A combined clinical and biomarker approach to predict diuretic response in acute heart failure

Background: Poor diuretic response in acute heart failure is related to poor clinical outcome. The underlying mechanisms and pathophysiology behind diuretic resistance are incompletely understood. We evaluated a combined approach using clinical characteristics and biomarkers to predict diuretic response in acute heart failure (AHF). Methods and results: We investigated explanatory and predictive models for diuretic response—weight loss at day 4 per 40 mg of furosemide—in 974 patients with AHF included in the PROTECT trial. Biomarkers, addressing multiple pathophysiological pathways, were determined at baseline and after 24 h. An explanatory baseline biomarker model of a poor diuretic response included low potassium, chloride, hemoglobin, myeloperoxidase, and high blood urea nitrogen, albumin, triglycerides, ST2 and neutrophil gelatinase-associated lipocalin (r2 = 0.086). Diuretic response after 24 h (early diuretic response) was a strong predictor of diuretic response (β = 0.467, P < 0.001; r2 = 0.523). Addition of diuretic response after 24 h to biomarkers and clinical characteristics significantly improved the predictive model (r2 = 0.586, P < 0.001). Conclusions: Biomarkers indicate that diuretic unresponsiveness is associated with an atherosclerotic profile with abnormal renal function and electrolytes. However, predicting diuretic response is difficult and biomarkers have limited additive value. Patients at risk of poor diuretic response can be identified by measuring early diuretic response after 24 h

Qualität von Schweizer Informationsmedien im Zeitverlauf

Medien übernehmen eine zentrale Rolle für die Gesellschaft. Sie stellen Öffentlichkeit her, lenken die Aufmerk­samkeit des Publikums und ermöglichen im Idealfall eine kritische Reflexion über wichtige politische, wirtschaft­liche, kulturelle und soziale Probleme. Der digitale Strukturwandel der Öffentlichkeit setzt das Schweizer Me­dienwesen jedoch zunehmend unter Druck. Vor diesem Hintergrund ist es entscheidend zu analysieren, inwiefern Informationsmedien – gerade in Zeiten des Umbruchs – ihrer publizistischen Verantwortung nachkommen und die Bürger mit ausreichender Berichterstattungsqualität versorgen. Diese Studie zeigt, wie sich die Berichterstat­tungsqualität von insgesamt 64 Schweizer Medien im Zeitraum zwischen 2015 und 2018 verändert hat. Gesamt­haft betrachtet verlieren die untersuchten Angebote trotz anhaltender struktureller Medienkrise nur leicht an Qualität, und nicht alle Qualitätsdimensionen sind gleichermassen betroffen. Professionelle, journalistische Stan­dards wie beispielsweise ein sachlicher Berichterstattungsstil, ein substantieller Anteil an redaktioneller Eigen­leistung sowie das Transparentmachen von Quellen bleiben über die Jahre hinweg auf hohem Niveau. Das ist ein wichtiger Befund, weil eine hohe Professionalität im Informationsjournalismus vertrauensbildend aufseiten des Publikums wirkt. Im Gegenzug verlieren die untersuchten Angebote bei der Relevanz und speziell bei der Vielfalt an Qualität. Auch in den Bereichen Einordnungleistung, Beitragsrelevanz und inhaltliche Vielfalt zeigen sich signifikante Einbussen. Vor allem die erklärende, Hintergründe vermittelnde Politikberichterstattung hat über die Jahre deutlich abgenommen. Zudem gewinnen Softnews an Bedeutung, und innerhalb des Hardnewsbereichs findet eine Verschiebung des Berichterstattungsfokus von gesamtgesellschaftlichen Zusammenhängen hin zu einer stärkeren Fokussierung auf Personen statt

Combining diuretic response and hemoconcentration to predict rehospitalization after admission for acute heart failure

Background—Both diuretic response and hemoconcentration are indicators of decongestion and have individually been found to predict rehospitalization after admission for acute heart failure (HF). This study examines the value of combining diuretic response and hemoconcentration to better predict patients at low risk for rehospitalization after admission for acute HF. Methods and Results—Diuretic response (defined as weight change per 40 mg of furosemide on day 4 after admission) and hemoconcentration (change in hemoglobin at discharge or day 7) were tested both individually and combined to predict the risk of HF and cardiovascular rehospitalization 60 days after hospitalization for acute HF. Analyses were performed in 1180 patients enrolled in the Placebo-Controlled Randomized Study of the Selective Adenosine Receptor Antagonist Rolofylline for Patients Hospitalized With Acute Decompensated Heart Failure and Volume Overload to Assess Treatment Effect on Congestion and Renal Function (PROTECT) trial and validated in 1776 patients enrolled in the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan (EVEREST) trial. Poor diuretic response was associated with low systolic blood pressure, high blood urea nitrogen, and history of coronary revascularization in both data sets (all P<0.05). Hemoconcentration was mainly associated with better renal function (P<0.05). Patients who displayed both favorable diuretic response and hemoconcentration had a markedly lower risk of rehospitalization for HF in PROTECT (multivariable HR, 0.41; 95% CI, 0.24 to 0.70; P<0.001) compared with all other patients. This finding was confirmed in EVEREST (multivariable HR, 0.52; 95% CI, 0.33 to 0.82; P=0.004) for patients with favorable diuretic response and hemoconcentration compared with all other patients. Conclusions—Combining 2 indicators of decongestion, hemoconcentration and diuretic response improves risk prediction for early rehospitalization after an admission for acute HF and may provide clinicians with an easily accessible tool to identify low-risk patients

The Chronic Kidney Disease Epidemiology Collaboration equation outperforms the Modification of Diet in Renal Disease equation for estimating glomerular filtration rate in chronic systolic heart failure

Aims The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula estimates glomerular filtration rate (GFR) better than the simplified Modification of Diet in Renal Disease (sMDRD) formula in numerous populations. It has not previously been validated in heart failure patients. Methods and results The GFR was measured in 120 patients with chronic systolic heart failure (CHF) using [I-125]iothalamate clearance (GFR(IOTH)) and estimated using the sMDRD and CKD-EPI equations. Accuracy, bias, and prognostic performance were compared. Cockcroft-Gault, CKD-EPI serum cystatin C, and CKD-EPI creatinine-serum cystatin C equations were compared in secondary analyses. Mean age was 59 +/- 12 years, 80% were male. Mean LVEF was 29 +/- 10%. Mean GFR(IOTH) was 74 +/- 27 mL/min/1.73 m(2), and mean estimated GFR was 66 +/- 23 mL/min/1.73 m(2) (CKD-EPI) and 63 +/- 21 mL/min/1.73m(2) (sMDRD). CKD-EPI showed less bias than sMDRD (-8 +/- 15 vs. -11 +/- 16 mL/min/1.73 m(2), P <0.001). Both equations underestimate at higher and overestimate at lower GFR(IOTH). Eleven patients (9%) were accurately reclassified into lower CKD classes with CKD-EPI. Cockcroft-Gault showed lower bias (-3 +/- 16 mL/min/1.73 m(2)) but worse precision and accuracy. Cystatin C-based estimation showed the lowest bias (-3 +/- 14 mL/min/1.73 m(2)) and the best precision and accuracy. Prognostic value did not differ between all GFR estimates Conclusion The CKD-EPI equation more accurately estimates measured GFR than the sMDRD equation in CHF patients, with less bias and greater accuracy and precision. The prognostic power of all GFR assessments was equivalent. Based on better performance and equal risk prediction, we believe the CKI-EPI equation should be the preferred creatinine-based GFR estimation method in heart failure patients, particularly those with preserved or moderately impaired renal function

MicroRNAs relate to early worsening of renal function in patients with acute heart failure

Background: Deregulation of microRNAs (miRNAs) may be involved in the pathogenesis of heart failure (HF) and renal disease. Our aim is to describe miRNA levels related to early worsening renal function in acute HF patients. Method and results: We studied the association between 12 circulating miRNAs and Worsening Renal Function (WRF; defined as an increase in the serum creatinine level of 0.3 mg per deciliter or more from admission to day 3), absolute change in creatinine and Neutrophil Gelatinase Associated Lipocalin (NGAL) from admission to day 3 in 98 patients hospitalized for acute HF. At baseline, circulating levels of all miRNAs were lower in patients with WRF, with statistically significant decreased levels of miR-199a-3p, miR-423-3p, and miR-let-7i-5p (p-value &lt; 0.05). The increase in creatinine during the first 3 days of hospitalization was significantly associated with lower levels of miR-199a-3p, miR-27a-3p, miR-652-3p, miR-423-5p, and miR-let-7i-5p, while the increase in NGAL was significantly associated with lower levels of miR-18a-5p, miR-106a-5p, miR-223-3p, miR-199a-3p and miR-423-3p. MiR-199a-3p was the strongest predictor of WRF, with an Odds Ratio of 1.48 (1.061–2.065; p-value = 0.021) and a C-index of 0.701. Conclusions: Our results show that the levels of circulating miRNAs at hospital admission for acute HF were consistently lower in patients who developed worsening of renal function. MiR-199a-3p was the best predictor of WRF in these patients