Changes In Creatinine Levels Research Articles

Utility of Intraoperative Cystoscopy in Detecting Ureteral Injury During Vaginal Hysterectomy

Ureteral injury is a serious complication of vaginal hysterectomy and other gynecologic surgery. Its incidence during vaginal surgery is estimated to be 0.9% to 1.7%. Although intraoperative cystoscopy can provide a timely diagnosis and expedite management, it is not routinely performed. Barriers to routine use include cost and training. As an alternative to cystoscopy, ureteral injury may be detected by symptoms, an increase in perioperative serum creatinine level, or both. The primary aim of this study was to determine the rate of ureteral injury and associated costs in patients undergoing selective cystoscopy during vaginal hysterectomy. Another aim was to determine whether changes in perioperative creatinine level could be used to reliably diagnose ureteral injury in the absence of intraoperative cystoscopy. A secondary analysis of a retrospective cohort study was performed. A total of 593 patients underwent vaginal hysterectomy for benign indications, with or without additional pelvic floor repairs, from January 2, 2004, through December 30, 2005, at Mayo Clinic (Rochester, Minn). A logistic regression model was constructed to determine the propensity for a surgeon to perform intraoperative cystoscopy, in order to allow adjustment for the likelihood of detecting ureteral injury in a given surgical case. The rate of ureteral injury and associated cost was determined in patients undergoing surgery both with and without cystoscopy. In cases in which cystoscopy was not performed, standard practice of postoperative creatinine level determination allowed the authors to investigate the feasibility of using perioperative change in creatinine level to detect ureteral injury. Of the 593 eligible patients included in the analysis, 230 (38.8%) underwent cystoscopy during the hysterectomy. Ureteral injuries occurred in 6 patients (2.6%) in the cystoscopy group and 5 (1.4%) in the no-cystoscopy group; the odds ratio was 1.92, with a 95% confidence interval (CI) of 0.58 to 6.36, P = 0.35. After adjusting for the propensity to perform cystoscopy, the association was further attenuated (odds ratio, 1.31; 95% CI, 0.19–9.09). Five of the 6 were detected intraoperatively; of those, 4 were successfully managed intraoperatively. Adjusted mean-predicted costs for patients undergoing and not undergoing cystoscopy were $10,686 (95% CI, $7500–$13,872) and $10,217 (95% CI, $6894–$13,540), respectively; P = 0.28. The 5 patients with ureteral injury in the no-cystoscopy group had a median increase in perioperative creatinine level of 0.2 mg/dL, whereas patients without injury had a median decrease in creatinine level of 0.1 mg/dL (P < 0.001). Overall, the likelihood of ureteral injury with and without cystoscopy is similar, and predictive costs do not significantly differ. The use of postoperative creatinine level to detect ureteral injury is highly sensitive, but limited by a low positive predictive value and variable range. Based on these data, the authors recommend routine universal screening cystoscopy for patients undergoing vaginal hysterectomy.

V11-09 CASE REPORT OF A LAPAROSCOPIC EXCISION OF PARA-AORTIC PHEOCHROMOCYTOMA BY LIGATION OF LEFT RENAL VEIN WITHOUT COMPROMISING RENAL FUNCTION

You have accessJournal of UrologyAdrenal/Single Port Surgery/LESS/NOTES1 Apr 2015V11-09 CASE REPORT OF A LAPAROSCOPIC EXCISION OF PARA-AORTIC PHEOCHROMOCYTOMA BY LIGATION OF LEFT RENAL VEIN WITHOUT COMPROMISING RENAL FUNCTION Bruno Benigno, Gustavo Guimaraes, Rodrigo Campos, Ricardo Favaretto, and Charles Zurstrassen Bruno BenignoBruno Benigno More articles by this author , Gustavo GuimaraesGustavo Guimaraes More articles by this author , Rodrigo CamposRodrigo Campos More articles by this author , Ricardo FavarettoRicardo Favaretto More articles by this author , and Charles ZurstrassenCharles Zurstrassen More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2607AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Demonstrate the impact on renal function, feasibility and safety of ligation of main left renal vein when dealing with complex retroperitoneal lesions. METHODS Case report of an 36 year/old, female with a retroperitoneal pheochromocytoma outside the adrenal gland that undergo a successful laparoscopic excision. The post-operative outcomes measured were: changes in creatinine levels and eGFR and blood pressure levels RESULTS There were minimum alteration in creatinine levels and GFR rates postoperatively. Blood pressure normalize and the patient is out of medications after 1 week CONCLUSIONS Ligation of left main renal vein is a feasible and safe maneuver when dealing with complex retroperitoneal lesions and showed no impact in renal function in perioperative period. Longer follow up is required © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e909 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Bruno Benigno More articles by this author Gustavo Guimaraes More articles by this author Rodrigo Campos More articles by this author Ricardo Favaretto More articles by this author Charles Zurstrassen More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Utility of intraoperative cystoscopy in detecting ureteral injury during vaginal hysterectomy.

The aim of this study was to determine the utility of intraoperative cystoscopy in detecting and managing ureteral injury among women undergoing vaginal hysterectomy. We performed a secondary analysis of a retrospective cohort study of 593 patients who underwent vaginal hysterectomy for benign indications, with or without additional pelvic floor reconstructive surgery, from January 2, 2004, through December 30, 2005. A logistic regression model determining the propensity to undergo intraoperative cystoscopy was constructed. Comparisons of ureteral injury and cost between patients with and without cystoscopy were adjusted for the cystoscopy propensity score. We further explored the feasibility of using perioperative change in creatinine level to detect ureteral injury. In total, 230 (38.8%) of 593 patients underwent cystoscopy. Six patients (2.6%) in the cystoscopy group and 5 (1.4%) in the no-cystoscopy group had ureteral injuries (odds ratio, 1.92; 95% confidence interval [CI], 0.58-6.36). This association was further attenuated after adjusting for the propensity to undergo cystoscopy (odds ratio, 1.31; 95% CI, 0.19-9.09). Four injuries detected cystoscopically were managed intraoperatively. Adjusted mean-predicted costs for patients undergoing cystoscopy were $10,686 (95% CI, $7500-$13,872) versus $10,217 (95% CI, $6894-$13,540). In the no-cystoscopy group, patients with ureteral injury had a median increase in creatinine level of 0.2 mg/dL, whereas patients without injury had a median decrease of 0.1 mg/dL (P < 0.001). The level of selection for cystoscopy did not significantly increase the mean predicted costs for patients. Reliance on postoperative creatinine level to detect ureteral injury, while highly sensitive, is limited by a low positive predictive value and variable range.

Incidence and Risk Factors of Acute Kidney Injury after Radical Cystectomy: Importance of Preoperative Serum Uric Acid Level.

Background: Acute kidney injury (AKI) is a common complication after surgery and increases costs, morbidity, and mortality of hospitalized patients. While radical cystectomy associates significantly with an increased risk of serious complications, including AKI, risk factors of AKI after radical cystectomy has not been reported. This study was performed to determine the incidence and independent predictors of AKI after radical cystectomy.Methods: All consecutive patients who underwent radical cystectomy in 2001-2013 in a single tertiary-care center were identified. Their demographics, laboratory values, and intraoperative data were recorded. Postoperative AKI was defined and staged according to the Acute Kidney Injury Network criteria on the basis of postoperative changes in creatinine levels. Independent predictors of AKI were identified by univariate and multivariate logistic regression analyses.Results: Of the 238 patients who met the eligibility criteria, 91 (38.2%) developed AKI. Univariate logistic regression analyses showed that male gender, high serum uric acid level, and long operation time associated with the development of AKI. On multivariate logistic regression analysis, preoperative serum uric acid concentration (odds ratio [OR] = 1.251; 95% confidence interval [CI] = 1.048-1.493; P = 0.013) and operation time (OR = 1.005; 95% CI = 1.002-1.008; P = 0.003) remained as independent predictors of AKI after radical cystectomy.Conclusions: AKI after radical cystectomy was a relatively common complication. Its independent risk factors were high preoperative serum uric acid concentration and long operation time. These observations can help to prevent AKI after radical cystectomy.

Relationship between red cell distribution width and contrast-induced nephropathy in patients who underwent primary percutaneous coronary intervention.

This study evaluated the relationship between contrast-induced nephropathy (CIN) and red cell distribution width (RDW) in patients who underwent primary percutaneous coronary intervention (PCI). A total of 359 patients with ST elevation myocardial infarction (STEMI) who had undergone primary PCI were included in the study. An increase of 25% in serum creatinine value after 48 h, or an increase of >0.5 mg/dL in the basal value was defined as CIN. Of the patients included in the study, 49 (13.8%) developed CIN. Compared to the CIN-negative group, CIN-positive patients had increased RDW values (16.9 ± 2.00 and 14.8 ± 2.14 respectively, p<0.001). The latter were also older patients, and had increased age rates of diabetes mellitus, baseline creatinine, ∆-creatinine and amount of contrast media were higher and left ventricular ejection fraction and baseline glomerular filtration rate (GFR) were lower in the CIN-positive group than in the CIN-negative group. A statistically weak correlation was found between RDW and change in creatinine levels (∆-creatinine) (r=0.250, p=0.002). Diabetes mellitus (odds ratio [OR]: 3.252, 95% CI=1.184-8.951, p=0.022), high RDW (OR: 1.716, 95% CI=1.363-2.157, p<0.001), baseline low GFR (OR: 0.941, 95% CI=0.925-0.971, p<0.001), ∆-creatinine (OR: 1.197, 95% CI=1.061-2.986, p=0.006) and increased amount of contrast media (OR: 1.187, 95% CI=1.048-3.02, p=0.001) used were observed as independent predictors of CIN. The study found diabetes mellitus, high RDW, basal low GFR, ∆-creatinine and increased contrast amount used to be the independent predictors of CIN in STEMI patients who underwent PCI.

OUTCOMES OF ULTRAFILTRATION IN ADVANCED HEART FAILURE PATIENTS RESISTANT TO DIURETIC THERAPY

Over the last 2 decades, the treatment of advanced HF has seen the introduction of several novel medications and devices. Ultrafiltration (UF) is a strategy that has been used for treatment of refractory edema for many years. In 2012, the CARRESS-HF trial compared UF as a first line alternative to diuretic therapy in patients with acute decompensated HF. In our study, we examined the impact of UF in advanced decompensated HF patients resistant to diuretic therapy. This is a single-centered prospective analysis of 18 patients between 2010 to 2012 with advanced HF receiving UF after failing conventional diuretic therapy. The mean age of our patients was 67 ± 9 years, with 88% male patients. On enrollment, 66% of patients had NYHA Class III symptoms, 13 patients had 3+ pitting edema and mean LVEF was 35.8 ± 16%. Eight patients had ≥ 1 admission in the previous year, related to HF. UF fluid removal rate was performed at an average of 116.8 ± 61 mL per hour. We measured serum creatinine, pre and post-UF, weight change, need for inotropes, need for loop diuretics at discharge, and final outcomes. UF in our patient population demonstrated 55% survival rate at 1 year. The average length of time of UF was 3.98 ± 3.45 days, with 1 patient requiring 16 days of UF. The mean change in creatinine level at 96 hours was -5.86 ± 17.7 μmol per liter. The mean weight change post-UF was -6.7 ± 4.8 kg. There were no bleeding complications noted. Other complications included seizures secondary to hyponatremia in 1 patient, rise in creatinine in 8 patients. Eight patients required inotropes while on UF, with 1 requiring post-UF pressor support after acute decompensation (due to H1N1 infection). Five patients were taken off UF due to success (1 at 17 hours, 2 at 48 hours, 1 at 72 hours, and 1 at 168 hours), assessed by improvement in NYHA class and volume status. Complications resulting in discontinuation of UF included line infection (1), death due to VF (1), worsening creatinine (5), VT (1), hypotension (1), received VAD (1), filter clot (2), seizure (1) and line infection (1). In conclusion, UF can be used with careful consideration in a selected population of advanced HF patients resistant to diuretic therapy. Future larger studies are required in these subsets of patients to determine the efficacy and full extent of adverse effects of UF.

Comparative Analysis of Pedicular Vascular Control Techniques during Laparoscopic Nephrectomy: En Bloc Stapling or Separate Ligation?

Objective: To compare the safety and efficacy of en bloc stapling and separate ligation techniques for renal vascular control during laparoscopic nephrectomy. Patients and Methods: Clinical data were collected from 60 patients who underwent laparoscopic nephrectomies using en bloc stapling (n = 27, group 1) or the separate ligation method (n = 33, group 2). Comparative analysis was carried out between the two groups, examining operative times, blood loss, intra- and postoperative complications and hospital stay. Results: Compared with the separate ligation method, the en bloc hilar control technique was associated with a shorter total operating time (98 vs. 121 min, p = 0.029). However, both groups were similar in terms of estimated blood loss, hemoglobin drop, changes in creatinine level and postoperative hospital stay. The total complication rates in group 1 and 2 were 3.7 and 15.1%, respectively, with a statistically significant difference. There were no complications related to the use of the endo-GIA stapler and no patients required conversion to open surgery in group 1. In group 2, 2 patients required conversion to open surgery, including 1 due to renal vein bleeding secondary to inaccurate vascular control and the other due to bleeding from the vena cava during dissection. In addition, 1 patient had a superficial bowel injury that was repaired laparoscopically and another had a superficial liver tear that was managed without conversion or transfusion. Conclusion: En bloc ligation of the renal hilum is an easy and reliable technique that allows safe and fast control of the renal pedicle.

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AIM: To evaluate resistive index in various stages of liver cirrhosis and to determine its significance in developing hepatorenal syndrome. METHODS: Study included 60 cirrhotic patients divided into 4 groups (15 patients each): compensated liver cirrhosis (group A), diuretic responsive ascites (group B), refractory ascites (group C), hepatorenal syndrome (group D) and ten healthy persons as control group (E). All patients subjected to detailed history taking and clinical examination. Laboratory investigations included simple urine analysis, complete blood picture, liver function tests, blood urea and serum creatinine, serum sodium and serum potassium, and protein concentration. Ultrasonographic examination and renal duplex Doppler were under taken to assess the Resistive index. RESULTS: The RI of interlobar and arcuate arteries were significantly higher in all patient groups than in control group (p <0.05), the RI was significantly higher in patients with refractory ascites than in patients with diuretic responsive ascites, and also in patient of diuretic responsible ascites than in patients with compensated cirrhosis (p < 0.05), in patient with hepatorenal syndrome than in patient with diuretic responsive ascites and patients with compensated cirrhosis (p<0.05). Also Creatinine levels & blood urea levels in patients with the hepatorenal syndrome was significantly higher than that of other different groups (p<0.05) but there was no significant change in creatinine levels between patients with compensated cirrhosis and control group. While creatinine levels in patient with diuretic responsive ascites was significantly higher than that in patient with compensated cirrhosis (p<0.05) there was no significant change between patient with diuretic responsive ascites and patient with refractory ascites. CONCLUSION: Resistive index increases with degree of hepatic decompensation. Renal duplex ultrasound is a non- invasive, simple and easy method to study intrarenal hemodynamics in patients with liver cirrhosis INTRODUCTION: Renal hemodynamic changes with intense intrarenal vasoconstriction begin early in the course of liver disease before changes in the level of serum urea and serum creatinine1. Patients with liver cirrhosis and portal hypertension develop circulatory dysfunction characterized by disturbance in systemic and renal hemodynamics. Hepatorenal syndrome (HRS) is a functional and reversible form of renal failure that occurs in patients with advanced chronic liver disease. The distinctive hallmark feature of HRS is the intense renal vasoconstriction caused by interactions between systemic and portal hemodynamics. This results in inactivation of vasoconstrictors and suppression of vasodilators in the renal circulation. Although the assessment of kidney function is of great clinical importance in patients with liver cirrhosis and ascites, serum creatinine and even

Markers of and Risk Factors for the Development and Progression of Diabetic Kidney Disease

Diabetic kidney disease (DKD) occurs in 25%-40% of patients with diabetes. Given the dual problems of a significant risk of progression from DKD to end-stage renal disease (ESRD) and increased cardiovascular morbidity and mortality, it is important to identify patients at risk of DKD and ESRD and initiate protective renal and cardiovascular therapies. The importance of preventive therapy is emphasized further by worldwide increases in the incidence of diabetes. This review summarizes the evidence regarding the prognostic value and benefits of targeting established and novel risk markers for DKD development and progression. Family history of DKD, smoking history, and glycemic, blood pressure, and plasma lipid level control are established factors for identifying people at greatest risk of DKD development and progression. Absolute albumin excretion rate (AER) and glomerular filtration rate (GFR) measurements also are important, although AER categorization generally lacks the necessary specificity and sensitivity, and estimates of declining GFR are compromised by methodological limitations for GFRs in the normal-to-high range. Emerging risk markers for progressive loss of kidney function include markers of oxidation and inflammation, profibrotic cytokines, uric acid, advanced glycation end products, functional and structural markers of vascular dysfunction, kidney structural changes, and tubular biomarkers. Among these, the most promising are serum uric acid and soluble tumor necrosis factor receptor (type 1 and type 2) levels, especially in relation to GFR changes. At present, these can only be considered as risk markers because they only identify an individual at increased risk of progressive DKD and not necessarily related to the causal pathway promoting kidney damage. Further work is needed to establish whether modulating these factors improves the prognosis in DKD. Although change in urinary peptidome levels also is a promising marker, there currently is neither a clinical assay nor adequate studies defining its prognostic value. Until these or other novel markers become available for clinical use, predictive accuracy often may be increased with greater attention to established markers.

Meta-Analysis of Ultrafiltration versus Diuretics Treatment Option for Overload Volume Reduction in Patients with Acute Decompensated Heart Failure.

IntroductionAlthough diuretics are mainly used for the treatment of acute decompensated heart failure (ADHF), inadequate responses and complications have led to the use of extracorporeal ultrafiltration (UF) as an alternative strategy for reducing volume overloads in patients with ADHF.ObjectiveThe aim of our study is to perform meta-analysis of the results obtained from studies on extracorporeal venous ultrafiltration and compare them with those of standard diuretic treatment for overload volume reduction in acute decompensated heart failure.MethodsMEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases were systematically searched using a pre‑specified criterion. Pooled estimates of outcomes after 48 h (weight change, serum creatinine level, and all-cause mortality) were computed using random effect models. Pooled weighted mean differences were calculated for weight loss and change in creatinine level, whereas a pooled risk ratio was used for the analysis of binary all-cause mortality outcome.ResultsA total of nine studies, involving 613 patients, met the eligibility criteria. The mean weight loss in patients who underwent UF therapy was 1.78 kg [95% Confidence Interval (CI): −2.65 to −0.91 kg; p < 0.001) more than those who received standard diuretic therapy. The post-intervention creatinine level, however, was not significantly different (mean change = −0.25 mg/dL; 95% CI: −0.56 to 0.06 mg/dL; p = 0.112). The risk of all-cause mortality persisted in patients treated with UF compared with patients treated with standard diuretics (Pooled RR = 1.00; 95% CI: 0.64–1.56; p = 0.993).ConclusionCompared with standard diuretic therapy, UF treatment for overload volume reduction in individuals suffering from ADHF, resulted in significant reduction of body weight within 48 h. However, no significant decrease of serum creatinine level or reduction of all-cause mortality was observed.

Loop diuretic strategies in patients with acute decompensated heart failure: A meta-analysis of randomized controlled trials

PurposeThe safety and efficacy of continuous infusion vs bolus injection of intravenous loop diuretics to treat acute decompensated heart failure were debated. Our aim is to compare the administration routes of diuretics in hospitalized patients with acute decompensated heart failure. MethodsA systematic review and meta-analysis of randomized controlled trials was performed to evaluate the effects of continuous infusion vs bolus administration of loop diuretics in patients with acute decompensated heart failure. The primary end points were urine outputs, body weight loss, all causes of mortality, and death from cardiovascular causes. Secondary end points were electrolyte imbalance, change in creatinine levels, tinnitus or hearing loss, and days of hospitalization. ResultsTen randomized controlled trials with 518 patients were identified. Continuous infusion of diuretics was associated with a significantly greater weight loss (weighted mean difference, 0.78; 95% confidence interval, 0.03-1.54) compared with bolus injection. Urine output, the incidence of electrolyte imbalance, change in creatinine level, length of hospitalization, the incidence of ototoxicity, cardiac mortality, and all-cause mortality showed no significant differences between the 2 groups. ConclusionMeta-analysis of the existing limited studies did not confirm any significant differences in the safety and efficacy with continuous administration of loop diuretic, compared with bolus injection in patients with acute decompensated heart failure.

Primary Stent Angioplasty of the Inferior Vena Cava After Liver Transplantation and Liver Resection

This study evaluated technical efficacy and safety of stent angioplasty of the inferior vena cava (IVC) after liver transplantation or liver resection and analysis of changes in creatinine levels and patients' weight. Between October 2004 and February 2011, 16 patients (mean age, 52.6years) with symptomatic IVC stenoses after liver transplantation (n=10) or liver resection (n=6) were subjected to stent angioplasty. Enrollment criteria included edema and/or ascites. The smallest diameter of the IVC, serum creatinine values, and patients' weight were assessed before and after stent placement and respective values were compared. Technical and clinical success, patency rates, related complications, and patients' survival were analyzed. Stent placement was technically successful in 16 patients (100%). Clinical success was achieved in 13 patients (81.25%), reflecting two patients with early restenosis and one patient suffering from thrombosis distal to the stent. Mean follow-up was 372days. Primary patencies were 75% (n=12). Primary assisted patencies were 93.75% (n=15). Serum creatinine levels decreased significantly (p=0.01) from 1.68mg/dl before to 1.08mg/dl after stent placement. Patients' weight decreased (mean 2.1%). No angioplasty-related complications occurred. Stent angioplasty of the IVC is an effective and safe treatment of stenoses after liver transplantation and resection and has a positive effect on creatinine levels.

Adjunctive Vancomycin Powder in Pediatric Spine Surgery is Safe

Therapeutic level II cohort study. To evaluate the safety of adjunctive local application of vancomycin powder (VP) for infection prophylaxis in posterior instrumented thoracic and lumbar spine wounds in pediatric patients weighing more than 25 kg. Spine surgeons have largely turned to vancomycin prophylaxis in an attempt to decrease the incidence of late surgical site infection and acute surgical site infection from methicillin-resistant Staphylococcus aureus. In adult patients, the adjunctive local application of VP with an intravenous cephalosporin has been shown to decrease postsurgical wound infection rates significantly; however, the safety of VP as an adjunct in pediatric spine surgery has not been reported. We reviewed data collected under a systematic protocol specifically designed to monitor the safety profile of VP. We measured changes in creatinine and systemic vancomycin levels after intrawound application of 500 mg of unreconstituted VP during spine deformity correction surgery in patients weighing more than 25 kg (patients also received routine intravenous cephalosporin prophylaxis). Laboratory values were measured preoperatively and on postoperative days 1 and 4. Any adverse reactions and infections through available follow-up (2-8 mo) were recorded. Eighty-seven consecutive pediatric patients with spinal deformity weighing more than 25 kg who received intraoperative VP during a 9-month period were identified. Sixty-three percent of the patients in this series had adolescent idiopathic scoliosis, 15% congenital scoliosis, 15% neuromuscular scoliosis, and 5% spondylolisthesis. The average change in creatinine levels between the preoperative and postoperative day 1 draw was -0.03 and between the preoperative and postoperative day 4 draw was -0.075. The postoperative systemic vancomycin levels remained undetectable. None of the patients experienced nephrotoxicity or red man syndrome. Three of the 87 patients developed a surgical site infection. In this cohort there were no clinically significant changes in creatinine level or systemic vancomycin level caused by use of intraoperative VP. 2.

Change in creatinine level from any cause is associated with long term prognosis in patients with stable angina pectoris undergoing elective percutaneous coronary intervention

Background and aim: Transient elevation of creatinine level after coronary angiography is well known predictor of worse long term prognosis. Prognostic role of significant change (increase or decrease) in creatinine level from any cause remains unknown. Methods: We analyzed 4554 patients undergoing drug eluting stent or bare metal stent implantation between 2003 and 2011 at our institution. Patients were divided into two groups: Group A (n=359) comprised patients in whom change (increase or decrease) in creatinine level was noted during hospitalization and exceeded 25% and group B (n=4195) comprised the remaining patients. Patients on dialysis were excluded from the analysis. 12-months difference in mortality was assessed with Kaplan Meier method and log-rank testing. Follow-up data was available for 3679 patients (80.7%) Results: Patients in Group A were older (67.8±9.6 vs. 63.3±9.4, p<0.001), more often female (36.5% vs. 27.9%), diabetic (40.9% vs. 34.4%, p<0.001) and were more often burdened with obstructive pulmonary disease (13.65% vs. 5.34%, p<.001). Ejection fraction was lower in Group A (41.3%± 13.0% vs. 46.6%±10.4%) and patients in Group A had more often symptoms of severe heart failure – NYHA III/IV (23.7% vs. 12.3%, p<0.001), lower levels of hematocrit at admission (38.2%± 5.3% vs. 40.5% ±4.2, p<0.001) higher levels of uric acid (436.6±135.3 vs. 371.4±102.8 umol/l) and white blood cells (9.5±2.5 vs. 7.7±2.5, p<0.001 103/ml). Patients in group A had also higher rate of bleeding complications (7.8% vs. 1.9%, p<0.001) and worse 12-months outcome. ![Figure][1] Figure 1 Conclusions: Any change in creatinine level greater than 25% was associated with unfavorable clinical characteristics and worse 12-months outcome in analyzed cohort. [1]: pending:yes

Escalating diuretic strategy beats ultrafiltration in decompensated heart failure

Background: Ultrafiltration is an alternative strategy to diuretic therapy for the treatment of patients with acute decompensated heart failure. Little is known about the efficacy and safety of ultrafiltration in patients with acute decompensated heart failure complicated by persistent congestion and worsened renal function. Methods: We randomly assigned a total of 188 patients with acute decompensated heart failure, worsened renal function, and persistent congestion to a strategy of stepped pharmacologic therapy (94 patients) or ultrafiltration (94 patients). The primary endpoint was the bivariate change from baseline in the serum creatinine level and body weight, as assessed 96 h after random assignment. Patients were followed for 60 days. Results: Ultrafiltration was inferior to pharmacologic therapy with respect to the bivariate end point of the change in the serum creatinine level and body weight 96 h after enrollment (p = 0.003), owing primarily to an increase in the creatinine level in the ultrafiltration group. At 96 h, the mean change in the creatinine level was −0.04 ± 0.53 mg per deciliter (−3.5 ± 46.9 μmol per liter) in the pharmacologic-therapy group, as compared with +0.23 ± 0.70 mg per deciliter (20.3 ± 61.9 μmol per liter) in the ultrafiltration group (p = 0.003). There was no significant difference in weight loss 96 h after enrollment between patients in the pharmacologic-therapy group and those in the ultrafiltration group (a loss of 5.5 ± 5.1 kg [12.1 ± 11.3 lb] and 5.7 ± 3.9 kg [12.6 ± 8.5 lb], respectively; p = 0.58). A higher percentage of patients in the ultrafiltration group than in the pharmacologic-therapy group had a serious adverse event (72% vs. 57%, p = 0.03). Conclusions: In a randomized trial involving patients hospitalized for acute decompensated heart failure, worsened renal function, and persistent congestion, the use of a stepped pharmacologic-therapy algorithm was superior to a strategy of ultrafiltration for the preservation of renal function at 96 h, with a similar amount of weight loss with the two approaches. Ultrafiltration was associated with a higher rate of adverse events.

Protocolo diagnóstico de la disminución de la función renal en un paciente con una enfermedad autoinmune sistémica

Altered renal function in patients diagnosed with systemic autoimmune disease is particularly important, since renal involvement with worse prognosis in these cases. The regular analytical monitoring of these patients who are subject to detect changes in creatinine levels or alterations in urinalysis that will make a diagnosis and treatment. It is also important to recognize the role of immunosuppressive drugs and concomitant pathology in the study of renal function. To emphasize the usefulness of urine sediment study and urine of 24h to detect possible renal and glomerular damage, and the need for renal biopsy to obtain an accurate histologic diagnosis.

Can Neutrophil Gelatinase–associated Lipocalin Help Depict Early Contrast Material–induced Nephropathy?

To evaluate the utility of serum and urinary neutrophil gelatinase-associated lipocalin (NGAL) in depicting an event of contrast material-induced nephropathy (CIN) in patients who received iodinated contrast media, gadoterate meglumine, or radiopharmaceutical technetium-99m ((99m)Tc) and to evaluate the protective effect exerted by isotonic saline infusion, sodium bicarbonate administration, or N-acetylcysteine administration. Institutional ethics committee approval was given, and informed consent was obtained. One hundred twenty patients were enrolled in a prospective study and divided into three groups: iomeprol group, magnetic resonance (MR) imaging group (gadoterate meglumine), and renal scintigraphy group ((99m)Tc). They randomly received N-acetylcysteine, physiologic saline, or sodium bicarbonate. Receiver operating characteristic (ROC) analysis, Kaplan-Meier curves, and Cox proportional hazard regression analysis were used. In the MR imaging and renal scintigraphy groups, there were significant changes in serum creatinine and NGAL levels, and there were no cases of CIN. In the iomeprol group, an early rise in NGAL was found, while serum creatinine level changes occurred 24 hours after contrast material administration. At ROC analysis, NGAL showed high sensitivity and specificity (serum NGAL: area under the curve, 0.995; 95% confidence interval [CI]: 0.868, 0.992; urinary NGAL: area under the curve, 0.992; 95% CI: 0.925, 1.000) in identifying CIN 8 hours after iomeprol administration. Regression analysis showed that NGAL independently predicted CIN. Administration of N-acetylcysteine, sodium bicarbonate, or physiologic saline did not influence NGAL level. NGAL depicted CIN in patients who received iodinated contrast material within 8 hours of contrast material administration. http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12120578/-/DC1.

Nephrotoxicity of iodixanol versus iopamidol in patients with acute coronary syndrome

The iso-osmolar contrast agent iodixanol may be associated with fewer contrast-induced acute kidney injuries when compared with low-osmolar contrast agents. The aim of this study is to compare iodixanol and iopamidol in patients with acute coronary syndrome (ACS) who are currently undergoing coronary angiography. Two hundred and seventy five consecutive patients who presented to a tertiary cardiovascular center with acute non-ST elevation myocardial infarction and underwent coronary angiography as a part of an early invasive strategy were included in the study (mean age 58±11 years, 79% male). Study participants were administered either iodixanol (n=45) or iopamidol (n=230) and the groups were compared for the highest creatinine levels, the absolute and percent change in creatinine levels, and for the development of contrast induced nephropathy within 72 hours of the procedure. Baseline demographic and clinical characteristics of the patients were similar between the two groups. There were no differences in the preprocedural serum creatinine (iopamidol 1.10±0.54 mg/dl, iodixanol 1.09±0.24 mg/dl, p=0.680), glomerular filtration rate (iopamidol 89±35 ml/dk/1.73 m(2), iodixanol 89±26 ml/dk/1.73 m(2), p=0.934), or contrast volume used during the procedure (iopamidol 180±80 ml vs. iodixanol 166±73 ml, p=0.226) between the groups. The absolute change in serum creatinine after the procedure (iopamidol 0.136±0.346 mg/dl, iodixanol 0.072±0.070 mg/dl, p=0.118) and the percent change in serum creatinine after the procedure (iopamidol 12.1±29.6%, iodixanol 6.8±6.9%, p=0.075) were not statistically significant between the two groups. Contrast induced nephropathy developed 10% (95% confidence interval [CI] 6-14%) in iopamidol group whereas it was 2.2% (95% CI -2-7%) in iodixanol group (p=0.144). Iodixanol was not superior to iopamidol regarding contrast induced acute kidney injury after coronary angiography in an unselected general patient population with ACS.

Effect of Fenofibrate Therapy on Blood Creatinine Levels in Patients with Hypertension and Hypertriglyceridemia

Results: Baseline parameters except lipid profiles were similar between the fenofibrate and control groups. Creatinine levels increased in the fenofibrate group (from 0.90±0.18 mg/dL to 1.05±0.22 mg/dL, p<0.001) and did not change in the control group (from 0.91±0.12 mg/dL to 0.92±0.14 mg/dL, p=0.39). The elevation was more pronounced in the fenofibrate group than in the control group (0.15±0.12 vs. 0.02±0.11 mg/dL, p<0.001). Changes in creatinine levels were only associated with fenofibrate therapy (r=0.52, p<0.001) in the stepwise linear regression analysis. Conclusion: Fenofibrate therapy for 1-3 years significantly increased creatinine levels in hypertensive patients with hypertriglyceridemia. This finding suggests that follow-up measurement of creatinine level is necessary with fenofibrate therapy.

Ultrafiltration in Decompensated Heart Failure with Cardiorenal Syndrome

BackgroundUltrafiltration is an alternative strategy to diuretic therapy for the treatment of patients with acute decompensated heart failure. Little is known about the efficacy and safety of ultrafiltration in patients with acute decompensated heart failure complicated by persistent congestion and worsened renal function.MethodsWe randomly assigned a total of 188 patients with acute decompensated heart failure, worsened renal function, and persistent congestion to a strategy of stepped pharmacologic therapy (94 patients) or ultrafiltration (94 patients). The primary end point was the bivariate change from baseline in the serum creatinine level and body weight, as assessed 96 hours after random assignment. Patients were followed for 60 days.ResultsUltrafiltration was inferior to pharmacologic therapy with respect to the bivariate end point of the change in the serum creatinine level and body weight 96 hours after enrollment (P=0.003), owing primarily to an increase in the creatinine level in the ultrafiltration group. At 96 hours, the mean change in the creatinine level was −0.04±0.53 mg per deciliter (−3.5±46.9 μmol per liter) in the pharmacologic-therapy group, as compared with +0.23±0.70 mg per deciliter (20.3±61.9 μmol per liter) in the ultrafiltration group (P=0.003). There was no significant difference in weight loss 96 hours after enrollment between patients in the pharmacologic-therapy group and those in the ultrafiltration group (a loss of 5.5±5.1 kg [12.1±11.3 lb] and 5.7±3.9 kg [12.6±8.5 lb], respectively; P=0.58). A higher percentage of patients in the ultrafiltration group than in the pharmacologic-therapy group had a serious adverse event (72% vs. 57%, P=0.03).ConclusionsIn a randomized trial involving patients hospitalized for acute decompensated heart failure, worsened renal function, and persistent congestion, the use of a stepped pharmacologic-therapy algorithm was superior to a strategy of ultrafiltration for the preservation of renal function at 96 hours, with a similar amount of weight loss with the two approaches. Ultrafiltration was associated with a higher rate of adverse events. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT00608491.)