Heart Failure, Diabetes Mellitus, and Chronic Kidney Disease

Chronic kidney disease and its complications are one of the leading causes of morbidity, disability and mortality in the world population, due to both the widespread prevalence of arterial hypertension, diabetes mellitus and coronary heart disease, and the increase in life expectancy. In the terminal stage of chronic kidney disease, mortality from cardiovascular events increases significantly. This review examines the most common risk factors for stroke in end-stage kidney disease. The role of arterial hypertension, diabetes mellitus, chronic heart failure is discussed, taking into account common risk factors, hyperactivation of the renin-angiotensin-aldosterone system, the development of oxidative stress, volume overload with an increase in the size of the left atrium and a subsequent increase in the risk of thrombosis and stroke in patients with end-stage kidney disease on programmed hemodialysis. In addition, data are presented in the study of the contribution of bone mineral disorders to the occurrence of cerebral complications in this category of patients. Timely diagnosis of cardiovascular diseases and secondary prevention of stroke, including adequate antihypertensive, hypoglycemic therapy and correction of heart failure with blockers of the renin-angiotensin-aldosterone system, as well as the elimination of bone mineral disorders are currently a very popular approach to improving the quality of life and increased survival in the discussed category of patients. Understanding the pathogenetic mechanism of stroke in patients with end-stage kidney disease on programmed hemodialysis, with the study of risk factors in the development of an acute cerebrovascular accident, will help to develop a strategy for their management.

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Metformin Use and Clinical Outcomes Among Patients With Diabetes Mellitus With or Without Heart Failure or Kidney Dysfunction

Circulation ◽

10.1161/circulationaha.119.040144 ◽

2019 ◽

Vol 140 (12) ◽

pp. 1004-1014 ◽

Cited By ~ 17

Author(s):

Brian A. Bergmark ◽

Deepak L. Bhatt ◽

Darren K. McGuire ◽

Avivit Cahn ◽

Ofri Mosenzon ◽

...

Keyword(s):

Diabetes Mellitus ◽

Heart Failure ◽

Type 2 Diabetes ◽

Chronic Kidney Disease ◽

Type 2 Diabetes Mellitus ◽

Kidney Disease ◽

Cardiovascular Death ◽

Inverse Probability ◽

All Cause Mortality

Background: Metformin is first-line therapy for type 2 diabetes mellitus, although its effects on the cardiovascular system are unproved. Methods: In this post hoc analysis, patients in SAVOR-TIMI 53 (Saxagliptin and Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus) with baseline biomarker samples (n=12 156) were classified as ever versus never taking metformin during the trial period. Associations between metformin exposure and outcomes were estimated with inverse probability of treatment weighting Cox modeling for the composite end point of cardiovascular death, myocardial infarction, or ischemic stroke, as well as cardiovascular death and all-cause mortality, with biomarkers included as covariates. Additional sensitivity analyses included propensity score matching and Cox multivariable models. Results: Of the 12 156 patients with baseline biomarker samples, 8971 (74%) had metformin exposure, 1611 (13%) had prior heart failure, and 1332 (11%) had at least moderate chronic kidney disease (estimated glomerular filtration rate ≤45 mL·min −1 ·1.73 m −2 ). Metformin use was associated with no difference in risk for the composite end point (hazard ratio for inverse probability of treatment weighting, 0.92 [95% CI, 0.76–1.11]) but lower risk of all-cause mortality (hazard ratio for inverse probability of treatment weighting, 0.75 [95% CI, 0.59–0.95]). There was no significant relationship between metformin use and these end points in patients with prior heart failure or moderate to severe chronic kidney disease. Conclusions: In a cohort of 12 156 patients with type 2 diabetes mellitus and high cardiovascular risk, metformin use was associated with lower rates of all-cause mortality, including after adjustment for clinical variables and biomarkers, but not lower rates of the composite end point of cardiovascular death, myocardial infarction, or ischemic stroke. This association was most apparent in patients without prior heart failure or moderate to severe chronic kidney disease. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01107886.

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