2) The program is intended for #HCPs & is supported by an independent educational grant from Bayer. Statement of accreditation and faculty disclosures at https://t.co/gvXca4GHMU. Follow this 🧵for 0.75hr 🆓 CE/#CMEcredit–all delivered right here on X!
— cardio-met (@cardiomet_CE) April 15, 2024
4) Let us extend this metaphor into #cardiorenal physiology and disease by looking at the cross talk between the heart and the kidneys
— cardio-met (@cardiomet_CE) April 15, 2024
🔓 https://t.co/8BUlLrfhOM pic.twitter.com/BlYERK0arR
5b) He further postulated that the final composition of the urine is the result of resorption processes taking place in the renal tubuli located downstream of the renal glomeruli
— cardio-met (@cardiomet_CE) April 15, 2024
5d) His work was published at a time when the physiological role of the kidneys was still being debated
— cardio-met (@cardiomet_CE) April 15, 2024
At that time, a natural force (rather than #bloodpressure) was thought to be the driving force for urine production
🔓 https://t.co/n4mHAfdKhX pic.twitter.com/QYRlmdBEjb
6b) Likewise, as a result of less glomerular filtration, the ensuing hypervolemia may lead to acute heart failure or aggravate a chronic heart failure (#CHF) condition
— cardio-met (@cardiomet_CE) April 15, 2024
Thus, the heart and kidneys are both functionally dependent on each other
🔓 https://t.co/n4mHAfdKhX
7b) Guyton contributed physiological research on the role of the peripheral circulation to blood pressure regulation, which, in turn, affects kidney function
— cardio-met (@cardiomet_CE) April 15, 2024
🔓 https://t.co/8kCqn2bNpu pic.twitter.com/0Gd1xfBA2c
7d) Thus, Carl Ludwig’s work laid the basis for further research on the autonomic control of circulation
— cardio-met (@cardiomet_CE) April 15, 2024
🔓 https://t.co/n4mHAfdKhX pic.twitter.com/AUS8CWQA1T
8b) And our understanding of the bi-directional links between cardiac and kidney function has expanded significantly since then pic.twitter.com/szaeHVAwqa
— cardio-met (@cardiomet_CE) April 15, 2024
9b) Although this classification has been of great value for awareness for researchers & clinicians, as well as the ID of pts, it is based largely on expert opinion. Data to support the distinction based on pathophys, tx, & prognosis are limited.
— cardio-met (@cardiomet_CE) April 15, 2024
🔓 https://t.co/Sicp7Wfapt
10a) Since the early 2000s, the definition of #cardiorenal syndrome #CRS has evolvedhttps://t.co/vANFxHGEnP pic.twitter.com/ds4LdIpoax
— cardio-met (@cardiomet_CE) April 15, 2024
10c) #Kidney dysfunction in heart failure is now also thought to develop as a result of reduced cardiac output, which results in increased cardiac congestion, increased right atrial pressure, and increased central venous pressure
— cardio-met (@cardiomet_CE) April 15, 2024
11a) The regulation of cardiac and kidney function involves a complex interplay between (neuro)hormones, sympathetic nervous activity, and filling statushttps://t.co/UXN1hXMCNZ
— cardio-met (@cardiomet_CE) April 15, 2024
11c) Increased sympathetic nervous activity can further enhance #RAAS-mediated fluid overload and increase systemic vasoconstriction#VisualArt by @medcomic pic.twitter.com/vyCom8fKKK
— cardio-met (@cardiomet_CE) April 15, 2024
12b) Cardiac and kidney dysfunction can be further accelerated by the presence of cardio-renal anemia, which can be triggered by reductions in hemoglobin, iron, #fetuin A and renal erythropoietin (#EPO), . . .
— cardio-met (@cardiomet_CE) April 15, 2024
12d) In a set of complex dynamic control systems, hyperphosphatemia can result in both the increased production of parathyroid hormone (#PTH) and/or fibroblast growth factor 23 (#FGF_23)
— cardio-met (@cardiomet_CE) April 15, 2024
13) Going back to our canary in the coal mine metaphor, what can we use as our canary to warn us of danger ahead?
— cardio-met (@cardiomet_CE) April 15, 2024
This table shows the associations of #albuminuria with #cardiovascular disease#Nephpearls #Cardiorenal
🔓 https://t.co/Hs5SFBUWtK pic.twitter.com/pKvzACeFIq
14b) The physiologic role of albumin is to maintain plasma oncotic pressure and to transport various endogenous and exogenous ligands through the bloodstream to target cells
— cardio-met (@cardiomet_CE) April 15, 2024
14d) Albuminuria involves structural damage in the glomerulus, which is associated with an increased risk for undesirable cardiovascular and kidney outcomes
— cardio-met (@cardiomet_CE) April 15, 2024
🔓 https://t.co/Hs5SFBUWtK pic.twitter.com/8bU1dYuj4V
15b) . . . because of the shared pathological processes with #CKD and because of compensatory mechanisms in chronic #cardiovascular disease #Nephpearls #Cardiorenal
— cardio-met (@cardiomet_CE) April 15, 2024
🔓 https://t.co/Hs5SFBUWtK pic.twitter.com/hNepVsHyE6
16b) In the @goKDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of #CKD, clinical terminology was changed to focus on #albuminuria rather than #proteinuria as albumin is the principal component of urinary protein in most kidney diseases
— cardio-met (@cardiomet_CE) April 15, 2024
16d) In addition, assays to measure #albumin are more precise & sensitive than those used to measure urine protein
— cardio-met (@cardiomet_CE) April 15, 2024
🔓 https://t.co/tm4Z3su46z#VisualAbstract by @AnnaGaddy pic.twitter.com/bc7YwPnko7
17b) It is also important to recognize that there are factors causing biological variation in urine albumin or urine protein, thereby significantly affecting the interpretation of these tests in certain circumstances #Nephpearls #Cardiorenal
— cardio-met (@cardiomet_CE) April 15, 2024
🔓 https://t.co/QZVjaGXnSp pic.twitter.com/5tmEJFBJC2
18b) There are several methods to detect albuminuria in daily clinical practice
— cardio-met (@cardiomet_CE) April 15, 2024
Studies examining the diagnostic accuracy of tests to quantify urine #albumin and other proteins usually compare tests with laboratory quantification from 24-hour urine collections
18d) Because #creatinine excretion in the urine is fairly constant throughout the 24 hour period, the measurement of ACR (or PCR) allows correction for variations in urinary concentration
— cardio-met (@cardiomet_CE) April 15, 2024
ACR is a suitable alternative to timed measurement of urine albumin loss
18f) The numeric equivalence of #ACR in mg/g (mg/mmol) to approximately g/d is based on the simple assumption that creatinine excretion rate (CER) approximates 1 gram/d (10 mmol/d)
— cardio-met (@cardiomet_CE) April 15, 2024
18h) Use of urinary albumin measurement as the preferred test for proteinuria detection will improve the sensitivity, quality, and consistency of approach to the early detection and management of kidney disease
— cardio-met (@cardiomet_CE) April 15, 2024
19a) Elevated levels of urine albumin are one of the earliest signs of #CKD and damage of the kidney microvasculature
— cardio-met (@cardiomet_CE) April 15, 2024
19c) Several guidelines recommend screening for #albuminuria @goKDIGO @ACCinTouch @American_Heart @ISHBP @AmDiabetesAssn #Nephpearls #Cardiorenal
— cardio-met (@cardiomet_CE) April 15, 2024
🔓 https://t.co/Hs5SFBUWtK pic.twitter.com/FWNinGZG36
20) Despite this however, there are factors that have been identified that contribute to low albuminuria testing rates
— cardio-met (@cardiomet_CE) April 15, 2024
🔓 https://t.co/Hs5SFBUWtK pic.twitter.com/hN5Ij0cpar
22a) There is significant emphasis on the importance of detecting CKD, and considerations for the optimal methods for staging of CKD, and how to establish chronicity and etiology
— cardio-met (@cardiomet_CE) April 15, 2024
🔓 https://t.co/QZVjaGXnSp pic.twitter.com/qfWXIbi9bf
22c) Early detection of any chronic disease, including #CKD, provides greater opportunities to reduce morbidity as treatments can be initiated earlier in the disease course
— cardio-met (@cardiomet_CE) April 15, 2024
23a) Practice Point 1.1.1.2 from @goKDIGO: Following incidental detection of elevated urinary albumin-to-creatinine ratio (#ACR), #hematuria, or low estimated GFR (#eGFR), repeat tests to confirm presence of CKD
— cardio-met (@cardiomet_CE) April 15, 2024
🔓 https://t.co/QZVjaGXnSp
23c) Monitoring #CKD through the surveillance of #albuminuria and #GFR serves to update staging for prognosis, identify timing of intervention strategies, and assess the effectiveness of specific treatments
— cardio-met (@cardiomet_CE) April 15, 2024
24a) Practice Point 2.1.2 from @goKDIGO: Assess #albuminuria and #GFR more often for individuals at higher risk of #CKD progression when measurement will impact therapeutic decisions
— cardio-met (@cardiomet_CE) April 15, 2024
24c In addition, progression risk may vary by the etiology of CKD within a specific stage based on GFR and albuminuria or proteinuria
— cardio-met (@cardiomet_CE) April 15, 2024
🔓 https://t.co/QZVjaGXnSp pic.twitter.com/igQRcnSplI
25b) Small fluctuations in #albuminuria or #proteinuria levels may not indicate disease progression
— cardio-met (@cardiomet_CE) April 15, 2024
Appreciation of factors that impact albuminuria and changes in the measure is also important for healthcare providers
🔓 https://t.co/QZVjaGXnSp pic.twitter.com/mlwpptiTiB
26b) However, changes in albuminuria within an individual have substantial variability, with large fluctuations expected given that the 95% CI around repeat ACR testing is approximately 50%
— cardio-met (@cardiomet_CE) April 15, 2024
26d) Conversely, reductions of the ACR by up to 50% are also consistent with random fluctuation
— cardio-met (@cardiomet_CE) April 15, 2024
🔓 https://t.co/QZVjaGXnSp pic.twitter.com/LUQ3ExXpFg
27b)
— cardio-met (@cardiomet_CE) April 15, 2024
🔑 It is well established that there is a strong association of #albuminuria with several manifestations of #CVD and CVD mortality
🔑 Despite this knowledge, rates of albuminuria screening in high-risk patients, such as those with diabetes or hypertension, are low
27d)
— cardio-met (@cardiomet_CE) April 15, 2024
🔑 Albuminuria diagnosis supports the identification of patients at risk of #CVD and #CKD and presents a crucial early opportunity to intervene with cardiorenal-protective therapy to slow disease progression and improve patient outcomes
🔓 https://t.co/Hs5SFBUWtK pic.twitter.com/ZDXkwVa6a9
28a) So, what have we learned? Elevated levels of WHAT are one of the earliest signs of CKD and damage of the kidney microvasculature?
— cardio-met (@cardiomet_CE) April 15, 2024
A. Urine Albumin
B. Serum Creatinine
C. Urine pH
D. Estimated GFR (calculated by CKD-EPI equation)
28c) Epidemiologic data demonstrate a strong relationship between the quantity of urine albumin with both kidney and CVD risk and observed CVD even at very low levels
— cardio-met (@cardiomet_CE) April 15, 2024
28d) It’s D. All of these can ⬆️albuminuria & proteinuria. Small fluctuations in these levels may not always indicate disease progression
— cardio-met (@cardiomet_CE) April 15, 2024
Appreciation of factors that impact albuminuria and changes in the measure are also important to know
🔓 https://t.co/QZVjaGXnSp pic.twitter.com/piIkG6pEcj
29) So you just earned 0.75hr 🆓 CE/#CME. Claim it NOW at https://t.co/uwlVlKvcHH and FOLLOW US so that you don't miss the next #tweetorial from @edgarvlermamd on Early, Optimal Management of #CKD and #Cardiorenal Disease to Prevent Disease Progression and Improve Outcomes! pic.twitter.com/CKshp7kfwO
— cardio-met (@cardiomet_CE) April 15, 2024