Parag Kale M.D.

Tecson, K. M., H. Hashemi, A. Afzal, T. A. Gong, P. Kale and P. A. McCullough (2019). “Community-Acquired Acute Kidney Injury as a Risk Factor of de novo Heart Failure Hospitalization.” Cardiorenal Med 9(4): 252-260.

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OBJECTIVES: Because patients with hospital-acquired acute kidney injury (AKI) are at risk for subsequent development of heart failure (HF) and little is known about the relation between community-acquired AKI (CA-AKI) and HF, we sought to determine if CA-AKI is a risk factor for incident HF hospitalization. METHODS: We utilized Baylor Scott & White Health databases at the primary care and inpatient hospitalization levels to identify adults without a prior history of HF who had 2 or more serum creatinine measurements within 13 months in the primary care setting. We defined CA-AKI as a serum creatinine increase >/=0.3 mg/dL or >/=1.5 times the baseline for consecutive values within a 13-month period. We created a flag for de novo HF hospitalization at 90, 180, and 365 days following CA-AKI evaluation. RESULTS: In the analyses, 210,895 unique adults were included, of whom 5,358 (2.5%) had CA-AKI. Those with CA-AKI had higher rates of comorbidities, higher rate of males (48 vs. 42%, p < 0.001), and were older (61.5 [50.3, 73.1] vs. 54.1 [42.8, 64.7] years, p < 0.001) than those who did not have CA-AKI. In total, 607 (0.3%), 833 (0.4%), and 1,089 (0.5%) individuals had an incident HF hospitalization in the 90, 180, and 365 days following the CA-AKI evaluation, respectively. After adjusting for demographic and clinical characteristics, patients with CA-AKI had >2 times the risk of de novo HF hospitalization compared with patients who did not have CA-AKI (90 days: 2.35 [1.83-3.02], p < 0.001; 180 days: 2.52 [2.04-3.13], p < 0.001; 365 days: 2.16 [1.77-2.64], p < 0.001). These multivariable models yielded strong predictive abilities, with the areas under the receiver-operating characteristic curve >0.90. CONCLUSION: After controlling for baseline and clinical characteristics, patients with CA-AKI were at approximately twofold the risk of de novo HF hospitalization (within 90, 180, and 365 days) compared with those who did not have CA-AKI. Hence, detecting CA-AKI may provide an opportunity for early intervention at the primary care level to possibly delay HF development.

Gong, T. A., S. M. Joseph, B. Lima, G. V. Gonzalez-Stawinski, A. K. Jamil, J. Felius, H. Qin, G. Saracino, A. E. Rafael, P. Kale and S. A. Hall (2018). “Donor predicted heart mass as predictor of primary graft dysfunction.” J Heart Lung Transplant 37(7): 826-835.

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BACKGROUND: Concern over the hazards associated with undersized donor hearts has impeded the utilization of otherwise viable allografts for transplantation. Previous studies have indicated predicted heart mass (PHM) may provide better size matching in cardiac transplantation than total body weight (TBW). We investigated whether size-matching donor hearts by PHM is a better predictor of primary graft dysfunction (PGD) than matching by TBW. METHODS: Records of consecutive adult cardiac transplants performed between 2012 and 2016 at a single-center academic hospital were reviewed. We compared patients implanted with hearts undersized by >/=30% with those implanted with donor hearts matched for size (within 30%), and performed the analysis both for undersizing by PHM and for undersizing by TBW. The primary outcome was moderate/severe PGD within 24 hours, according to the 2014 International Society for Heart and Lung Transplantation consensus. Secondary outcome was 1-year survival. RESULTS: Of 253 patients, 21 (8%) and 30 (12%) received hearts undersized by TBW and PHM, respectively. The overall rate of moderate/severe PGD was 13% (33 patients). PGD was associated with undersizing if performed by PHM (p = 0.007), but not if performed by TBW (p = 0.49). One-year survival was not different between groups (log-rank, p > 0.8). Multivariate analysis confirmed that undersizing donor hearts by PHM, but not by TBW, was predictive of moderate/severe PGD (OR 3.3, 95% CI 1.3 to 8.6). CONCLUSIONS: Undersized donor hearts by >/=30% by PHM may increase rates of PGD after transplantation, confirming that PHM provides more clinically appropriate size matching than TBW. Better size matching may ultimately allow for expanding the donor pool.

Kale, P. and A. Afzal (2018). “Stage B Heart Failure: To Strain or Not to Strain.” JACC Cardiovasc Imaging. May 11.[Epub ahead of print].

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Heart failure (HF) has been considered a progressive disorder than can be represented as a clinical continuum. In 2005, American College of Cardiology/American Heart Association updated the guidelines for management of HF and identified 4 states of heart failure with clinical recommendations for each stage. These guidelines helped address some of the confusion stemming from the symptom severity-based New York Heart Association functional classification. Symptom severity can change drastically over a short period either from medical therapy or absence of it, which can create confusion on treatment recommendations based solely on New York Heart Association functional classification. In the current schema, Stage B heart failure (SBHF) includes patients with Stage A HF who have structural heart disease but no current or prior symptoms of HF. It has been estimated that the number of patients in Stage B is about 2 times higher than Stages C and D combined. (Brief excerpt from this commentary, in press; no abstract available.)