Evolution of the prevalence of the cardiorenal continuum in hospitalized patients with type 2 diabetes in real clinical practice (experience of Moscow City Clinical Hospital No. 52 of Moscow Health Department)

• Mikhail B. Antsiferov
• Mariana A. Lysenko
• Тatyana N. Markova
• Eugene M. Zeltyn-Abramov
• Natalya I. Belavina
• Margarita A. Ovchinnikova
• Anastasia A. Anchutina
• Irina A. Ivanova

Abstract

It is known that the leading cause of death in patients with type 2 diabetes mellitus (T2DM) is chronic heart failure (CHF), and the leading complication that significantly aggravates the patient’s prognosis is chronic kidney disease (CKD). In this regard, the active introduction into practice of methods for the early diagnosis of CHF and CKD, as well as the cardio-renal-metabolic approach to therapy, are the key to favorable long-term outcomes and a high quality of life in patients with type 2 diabetes.

Aim. To estimate the prevalence of CHF and CKD in hospitalized patients with T2DM in 2019 and 2023.

Material and methods. A single-center retrospective study was conducted in 2019 and a single-center prospective comparative study in 2023. The study included patients with T2DM aged ≥50 years, experience of T2DM ≥3 years. In 2019, the diagnosis of CHF was carried out in accordance with the clinical picture, determined by indications for the N-terminal pro-B-type natriuretic peptide (NT-proBNP) and performed according to the indications of echocardiography (ECHO-CG). In 2023, NT-proBNP was determined for all hospitalized patients for the purpose of diagnosing CHF and ECHO-CG was performed with an assessment of indicators using the HFA-PEFF (Heart Failure Association Pre-test assessment, Echocardiography and natriuretic peptide, Functional testing, Final etiology) scale. In 2019 and 2023 CKD was diagnosed with GFR <60.0 ml/min/1.73 m² and/or albumin/creatinine ratio ≥3 mg/mmol.

Results. 28.3% of patients had newly diagnosed CHF during hospitalization in 2019, and 25.0% in 2023 (p=0.680). The number of patients diagnosed with CHF at discharge was comparable in both groups (56.7% vs 58.3%, p=0.853), moreover in 2023, 62.9% of hospitalized patients had CHF with preserved ejection fraction (HFpEF; 50% or more), 34.3% with mid-range ejection fraction (40–49%), 2.9% – with a reduced ejection fraction (less than 40%). During hospitalization the diagnosis of CHF was removed in 10.5% in 2019 and in 25.9% in 2023. Upon admission 71.4% of patients in 2019 and 65.1% in 2023 had CKD. Newly diagnosed CKD C 3a or more and/or A2 or more (CKD advanced stages) was found in 31.7% and 11.7% of cases (p<0.001), and the total number of patients in this category at discharge was 46.7% and 58.3%, respectively (p=0.201). The prevalence of comorbidities: CHF and advanced CKD simultaneously in patients at discharge was 26.7% in 2019, 35.0% in 2023 (p=0.323), and in general, CHF and/or advanced CKD had 76.7% of patients in 2019 and 81.7% in 2023. There were no differences in the level of glycated hemoglobin (HbA1c), body mass index (BMI), duration of T2DM and arterial hypertension (AH) in groups with and without HFpEF, with and without advanced CKD. When analyzing the ROC curves of the dependence of the probability of developing CHFpEF on NT-proBNP, a statistically significant risk assessment model was obtained – AUC = 0.977±0.02 (95% CI 0.95–1.0), p<0.001. At NT-proBNP levels ≥105 pg/ml, a high risk of disease is predicted (OR 154.0; 95% CI 14.8–1600.0; p<0.001). In 2023, compared to 2019, more patients with CHF and/or advanced CKD were prescribed sodium glucose cotransporter type 2 inhibitors (iSGLT‑2, 91,8% vs 10,9%, respectively, p<0.001). The absence of prescription of iSGLT‑2 in 8.2% of patients in 2023 is associated with previously established or newly detected side effects.

Conclusions. 1. Among the patients hospitalized in 2023 with T2DM, 81.7% had CHF and/or advanced CKD, diagnosed according to modern standards. Of the 58.3% patients with CHF, the majority had CHFpEF (62.9%). Every second patient with CHF has advanced CKD, and vice versa.

2. Prevalence of CHF and CKD in 2019 and 2023 turned out to be comparable, however, the verification of the diagnosis of CHF in 2019 in most cases was carried out without an ECHO-CG and determination of the NT-proBNP. During hospitalization, CHF was removed in 10.5% in 2019 and in 25.9% in 2023 of patients with CHF at the time of admission according to medical records.

3. The level of NT-proBNP is the most significant indicator for the diagnosis of CHFpEF. An increase in the level of NT-proBNP ≥105 pg/ml predicts a high chance of developing CHF.

4. There were no differences in HbA1c, BMI, duration of T2DM2 and AH in groups with and without CHFpEF, with and without advanced CKD.

5. More patients with CHF and/or advanced CKD were prescribed iSGLT‑2 in 2023 (10.9% in 2019 vs 91.8% in 2023, p<0.001). The absence of prescription of iSGLT‑2 in 8.2% of patients in 2023 is associated with previously established or newly detected side effects.

Keywords:type 2 diabetes mellitus; chronic heart failure; chronic kidney disease; cardiorenal continuum; sodium glucose cotransporter type 2 inhibitors

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