensive array of biomarkers, representing several aspects of anthracycline-induced cardiotoxicity, including cardiac injury and remodeling, free radical overload and the inflammation accompanying the injury. It was shown that predominantly the markers of cardiac injury may be suitable for the early detection of anthracycline-induced cardiotoxicity. In the second part of this thesis we evaluated a new, free-radical scavenging compound against anthracycline-induced cardiotoxicity using this approach. The failure of this compound to show efficacy against anthracycline-induced cardiotoxicity in our model suggests that a broader approach toward the mechanism of anthracycline-induced cardiotoxicity is necessaryUBL - phd migration 201

STRUCTURE-FUNCTION RELATIONSHIPS AND ACTION MECHANISM OF KRAIT NATRIURETIC PEPTIDE

Ph.DDOCTOR OF PHILOSOPH

Biomarkers in systemic scelrosis

Systemic sclerosis (SSc; scleroderma) is a chronic multisystem autoimmune disease that includes prominent skin involvement in all patients and is characterized by fibrosis, inflammation, and microvascular injury of the skin and internal organs. Clinical trial design for patients with systemic sclerosis (SSc) has been confounded by the heterogeneity of disease progression and lack of objective outcome measures. This has hampered identification of therapies for patients who have frequently fatal fibrotic complications. Direct pulmonary complications are the leading cause of death in SSc. For clinical trials in patients with diffuse cutaneous SSc, identification of a pharmacodynamic biomarker associated with clinical improvement would allow for alternative approaches to trial design. Furthermore, identification of a diagnostic biomarker for SSc complicated by pulmonary arterial hypertension (SSc-PAH) would provide a reliable non-invasive method for diagnosis of pulmonary arterial hypertension. Through the combination of high throughput technologies and clinical information we have identified three preliminary biomarkers for SSc: i) Two pharmacodynamic biomarkers for diffuse skin disease (dcSSc), one in using mRNA from skin biopsies and one using proteomic profiles from sera; ii) a serum based proteomic classifier for the screening and diagnostic evaluation of pulmonary arterial hypertension in systemic sclerosis. We show these biomarkers can be applied to assess changes in skin disease in dSSc patients over time and with further development could be used to supplement or replace the physical examination assessment (Modified Rodnan Skin Score, MRSS) as an outcome measure in clinical trials for dcSSc patients. Routine use of these biomarkers in SSc clinical trial design could expand treatment options for a patient population that currently has few if any treatment options that slow progression of disease. Furthermore we identified a serum biomarker for the major SSc pulmonary complication, SSc-PAH. This diagnostic SSc-PAH biomarker has the potential to be used as a screening tool in order to reduce the need for unnecessary invasive diagnostic procedures. This non-invasive screening method could lead to early diagnosis thus improving patient survival and aid in clinical management of a complication for which there are several treatments but which is still frequently fatal.2018-06-15T00:00:00