2) This program is supported by educational grants from AstraZeneca, Bayer, and Boehringer Ingelheim Pharmaceuticals Inc. and Eli Lilly Company.
— @CKD_ce (@ckd_ce) October 6, 2022
4) If the canaries died while in the mine, it would alert the miners that they’ve been highly exposed to bad air and need to exit. https://t.co/VBytzPuhcX pic.twitter.com/gIoIuktP7f
— @CKD_ce (@ckd_ce) October 6, 2022
6) We’ve known that kidney dysfunction is an early warning of cardiac disease since….get this…1836! Dr. Bright described cases of individuals with ‘albuMENuria” (I know, I know) who, upon autopsy, had “lesions in the organs of circulation and respiration”.
— @CKD_ce (@ckd_ce) October 6, 2022
8) Today, we know that both low #eGFR and high albuminuria are associated with a greater incidence of #CV disease. To put this in perspective:
— @CKD_ce (@ckd_ce) October 6, 2022
10) The incidence of all forms of cardiac disease are increased: #Afib, #HF, #CAD, #stroke, valvular disorder. The common step appears to be the accelerated development of left ventricular hypertrophy (#LVH). pic.twitter.com/NgJ8Ao2be2
— @CKD_ce (@ckd_ce) October 6, 2022
12) The primary risk factor for #CVD in #CKD patients is….CKD itself! That’s not to say, however, that the traditional risk factors don’t play a role. Don’t forget that #hypertension, #DM, tobacco use 🚬(yup…a habit that’ll never, ever go away), dyslipidemia . . .
— @CKD_ce (@ckd_ce) October 6, 2022
14) Pathophysiology of heart disease in #CKD really boils down to LV mass and function. Nearly three-quarters of incident #ESKD patients have #LVH. It is purported that hypertrophy itself can reduce capillary density and create a perpetual oxygen supply-demand mismatch.
— @CKD_ce (@ckd_ce) October 6, 2022
16a) #Atherosclerosis does *not* appear to be the primary driving force for #LVH development. That has important therapeutic implications which we will discuss as we go along.
— @CKD_ce (@ckd_ce) October 6, 2022
17) Lastly, FGF23-#Klotho is also implicated in causing both vascular calcifications and #LVH.
— @CKD_ce (@ckd_ce) October 6, 2022
🔓https://t.co/Pdqv3AsgE7 (Tweets 10-13) pic.twitter.com/69My7YGk2J
19) Volume expansion results in stretching of the myocardial cells. Together, higher #afterload and #preload propel the development of #LVH. 🔓https://t.co/aj1Qq6kHdD pic.twitter.com/RvrTv1XagV
— @CKD_ce (@ckd_ce) October 6, 2022
21) Did you know? It’s c.
— @CKD_ce (@ckd_ce) October 6, 2022
Some of the more common diagnostic tests have limited utility in patients with #CKD. For example, chest pain is unreliable, with 50% of patients reporting chest pain and not having coronary artery obstruction at catheterization. pic.twitter.com/gH0mCF1hrT
22b) That’s not to say that one shouldn’t obtain an #ECG, but interpretation should be based on comparison with prior ECGs.
— @CKD_ce (@ckd_ce) October 6, 2022
24) Exercise stress testing isn’t reliable in #CKD or #ESKD patients because of the baseline abnormal ECG that many of these patients already have (see tweet 22). Moreover, many #dialysis patients aren’t able to reach the necessary heart rate for this test to be conducted.
— @CKD_ce (@ckd_ce) October 6, 2022
26) Coronary angiography is at the top of the list of valuable diagnostic testing, so why don’t more advanced CKD/ESKD patients receive it? In two words…#contrast #nephropathy.
— @CKD_ce (@ckd_ce) October 6, 2022
28) Cardiac #MRI is another useful test to elucidate structural changes in and around the heart. Many fear the contrast used in the MRI can precipitate nephrogenic systemic fibrosis, but this seems to be . . .
— @CKD_ce (@ckd_ce) October 6, 2022
30) CT coronary angiography (#CTCA) offers valuable diagnostic information in a less invasive manner than the standard diagnostic cardiac catheterization. It results in a calcium score which can be followed over time.
— @CKD_ce (@ckd_ce) October 6, 2022
32) And finally cardiac biomarkers: TnI, TnT, #BNP, N-terminal pro-B-type natriuretic peptide, hrCRP, and dimethylarginine. All are elevated in #ESKD patients at baseline and it is still unclear if early intervention based on these markers alters one’s cardiac prognosis.
— @CKD_ce (@ckd_ce) October 6, 2022
34) So how do we mitigate cardiac dysfunction in #CKD? Well, that’s a subject for another day—TOMORROW, in fact. Please join us again then for the remainder of this program and your link to CE/#CME! #cardiotwitter #nephtwitter #medtwitter #FOAMed @MedTweetorials
— @CKD_ce (@ckd_ce) October 6, 2022
36) We were asking about mitigating cardiac dysfunction in #CKD. There are multiple approaches, but the best is to limit progression CKD➡️ESKD. For that, early referral to a nephrologist is🔑. If that’s not possible (or if referral was delayed), here are some steps one can take.
— @CKD_ce (@ckd_ce) October 7, 2022
38) #Cholesterol: interestingly, cholesterol-lowering therapies haven’t shown to be as effective in the #CKD population. Perhaps because the main driver of cardiac disease is *not* atherosclerosis (tweet 16).
— @CKD_ce (@ckd_ce) October 7, 2022
40) Coronary #angiography is often performed in patients with advanced CKD/ESRD. The real risk of angiography is not contrast nephropathy (tweets 26-27), but rather a greater risk of post-procedure #stroke and #dialysis initiation . . .
— @CKD_ce (@ckd_ce) October 7, 2022
42) Beta-blockade: in the CKD/#ESKD population, not all beta-blockers are created equal. In 2 prospective & 1 retrospective trial of BB use in incident hemodialysis patients, bisoprolol resulted in⬇️ deaths, #HF, & #MIs than the more commonly prescribed metoprolol or carvedilol. pic.twitter.com/NkMl9vQwDj
— @CKD_ce (@ckd_ce) October 7, 2022
44) While the AMBER and DIAMOND trials showed patiromer to be an effective K-binder with MRA use, don’t forget that sodium zirconium silicate (#SZC) is also an option.
— @CKD_ce (@ckd_ce) October 7, 2022
46) For more on this important topic–the use of newer potassium binders to facilitate #RAASi therapy–go to other #accredited #tweetorials, still available for CE/#CME, at https://t.co/D9jsOpYu4i for programs by experts @ErinMichos @edgarvlermamd @md_pollack @sophia_kidney
— @CKD_ce (@ckd_ce) October 7, 2022
48) #Neprilysin inhibitors are another class of agents worthy of consideration. The PARADIGM-HF and UK-HARP-III trials suggest a cardio protective effect with the combination of sacubitril and an #ARB in #CKD patients. pic.twitter.com/VFXQDtagfU
— @CKD_ce (@ckd_ce) October 7, 2022
50) #Defibrillators. #ICDs are not often implanted in patients with advanced CKD/ESRD: perhaps for good reason. A meta-analysis showed an *increase* in mortality with ICD implantation in this patient population: 🔓https://t.co/F6sxX6pJCA pic.twitter.com/INgCYgfZfq
— @CKD_ce (@ckd_ce) October 7, 2022
52) McGuire et al gave us a great meta-analysis to assess kidney outcomes of 4 available #SGLT2i in pts with #T2D (🔓https://t.co/eYa5YIlQXQ). The SGLT2i data show the MOST consistent benefit for what #cardiometabolic metric?
— @CKD_ce (@ckd_ce) October 7, 2022
54) . . . with benefits for #HHF being the most consistent observation across the trials. But those kidney outcomes were impressive and have spurred much further study!
— @CKD_ce (@ckd_ce) October 7, 2022
56) Historically many cardiac-focused trials have excluded patients with advanced #CKD and/or #ESKD. Unsurprisingly, much of our understanding of heart disease in CKD is extrapolated from these trials, which is simply inadequate given the prevalence of CKD.
— @CKD_ce (@ckd_ce) October 7, 2022
58) Next, keep an eye out for the ALCHEMIST trial (MRAs in ESRD) (🔓https://t.co/GB1jVXlHqN) and further analyses of EMPEROR-Preserved (🔓https://t.co/CgSwSsPTOq).
— @CKD_ce (@ckd_ce) October 7, 2022
60a) There you have it. I hope you will follow us for the only accredited, serialized #tweetorials in #nephrology. Many thanks to my #NephTwitter and #CardioTwitter colleagues.
— @CKD_ce (@ckd_ce) October 7, 2022
61) So now, go claim your 0.75h CE/#CME credit! Just click on https://t.co/vzZul8teB9, and you'll have your certificate in 3 minutes or less. All free, all accredited, all expert authors, all the time . . . here at @ckd_CE. I am @nephondemand. Thanks for joining us!
— @CKD_ce (@ckd_ce) October 7, 2022