MD1340Y - Method for predicting the risk of cardiorenal syndrome in heart failure with intermediate and reduced ejection fraction - Google Patents
Method for predicting the risk of cardiorenal syndrome in heart failure with intermediate and reduced ejection fraction Download PDFInfo
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Abstract
Description
Invenţia se referă la medicină, în special la cardiologie şi nefrologie. The invention relates to medicine, in particular to cardiology and nephrology.
Numeroase sisteme de organe sunt strâns conectate între ele. În normă, această conexiune ajută la menţinerea homeostaziei şi funcţionării optime a organismului uman. În patologie, însă, organul afectat poate iniţia şi perpetua disfuncţii structurale şi funcţionale în alte organe, cu care se află în conexiune. Astfel, afecţiunile cardiace şi cele renale frecvent coexistă la acelaş pacient în faza acută sau cronică. Studiile observaţionale şi clinice au reuşit să demonstreze că bolile cardiace acute/cronice pot contribui direct la agravarea acută/cronică a bolii renale şi invers. Many organ systems are closely connected to each other. Normally, this connection helps to maintain homeostasis and optimal functioning of the human body. In pathology, however, the affected organ can initiate and perpetuate structural and functional dysfunctions in other organs, with which it is connected. Thus, cardiac and renal diseases frequently coexist in the same patient in the acute or chronic phase. Observational and clinical studies have been able to demonstrate that acute/chronic cardiac diseases can directly contribute to the acute/chronic worsening of renal disease and vice versa.
Diagnosticul de sindrom cardiorenal este o adevărată provocare clinică şi necesită respectarea a două cerinţe: confirmarea afectării concomitente a cordului şi rinichilor şi aprecierea patologiei primare pentru a putea aprecia algoritmul optim de tratament. The diagnosis of cardiorenal syndrome is a real clinical challenge and requires compliance with two requirements: confirmation of concomitant heart and kidney damage and assessment of the primary pathology in order to assess the optimal treatment algorithm.
În absenţa unor criterii sau ghiduri standardizate, în prezent se utilizează criteriile propuse de Ronco şi Cruz care prevăd diagnosticul iniţial al insuficienţei cardiace conform Ghidului insuficienţei cardiace acute şi cronice din 2016 în asociere cu dovezi de afectare ale funcţiei renale ce pot fi explicate prin prezenta patologiei cardiace (tabel 1) [1]. In the absence of standardized criteria or guidelines, the criteria proposed by Ronco and Cruz are currently used, which provide for the initial diagnosis of heart failure according to the 2016 Acute and Chronic Heart Failure Guidelines in association with evidence of impaired renal function that can be explained by the presence of cardiac pathology (table 1) [1].
Algoritmul de diagnostic al sindromului cardiorenal Diagnostic algorithm for cardiorenal syndrome
Tabelul 1 Table 1
ICC Debutul BCR Simptome tipice de IC Semne tipice de IC Reducerea FEVS SAU: FE normală sau moderat redusă şi VS nedilatat, şi/sau disfuncţie diastolică. (ESC,ACC/AHA) NT-proBNP >125 pg/ml Albuminurie şi/sau RFG ˂ 60ml/min/1,73m2 (KDIGO/KDOQI) Sau: Progresia BCR Scăderea progresivă a RFG ˃ 5 ml/min/1,73m2/an, sau ˃ 10 ml/min/1,73m2/5ani SAU: Creşterea albuminuriei Plus Asociere temporală Plus Plauzabilitate patofiziologicăCHF Onset of CKD Typical symptoms of CKD Typical signs of CKD Reduced LVEF OR: Normal or moderately reduced EF and non-dilated LV, and/or diastolic dysfunction. (ESC, ACC/AHA) NT-proBNP >125 pg/ml Albuminuria and/or GFR <60ml/min/1.73m2 (KDIGO/KDOQI) Or: CKD progression Progressive decrease in GFR >5ml/min/1.73m2/year, or >10ml/min/1.73m2/5 years OR: Increasing albuminuria Plus Temporal association Plus Pathophysiological plausibility
Pe de altă parte, există multiple formule de estimare a ratei filtrării glomerulare cu utilizarea: creatininei sau cistatinei C. Creatinina este un marker ieftin, accesibil, bine cunoscut, însă are variabilitate înaltă şi o latenţă de răspuns de cca 3 zile. Rata filtrării glomerulare măsurate se poate modifica cu >50% până când rata filtrării glomerulare estimate în baza creatininei ajunge la limita intervalului de referinţă. Pe de alta parte, cistatina C este un marker fidel, cu raspuns imediat şi variabilitate scăzută, însă este costisitor şi greu accesibil. Rezultatele obţinute la estimarea funcţiei renale variază în dependenţă de stadiul acut sau cronic al afectării sau de formula utilizată. On the other hand, there are multiple formulas for estimating glomerular filtration rate using: creatinine or cystatin C. Creatinine is a cheap, accessible, well-known marker, but it has high variability and a response latency of about 3 days. The measured glomerular filtration rate can change by >50% until the estimated glomerular filtration rate based on creatinine reaches the limit of the reference interval. On the other hand, cystatin C is a reliable marker, with immediate response and low variability, but it is expensive and difficult to access. The results obtained in estimating renal function vary depending on the acute or chronic stage of the disease or the formula used.
Am examinat funcţia renală la 170 pacienţi prin utilizarea a 10 formule diferite de estimare. Din tabelul 2 putem observă diferenţele de estimare. We examined renal function in 170 patients using 10 different estimation formulas. From Table 2 we can see the differences in estimation.
Valorile medii ale RFG estimate prin diferite ecuaţii la subiecţi cu sindrom cardiorenal şi fără afectare renală Average GFR values estimated by different equations in subjects with cardiorenal syndrome and without renal impairment
Tabelul 2 Table 2
RFG estimată SCR Medie±SEM nonSCR Medie±SEM p RFGcyscr 43,39±1,29 78,29±1,34 <0,0001 RFGcyscrG 50,92±1,63 91,91±1,89 <0,0001 RFGcys 37,77±1,41 67,64±1,79 <0,0001 RFGcysG 44,34±1,72 79,22±2.17 <0,0001 RFGepi 55,39±2,34 91,93±1.62 <0,0001 RFGepiG 64,74±2,78 108,1±2,51 <0,0001 RFGm 54,27±2,28 94,85±2,49 <0,0001 RFGmG 62,62±2,74 111,19±3,44 <0,0001 RFG100/cistatina 60,51±1,79 92,14±2,15 <0,0001 RFGCG 70,37±3,25 125,6±5,06 <0,0001Estimated RFG SCR Mean±SEM nonSCR Mean±SEM p RFGcyscr 43.39±1.29 78.29±1.34 <0.0001 RFGcyscrG 50.92±1.63 91.91±1.89 <0.0001 RFGcys 37.77±1.41 67.64±1.79 <0.0001 RFGcysG 44.34±1.72 79.22±2.17 <0.0001 RFGepi 55.39±2.34 91.93±1.62 <0.0001 RFGepiG 64.74±2.78 108.1±2.51 <0.0001 RFGm 54.27±2.28 94.85±2.49 <0.0001 RFGmG 62.62±2.74 111.19±3.44 <0.0001 RFG100/cystatin 60.51±1.79 92.14±2.15 <0.0001 RFGCG 70.37±3.25 125.6±5.06 <0.0001
Pentru diminuarea variabilităţii şi excluderea factorilor de confuzie am decis sa utilizăm formula EPI CKD în baza cistatinei şi creatininei ajustată la greutatea corporală, formula recomandată şi de ghidurile internationale de nefrologie. To reduce variability and exclude confounding factors, we decided to use the EPI CKD formula based on cystatin and creatinine adjusted for body weight, the formula also recommended by international nephrology guidelines.
Forman (2004) a studiat prevalenţa afectării renale la pacienţi spitalizaţi cu insuficienţă cardiacă. El a identificat factorii de risc ce determină afectarea renală şi a dezvoltat un model de predicţie a afectării renale cu sensibilitatea de 81% şi specificitatea de 62% utilizând anamnesticul de insuficienţă cardiacă, anamnesticul de diabet zaharat, valoarea tensiunii arteriale sistolice, creatinina serica. Curbele supravieţuirii au fost estimate utilizând metoda Kaplan-Meier. Efectul covariaţional a fost evaluat utilizând modelul regresional Cox [2]. Forman (2004) studied the prevalence of renal impairment in hospitalized patients with heart failure. He identified risk factors for renal impairment and developed a model for predicting renal impairment with a sensitivity of 81% and specificity of 62% using a history of heart failure, a history of diabetes, systolic blood pressure, and serum creatinine. Survival curves were estimated using the Kaplan-Meier method. The covariate effect was assessed using the Cox regression model [2].
Eficienţa aceastei metode se poate datora utilizării creatininei, care este marker de bază pentru diagnosticul afectării renale, deci este necesară o precizare: este aceasta o metodă de predicţie sau o metodă mai complicată de diagnostic. În plus, evoluţia insuficienţei cardiace nu este liniară, dar se asociază frecvent cu decompensări şi insuficienţă cardiacă acută, care induc episoade de insuficienţă renală acută cu creşterea marcată, temporară a creatininei. Aplicarea metodei elaborate de Forman în această situaţie va avea un rezultat fals pozitiv. The efficiency of this method may be due to the use of creatinine, which is a basic marker for the diagnosis of renal damage, so a clarification is necessary: is this a prediction method or a more complicated diagnostic method. In addition, the evolution of heart failure is not linear, but is frequently associated with decompensations and acute heart failure, which induce episodes of acute renal failure with a marked, temporary increase in creatinine. Applying the method developed by Forman in this situation will have a false positive result.
Un alt model de predicţie a afectării renale a fost elaborat de Cheng pe o cohortă de 1709 chinezi. Modelul utilizează vârsta, valorile tensionale, clasa funcţională a insuficientei cardiace, proteinuria şi administrarea intravenoasa a furosemidului. Another model for predicting renal damage was developed by Cheng on a cohort of 1709 Chinese. The model uses age, blood pressure values, functional class of heart failure, proteinuria and intravenous administration of furosemide.
Dezavantajele metodei propuse de Cheng constă în aceea că ea este destinată doar situaţiilor acute (risc de apariţie a insuficienţei renale acute în insuficienţa cardicacă acută, în infarct miocardic sau după chirurgia cardiacă) [3]. The disadvantages of the method proposed by Cheng are that it is intended only for acute situations (risk of acute renal failure in acute heart failure, myocardial infarction or after cardiac surgery) [3].
Matematic problema fiind formalizată se reduce la deducerea unei reguli, criteriu de discriminare, în baza analizei datelor a două selecţii: pacienţi care nu au afectare renală şi pacienţi care au dezvoltat sindrom cardiorenal tip 2. Folosirea analizei discriminante în analiza datelor statistice ne-a permis să deducem funcţia discriminantă propusă mai jos şi care este pusă în esenţa metodei de pronosticare. Mathematically, the problem being formalized, is reduced to deducing a rule, a discrimination criterion, based on the data analysis of two selections: patients who do not have kidney damage and patients who have developed type 2 cardiorenal syndrome. The use of discriminant analysis in the analysis of statistical data allowed us to deduce the discriminant function proposed below and which is at the heart of the prognostic method.
Problema pe care o rezolvă invenţia este obiectivizarea metodei de apreciere a riscului de dezvoltare a sindromului cardiorenal tip 2 în insuficienţa cardiacă cronică cu fracţie de ejecţie intermediară sau redusă (≤49%)pentru o monitorizare mai strictă şi ajustarea tacticii de tratament al pacienţilor cu risc crescut. The problem solved by the invention is the objectification of the method for assessing the risk of developing type 2 cardiorenal syndrome in chronic heart failure with intermediate or reduced ejection fraction (≤49%) for stricter monitoring and adjustment of treatment tactics for high-risk patients.
Esenţa invenţiei constă în aceea că se identifică vârsta pacientului (V), durata bolii cardiovasculare (DBCV) şi prezenţa tulburărilor de ritm din anamneză (TR), se efectuează examenul clinic şi paraclinic cu determinarea severităţii insuficienţei cardiace (IC) şi prezenţei cardiopatiei ischemice (CPI), nivelului peptidului natriuretic cerebral fragmentul N terminal (NTproBNP), nivelului seric al trigliceridelor (TRIG) şi al hormonului tireotrop seric (TSH), iar funcţia discriminantă (F) se calculează conform formulei: The essence of the invention consists in identifying the patient's age (V), the duration of cardiovascular disease (DBCV) and the presence of rhythm disorders in the anamnesis (TR), performing a clinical and paraclinical examination to determine the severity of heart failure (HF) and the presence of ischemic cardiopathy (IC), the level of brain natriuretic peptide N-terminal fragment (NTproBNP), the serum level of triglycerides (TRIG) and serum thyrotropin hormone (TSH), and the discriminant function (F) is calculated according to the formula:
F= - 16,775 + 0,111 · V + 0,145 · NTproBNP + 2,205 · TRIG + 1,413 · IC + 1,693 · TR + 0,499 · CPI + 0,040 · DBCV + 0,082 · TSH, F= - 16.775 + 0.111 · V + 0.145 · NTproBNP + 2.205 · TRIG + 1.413 · IC + 1.693 · TR + 0.499 · CPI + 0.040 · DBCV + 0.082 · TSH,
în cazul în care F > 0 se confirmă diagnosticul sau se pronostichează un risc crescut de sindrom cardiorenal, iar F < 0 se exclude diagnosticul sau se pronostichează un risc scăzut de sindrom cardiorenal. if F > 0, the diagnosis is confirmed or an increased risk of cardiorenal syndrome is predicted, and F < 0, the diagnosis is excluded or a low risk of cardiorenal syndrome is predicted.
Rezultatul constă în identificarea pacienţilor cu risc crescut de dezvoltare a sindromului cardiorenal la pacienţi cu insuficienţă cardiacă, datorită utilizării în metoda dată a parametrilor paraclinici suplimentari. The result consists in identifying patients at high risk of developing cardiorenal syndrome in patients with heart failure, due to the use of additional paraclinical parameters in this method.
Avantajul constă în sporirea exactităţii şi obiectivizării sindromului cardiorenal la pacienţii cu insuficienţă cardiacă. Metoda propusă permite depistarea precoce a bolnavilor cu risc sporit de agravare, indiferent de patologiile renale şi extrarenale coexistente, fapt ce impune o atenţie sporită pentru această categorie de pacienţi cu corijare la timp a programului terapeutic. The advantage lies in increasing the accuracy and objectification of cardiorenal syndrome in patients with heart failure. The proposed method allows early detection of patients with increased risk of worsening, regardless of coexisting renal and extrarenal pathologies, which requires increased attention for this category of patients with timely correction of the therapeutic program.
La etapa iniţială s-a colectat anamneza (aprecierea vârstei, duratei patologiei cardiovasculare, prezenţa tulburărilor de ritm) şi s-a efectuat examenul clinic primar (inclusiv aprecierea severităţii insuficienţei cardiace şi prezenţei cardiopatiei ischemice), examenul paraclinic în cadrul căruia s-a efectuat dozarea peptidului natriuretic cerebral, dozarea trigliceridelor şi a hormonului tireotrop. At the initial stage, the anamnesis was collected (assessment of age, duration of cardiovascular pathology, presence of rhythm disorders) and the primary clinical examination was performed (including assessment of the severity of heart failure and presence of ischemic cardiopathy), the paraclinical examination during which the dosage of brain natriuretic peptide, triglycerides and thyrotropin hormone were measured.
Verificarea funcţiei discriminante s-a efectuat la un lot de 170 pacienţi cu diagnosticul - insuficienţă cardiacă, apreciindu-se funcţia renală prin estimarea ratei filtrării glomerulare prin formula CKD-EPI în baza creatininei şi cistatinei C. Risc crescut de sindrom cardiorenal a fost considerat în cazul în care F > 0 şi si risc scăzut dacă F < 0. The discriminant function test was performed on a group of 170 patients with the diagnosis of heart failure, assessing renal function by estimating the glomerular filtration rate using the CKD-EPI formula based on creatinine and cystatin C. Increased risk of cardiorenal syndrome was considered if F > 0 and low risk if F < 0.
Conform datelor prezentate în tabelul 3, aşteptam rezultat nefavorabil/prezenţa sindromului cardiorenal în 81(47,65%) dintre cazuri, în mod real însă, sindromul cardiorenal a fost diagnosticat la 83(48,82%) pacienţi. Acest fenomen poate fi explicat prin dificultatea de diagnostic şi diferenţele dintre formulele de estimare a ratei filtrării glomerulare utilizate pentru confirmarea diagnosticului de sindrom cardiorenal. According to the data presented in Table 3, we expected an unfavorable outcome/presence of cardiorenal syndrome in 81 (47.65%) of the cases, but in reality, cardiorenal syndrome was diagnosed in 83 (48.82%) patients. This phenomenon can be explained by the difficulty of diagnosis and the differences between the formulas for estimating the glomerular filtration rate used to confirm the diagnosis of cardiorenal syndrome.
Tabelul 3 Table 3
Rezultatul real Rezultatul aşteptat Favorabil Nefavorabil Total Favorabil, persoane (%) 74(83,15%) 13(16,05%) 87(51,18%) Nefavorabil, persoane (%) 15(16,85%) 68(83,95%) 83(48,82%) Total, persoane (%) 89(52,35%) 81(47,65%) 170(100%)Actual result Expected result Favorable Unfavorable Total Favorable, people (%) 74(83.15%) 13(16.05%) 87(51.18%) Unfavorable, people (%) 15(16.85%) 68(83.95%) 83(48.82%) Total, people (%) 89(52.35%) 81(47.65%) 170(100%)
Drept indicaţie pentru utilizarea acestei metode constituie depistarea precoce a pacienţilor cu risc sporit de dezvoltare a sindromului cardiorenal în insuficienţa cardiacă în scopul întocmirii unei tactici precoce de tratament. An indication for using this method is the early detection of patients at increased risk of developing cardiorenal syndrome in heart failure in order to develop an early treatment tactic.
Contraindicaţii pentru utilizarea acestei metode nu sunt. There are no contraindications to using this method.
Exemple concrete de realizare Concrete examples of implementation
Exemplul 1 Example 1
Pacientul B., 83 ani, suferă de cardiopatie ischemică (CPI) de 33 ani, 1 an în urmă a suportat un infarct miocardic acut, tulburări de ritm (TR) nu a avut. A fost internat în secţia Cardiologie SCM „Sf.Treime” în stare de gravitate medie, stabilindu-se diagnosticul de insuficienţă cardiacă CF III NYHA (IC = 3). A fost aplicată metoda propusă de cercetare. S-au obţinut următoarele rezultate: V = 83 ani; TRIG = 0 (valoarea trigliceridelor serice 0,97 mmol/l); NTproBNP = 3,926 ng/ml; TSH - 4,8. Patient B., 83 years old, has been suffering from ischemic heart disease (IHD) for 33 years, 1 year ago he suffered an acute myocardial infarction, he did not have any rhythm disorders (RH). He was admitted to the Cardiology Department of the SCM "Sf.Treime" in a state of moderate severity, and the diagnosis of heart failure CF III NYHA (IC = 3) was established. The proposed research method was applied. The following results were obtained: V = 83 years old; TRIG = 0 (serum triglyceride value 0.97 mmol/l); NTproBNP = 3.926 ng/ml; TSH - 4.8.
Valoarea calculată a funcţiei discriminante este de F = 0,65673, adică F>0, ceea ce permite aprecierea unui risc crescut de sindrom cardiorenal. Metoda aplicată a demonstrat coincidenţa diagnosticului cu rezultatul real. The calculated value of the discriminant function is F = 0.65673, i.e. F>0, which allows the assessment of an increased risk of cardiorenal syndrome. The applied method demonstrated the coincidence of the diagnosis with the real result.
Exemplul 2 Example 2
Pacienta B., 61 ani, suferă de valvulopatie reumatismală de 22 ani, concomitent are hipertensiune arterială şi tulburări de ritm. Cardiopatie ischemică nu are. A fost internată în secţia Cardiologie SCM „Sf.Treime” în stare de gravitate medie, stabilindu-se diagnosticul de insuficienţă cardiacă CF III NYHA( IC=3). A fost aplicată metoda propusă de cercetare. S-au obţinut următoarele rezultate: V = 61 ani; TRIG = 0 (valoarea trigliceridelor serice 0,71 mmol/l); CPI = 0; NTproBNP = 1,231 ng/ml; TSH - 1,4. Patient B., 61 years old, has been suffering from rheumatic valvulopathy for 22 years, and also has hypertension and rhythm disorders. She does not have ischemic heart disease. She was admitted to the Cardiology Department of the SCM "Sf. Treime" in a state of moderate severity, and was diagnosed with heart failure CF III NYHA (IC=3). The proposed research method was applied. The following results were obtained: V = 61 years old; TRIG = 0 (serum triglyceride value 0.71 mmol/l); CPI = 0; NTproBNP = 1.231 ng/ml; TSH - 1.4.
Valoarea calculată a funcţiei discriminante este de F = - 2,89870, adică F<0, fapt care permite aprecierea unui risc scăzut de dezvoltare a sindromului cardiorenal la această pacientă, ceea ce demonstrează coincidenţa rezultatului aşteptat cu rezultatul real. The calculated value of the discriminant function is F = - 2.89870, i.e. F<0, which allows the assessment of a low risk of developing cardiorenal syndrome in this patient, which demonstrates the coincidence of the expected result with the actual result.
Exemplul 3 Example 3
Pacientul Z., 50 ani, suferă de cardiopatie ischemică de 7 ani, de asemenea 7 ani în urmă a suportat un infarct miocardic. Concomitent are hipertensiune arterială, dereglări de ritm nu are. A fost internat în secţia Cardiologie SCM „Sf.Treime” în stare de gravitate medie, fiind stabilit diagnosticul de insuficienţă cardiacă CF II NYHA. A fost aplicată metoda propusă de cercetare. În urma investigaţiilor efectuate s-au obţinut următoarele rezultate: V = 50 ani; TRIG = 1 (valoarea trigliceridelor serice 4,73 mmol/l); CPI = 3; NTproBNP = 0,338ng/ml; TSH - 0,4. Valoarea calculată a funcţiei discriminante este de F = - 0,94919, adică F<0, ceea ce permite aprecierea unui risc scăzut de sindrom cardiorenal, în realitate însă, a fost identificată alterarea funcţiei renale. Fapt ce demonstrează necoincidenţa rezultatului aşteptat cu rezultatul real. Acest fenomen poate fi explicat prin alegerea formulei de estimare şi greutăţii crescute a pacientului (IMC = 38,53kg/m2). La utilizarea formulei CKD-EPI în baza cistatinei şi creatininei ajustată la greutatea corporala rata filtrării glomerulare a fost de 46 ml/min, ceea ce corespunde diagnosticului de sindrom cardiorenal, iar la folosirea aceleiaşi formule neajustată la greutatea corporală, rata filtrării glomerulare a fost de 60 ml/min, ceea ce exclude diagnosticul. Patient Z., 50 years old, has been suffering from ischemic heart disease for 7 years, and also suffered a myocardial infarction 7 years ago. He also has hypertension, no rhythm disorders. He was admitted to the Cardiology Department of the SCM "Sf. Treime" in a state of moderate severity, being diagnosed with heart failure CF II NYHA. The proposed research method was applied. As a result of the investigations performed, the following results were obtained: V = 50 years old; TRIG = 1 (serum triglyceride value 4.73 mmol/l); CPI = 3; NTproBNP = 0.338ng/ml; TSH - 0.4. The calculated value of the discriminant function is F = - 0.94919, i.e. F<0, which allows the assessment of a low risk of cardiorenal syndrome, but in reality, renal function impairment was identified. This fact demonstrates the discrepancy between the expected result and the actual result. This phenomenon can be explained by the choice of the estimation formula and the increased weight of the patient (BMI = 38.53kg/m2). When using the CKD-EPI formula based on cystatin and creatinine adjusted to body weight, the glomerular filtration rate was 46 ml/min, which corresponds to the diagnosis of cardiorenal syndrome, and when using the same formula not adjusted to body weight, the glomerular filtration rate was 60 ml/min, which excludes the diagnosis.
Având la bază datele obţinute prin estimarea ratei filtrării glomerulare prin formula CKD-EPI în baza creatininei şi cistatinei C la pacienţii cu insuficienţă cardiacă, metoda de apreciere a riscului propusă permite depistarea precoce a bolnavilor cu risc sporit de agravare, fapt ce impune o atenţie sporită pentru această categorie de pacienţi cu corijare la timp al programului terapeutic. Based on the data obtained by estimating the glomerular filtration rate using the CKD-EPI formula based on creatinine and cystatin C in patients with heart failure, the proposed risk assessment method allows for the early detection of patients at increased risk of worsening, which requires increased attention for this category of patients with timely correction of the therapeutic program.
1. Cruz D. et al. Pathophysiology of Cardiorenal Syndrome Type 2 in Stable Chronic Heart Failure: Workgroup Statements from the Eleventh Consensus Conference of the Acute Dialysis Quality Initiative (ADQI). Contrib. Nephrol. 2013, No. 182, p. 117-136 1. Cruz D. et al. Pathophysiology of Cardiorenal Syndrome Type 2 in Stable Chronic Heart Failure: Workgroup Statements from the Eleventh Consensus Conference of the Acute Dialysis Quality Initiative (ADQI). Contribute. Nephrol. 2013, no. 182, p. 117-136
2. Forman D., Butler J., Wang Y., Abraham W., O'Connor C., Gottlieb S.S., Loh E., Massie B.M., Rich M.W., Stevenson L.W., Young J.B., Krumholz H.M. Incidence, Predictors at Admission, and Impact of Worsening Renal Function Among Patients Hospitalized With Heart Failure. Journal of the American College of Cardiology, 2004, No. 43(1), 2004, p. 61-67 2. Forman D., Butler J., Wang Y., Abraham W., O'Connor C., Gottlieb S.S., Loh E., Massie B.M., Rich M.W., Stevenson L.W., Young J.B., Krumholz H.M. Incidence, Predictors at Admission, and Impact of Worsening Renal Function Among Patients Hospitalized With Heart Failure. Journal of the American College of Cardiology, 2004, No. 43(1), 2004, p. 61-67
3. Cheng H., ChenY.. Clinical Prediction Scores for Type 1 Cardiorenal Syndrome Derived and Validated in Chinese Cohorts.Cardiorenal Med. No. 5, 2015, p.12-19 3. Cheng H., ChenY.. Clinical Prediction Scores for Type 1 Cardiorenal Syndrome Derived and Validated in Chinese Cohorts. Cardiorenal Med. No. 5, 2015, p.12-19
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