Concomitant Renal Insufficiency Research Articles

The Frequency of Fabry Disease in Acute Stroke Patients with Renal Insufficiency in Sakarya Province

Aim: This study aimed to investigate the frequency, clinical and genetic characteristics, and therapeutic options associated with Fabry disease (FD) in individuals with acute stroke and concomitant renal insufficiency.
 Material and Methods: An FD screening was performed on adult patients with renal dysfunction who were admitted to the neurology clinic due to acute stroke between 2015 and 2021. Screening was performed by a leukocyte α-galactosidase A (α-Gal A) enzyme activity assay using dried blood spot (DBS) samples from male patients. In cases where the enzyme activity was less than 2.5 nmol/ml/h, genetic analysis was performed. Female patients underwent direct genetic analysis.
 Results: Renal dysfunction was detected in 39 ischemic stroke patients and 5 hemorrhagic stroke patients out of a total of 401 cases. The enzyme level was found low in only one of the male patients. The c.680G>A (p.R227Q) mutation was observed in this male patient and a female patient. In the later stages of the study, it was realized with the help of pedigree analysis that these two cases were first-degree relatives. The same mutation was also detected in 13 first-degree and 2 second-degree relatives. The frequency of FD in our study group, which included patients with cerebral and renal involvement regardless of consanguinity, was 4.54%.
 Conclusion: Rapid detection of FD cases can be achieved by screening individuals presenting with multiple end-organ damages. To the best of our knowledge, this study highlights the underemphasized association between renal involvement and stroke in FD.

Sociodemographic and Clinical Profile of Long COVID-19 Patients, and Its Correlation with Medical Leave: A Comprehensive Descriptive and Multicenter Study.

The persistent condition of COVID-19 is characterized by a wide range of symptoms that have had a significant impact on both the health status and occupational life of the population. In this observational and multicenter study, the relationship between the sociodemographic and clinical profile of Spanish patients diagnosed with long COVID, and the work-related disability resulting from this pathology was analyzed. The analysis included 689 responses. A descriptive analysis of the variables recorded was performed, together with a bivariate analysis to determine associations between work-related disability and variables such as gender, age, health status, disabling symptoms or comorbidities. The results obtained highlight fatigue and lack of concentration (brain fog) as the most incapacitating symptoms among patients diagnosed with long COVID. Multivariate analysis revealed that time since diagnosis (OR: 0.57, CI95%: 0.36-0.89, p: 0.013), concomitant renal insufficiency (OR: 4.04, CI95%: 1.42-11.4, p: 0.008), and symptoms like fatigue (OR: 0.56, CI95%: 0.33-0.99) and tremors (OR: 2.0, CI95%: 1.06-3.69, p: 0.029), were associated with work-related disability. These findings highlight the need to improve the health and work-related management of this condition in the healthcare system. Besides risk factor control, it is suggested to pay special attention to determining the appropriate timing of medical leave work reintegration, along with coordination between primary care and occupational health services to ensure the gradual and tailored return of patients with long COVID to the workforce.

Dosing of basic pharmacotherapy and its effect on the prognosis of patients hospitalized for heart failure.

We analyzed the prescription and dosage of essential pharmacotherapy in chronic heart failure (HF) at the time of discharge from the hospitalization for cardiac decompensation and how it may have influenced the prognosis of the patients. We followed 4097 patients [mean age 70.7, 60.2% males] hospitalized for HF between 2010 and 2020. The vital status we ascertained from the population registry, other circumstances from the hospital information system. The prescription of beta-blockers (BB) was 77.5% (or only 60.8% of BB with evidence in HF), 79% of renin-angiotensin system (RAS) blockers, and 45.3% of mineralocorticoid receptor antagonists (MRA). Almost 87% of patients were treated with furosemide at the time of discharge, while only ≈53% of patients with ischemic etiology of HF took a statin. The highesttarget dose of BB was recommended in ≈11% of patients, RAS blockers in ≈ 24%, and MRA in ≈ 12% of patients. In patients with concomitant renal insufficiency, the prescription of BB and MRA was generally less frequent and on a significantly lower dosage. In contrast, the opposite was true for the RAS blocker (however statistically insignificant). In patients with EF ≤ 40%, the prescription of BB and RAS blockers were more frequent but in a significantly lower dosage. On the contrary, MRAs were recommended in these patients more often and in higher doses. In terms of mortality risk, patients treated only with a reduced dose of RAS blockers showed a 77% higher risk of death within one year (or 42% within five years). A significant relationship was also found between mortality and the recommended dose of furosemide. The prescription and dosage of essential pharmacotherapy are far from optimal, and in the case of RAS blockers, this affected the patient's prognosis as well.

Gaps of Medication Treatment Management Between Guidelines and Real-World for Inpatients With Type 2 Diabetes in China From Pharmacist's Perspective.

BackgroundThe prevalence of diabetes mellitus remains high in China, and more cardiovascular and cerebrovascular adverse events due to diabetes mellitus are likely to occur in the future.ObjectiveTo analyze the gap between the current pharmacotherapy management and the guidelines for inpatients with type 2 diabetes mellitus from the perspective of pharmacists so as to provide a reference for optimal pharmacotherapy management methods and models for patients with type 2 diabetes mellitus.MethodsThe study was a cross-sectional observational study. The study was conducted by investigating and analyzing the use of glucose-lowering drugs, adjustment of blood pressure management strategy, lipid management, weight management, and application of antiplatelet drugs in type 2 diabetes inpatients.ResultsA total of 1086 patients with type 2 diabetes were included. Metformin, glycosidase inhibitors, and basal insulin were the most used among type 2 diabetes inpatients. The use of SGLT-2, GLP-1 RAs, DPP-4, and metformin all showed significant increase. SGLT-2 inhibitors (SGLT-2i) showed the fastest increase from 2020 to 2021 (14.5% vs. 39.6%); However, the application rate of SGLT-2i was low among patients with combined ASCVD, renal insufficiency, and diabetic nephropathy (46.4%, 40.9%, and 45.8% respectively). For patients with substandard blood pressure at admission, the average rate of intervention by endocrinologists for adjusting the antihypertensive regimen during hospitalization was 55.6%, and the application rate of ACEI/ARB drugs reached 64.4%. The application rate of statins among patients with type 2 diabetes was still relatively high, at 78.8%. However, the overall intervention rate for patients with suboptimal LDL-c was only 24.1%. The application rate of antiplatelet agents for patients with ASCVD was 77.6%, which was higher than that for patients without ASCVD.ConclusionThere is still a gap between the practice of medication treatment management of Chinese inpatients with type 2 diabetes and the guidelines, especially in the application of GLP-1RAs and SGLT-2i in patients with concomitant ASCVD, diabetic nephropathy, and renal insufficiency. Meanwhile, physicians and pharmacists should pay more attention on achieving blood pressure and LDL-c standards in type 2 diabetic patients and provide timely interventions.

Abstract- Poster

Background:- ”Catatonia” is characterized by alterations in motor, behavioral, and vocal signs occurring in the context of medical, neurologic, & psychiatric disorders. While considering medical etiology, renal failure has been described as one of the factors. It may result in seizures & catatonia. Furthermore, renal failure even though rare has also been implicated in the causation.Aim:- We aim to report a rare case describing multiple etiologies (Renal failure, Seizure, Covid-19) & treatment in a patient with catatonia.Result/Case report:- The patient had Covid-19 infection with concomitant renal insufficiency with uremia. He developed an episode of seizure on 3rd day of admission and subsequently developed catatonic symptoms in the post-ictal phase. He did not respond to anticonvulsive treatment but did so with Lorazepam.Discussion:- A variety of conditions can produce catatonia. It is less widely recognized that this state may be caused by seizures; which in turn can also be due to renal failure. Catatonia occurring in the wake of seizures generally responds to the anticonvulsive medication. Even though rare and anecdotal, catatonia has been reported in a few cases reports in patients suffering from Covid-19 infection & it can occur in both the para & post-infectious states.Conclusion:- We also want to highlight that lorazepam proved to be an effective and safe choice for the treatment of catatonic symptoms & eventually led to the improvement in the symptomatology of Covid-19. Therefore, we also propose further studies for the treatment of such patients.

Early Outcomes of Multivisceral Transplant Using Hepatitis C–Positive Donors

In the era of direct-acting antiviral therapies, hepatitis C-positive organs offer a strategy to expand the donor pool. Heart failure patients with concomitant renal insufficiency benefit from combined heart/kidney transplant. In 2017, we began utilizing organs from hepatitis C donors for heart/kidney transplants. Characteristics and outcomes of heart/kidney transplants were collected at our institution from 2012 through 2019. We determined patient cohorts by donor hepatitis C antibody status, antibody positive (HCV+) vs antibody negative (HCV-). Outcomes of interest include survival, postoperative allograft function, and waitlist time. Summary and descriptive statistics, as well as survival analyses, were performed. Thirty-nine patients underwent heart/kidney transplantation from 2012-2019. Twelve patients received HCV+ organs, and 27 patients received HCV- organs with minimal differences in donor and recipient cohort characteristics. Recipients who consented to receive HCV+ organs had a shorter median waitlist time. HCV+ and HCV- groups had similar perioperative and early postoperative cardiac function and similar rates of delayed renal graft function. HCV+ recipients demonstrated higher creatinine levels at 3 months posttransplant compared with HCV- recipients, but by 1-year post-transplant, creatinine levels in both groups were similar. The groups had similar 30-day and 1-year survival. This study is a single-center series of heart/kidney transplant using HCV+ donors. When the potential increased risk of early postoperative renal dysfunction is balanced against similar survival and decreased waitlist time, the results suggest that HCV+ donors are an important source of transplantable organs for heart/kidney transplantation.

Igm-enriched-immunoglobulins associated with EMiC2 filter in the treatment of early septic shock after cardiac surgery

Introduction The occurrence of septic shock after cardiac surgery is a rare event with a reported prevalence between 0.39% and 2.5% (1). However patients who develop severe sepsis after cardiac procedures have a high mortality, varying from 65% to 79%. They also require a prolonged mechanical ventilation in intensive care unit and hospital length of stay. Reducing the time to diagnosis and early extracorporeal treatment is believed to be crucial factor for reducing mortality from multiple organ dysfunction is sepsis (1). We assessed the effectiveness of IgM enriched immunoglobulins (Pentaglobin Biotest Germany) 5mg/kg/3 days associated with 72 hours of chronic renal replacement therapy with Emic2 using citrate anticoagulation in septic shock after cardiac surgery. Methods Our retrospective study was performed in the Department of Cardiovascular Anesthesia and Intensive Care San Carlo Hospital between 01/01/2018 and 01/01/2019. Patients developed septic shock after elective cardiac surgery with the use extracorporeal circulation were included. Septic shock were diagnosed according to Sepsis Surviving Campaign criteria. We tested the serum concentration of IL-6, procalcitonin (PCT), white blood cell count (WBC) and Endotoxin Activity Assay (EAA) before treatment (T0) and at 24 (T1), 48 (T2) and 72 hours (T3) after treatment. We evaluated the dynamic changes in the serum concentrations and activity of these molecules and techniques. Results Finally, 11 patients (4 males) were included. The average age was 64.5±7.1 with EUROSCORE value of 13.5±2.3. Nine patients (90.0%) had concomitant renal insufficiency and 5 (45.5%)had chronic obstructive pulmonary disease. The serum concentration of IL-6 ranged from 313.4±111.1 µg/dl before the treatment to 446.1±117.5 µg/dl after 24 hours, 121.3±97.6 µg/dl after 48 hours and 67.6±36.7 µg/dl at 72 hours. At the same time the serum concentration of PCT decreased respectively from 7.3±2.3 mg/dl to 6.1±1.2 mg/dl; 4.5±2.1 mg/dl; and 2.1±1.9 mg/dl. Similarly the EAA decreased from 1.21±0.60 before the treatment to 0.35±0.14 at the end of the treatment. Discussion Our small study confirm that Pentaglobin associated with Emic2 treatment in early septic shock after cardiac surgery is safe and can reduce concentration of major cytokines of endotoxin activity. Further studies needed to assess the clinical efficacy of this promising treatment technique.

Current and Future Therapy of Hepatitis B and D

With approximately 240 million chronically infected people, hepatitis B virus (HBV) infection is a leading cause of cirrhosis and hepatocellular carcinoma in the world. Chronic HBV infection should be treated with antivirals, if either liver cirrhosis with detectable HBV DNA or relevant viral load (HBV DNA > 2000 IU/ml) and signs of liver damage (transaminase elevation, fibrosis, risk of liver cancer or similar) are present. The current standard therapy is a long-term treatment with nucleoside or nucleotide analogues such as entecavir, tenofovir disoproxil fumarate or tenofovir alafenamide, while in selected cases interferon treatment (for 48 weeks) may be useful. Entecavir and the new drug tenofovir alafenamide (TAF) are to be preferred over tenofovir disoproxil fumarate in patients with concomitant renal insufficiency or osteoporosis. Pregnant women with high viral load (> 200 000 IU/ml) should be treated with tenofovir in the third trimester to minimize the risk of neonatal transmission (in addition to immediate active-passive immunization). In conditions of immunosuppression (e. g. chemotherapy, rituximab, anti-TNF), even a "healed" HBV infection may reactivate in a life-threatening manner, requiring prophylactic antiviral therapy in addition to testing for HBV in high-risk situations. The current therapies primarily achieve virus suppression, but rarely the loss of HBs antigen, which is considered a functional cure. New strategies such as discontinuation of long-term antiviral therapy with provoked reactivation and also completely new drugs are currently in clinical trials. The most serious form of viral hepatitis is the co-/superinfection of HBV with the delta virus (HDV). Standard therapy for delta hepatitis is pegylated interferon-alfa, but the approval of new drugs such as the HBV entry inhibitor Myrcludex is expected in the near future.

Parsimonious assessment for reoperative aortic valve replacement; the deterrent effect of low left ventricular ejection fraction and renal impairment.

Patient comorbidities play a pivotal role in the surgical outcomes of reoperative aortic valve replacement (re-AVR). Low left ventricular ejection fraction (LVEF) and renal insufficiency (Cr >2 mg/dL) are known independent surgical risk factors. Improved preoperative risk assessment can help determine the best therapeutic approach. We hypothesize that re-AVR patients with low LVEF and concomitant renal insufficiency have a prohibitive surgical risk and may benefit from transcatheter AVR (TAVR). From January 2002 to March 2013, we reviewed 232 patients who underwent isolated re-AVR. Patients older than 80 years were excluded to adjust for unobserved frailty. We identified 37 patients with a ≤35% LVEF (low ejection fraction group-LEF) and 195 patients with >35% LVEF (High ejection fraction group-HEF). The mean age was 68.4±11.5 years and there were more females (86.5% versus 64.1%, P=0.007) in the LEF group. The prevalence of renal insufficiency was higher in LEF patients (27% versus 5.6%, P=0.001). Higher operative mortality (13.5% versus 3.1%, P=0.018) was observed in the LEF group. Stroke rates were similar in both groups (8.1% versus 4.1%, P=0.39). Unadjusted cumulative survival was significantly lower in LEF patients (6.6 years, 95% CI: 5.2-8.0, versus 9.7 years, 95% CI: 8.9-10.4, P=0.024). In patients without renal insufficiency, LEF and HEF had similar survival (8.3 years, 95% CI: 7.1-9.5, versus 9.9 years, 95% CI: 9.1-10.6, P=0.90). Contrarily, in patients with renal insufficiency, LEF led to a significantly lower survival (1.1 years, 95% CI: 0.1-2.0, versus 4.8 years, 95% CI: 2.2-7.3, P=0.050). Adjusted survival analysis revealed elevations in baseline creatinine (HR =4.28, P<0.001) and LEF (HR =5.33, P=0.041) as significant predictors of long-term survival, with a significant interaction between these comorbidities (HR =7.28, P<0.001). In re-AVR patients, low LVEF (≤35%) is associated with increased operative mortality. Concomitant renal insufficiency in these patients results in a prohibitively low cumulative survival. These reoperative surgical outcomes should warrant expanding the role of TAVR for reoperative patients with LEF and renal impairment.

Extraction of 223Radium by haemodialysis after treatment of metastatic castration-resistant prostate cancer

223Radium-dichloride (223Ra) administration is an upcoming therapeutic option in patients with castration-resistant metastatic prostate cancer (mCRPC), whose renal and faecal excretion of 223Ra has been primarily estimated from data of a phase-I clinical trial in patients with normal renal function. In the rare case of concomitant renal insufficiency requiring haemodialysis (HD), an estimation of the contamination of dialysate would be beneficial. The excretion of 223Ra and its concentration in the dialysate in a patient with mCRPC and end-stage renal disease was examined for six consecutive treatment cycles. Dialysate samples were measured using a commercial system with NaI-scintillation detector. HD showed a residual activity level in the remaining dialysate. The excreted activity was a median of 46.1 kBq (range = 42.0- 83.4 kBq) and 11.2 kBq (range = 8.4- 19.9 kBq) for the first (24 h post injection p.i.) and second HD (96 h p.i.), respectively. The activity concentration decreased significantly from a median of 4.18 kBq/l (range = 2.98-5.14 kBq/l) to 0.85 kBq/l (range = 0.69- 1.31 kBq/l, p < 0.0001). For all consecutive time points, the activity concentration further decreased significantly (p < 0.0001). The activity concentration of dialysate from HD performed 125.4 h p.i. [95 % confidence interval = 120.5-130.4 h p.i.] reached the threshold for unrestricted waste disposal. The observed extraction of 223Ra by HD exceeded the data determined from the phase-I study. The activity concentration in the dialysate observed for the first HD's p.i. was above the threshold for unrestricted disposal of radioactive waste in Germany. Therefore, the specific requirement for waste handling has to be followed to fulfil the radiation protection regulations.

Abstract WP314: Renal Insufficiency Worsens Outcomes in Cerebrovascular Disease

Introduction/Hypothesis: We were interested in studying patient outcomes with acute cerebrovascular disease (ACVD) who had concomitant acute or chronic renal insufficiency (RI). Methods: We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database (1998-2009) and identified 1,760,415 adult ACVD patients among 92,848,710 patients enrolled. Using SAS 6.4 and applying SPSS 22 the outcome variables mortality, length of hospital stay (LOS), HC (HC) &gt;$20,000, and disposition (home or any care facility) were selected. Logistic regression analyses were performed adjusting for the covariates hypertension (HTN), diabetes mellitus (DM), age, race, sex, number of comorbidities, and care complexity (numbers of inpatient procedures) among all ACVD with and without RI. Results: Mean age was 71 years (SD 15) with 76% &gt;65 years old; 54% female gender; 55% Whites, 11% Blacks, 6% Hispanics. Among all ACVD, 66% had HTN, 28% DM, RI 9%, LOS 7.6 days (SD 9.8), in-patient mortality 12%; disposition home 42% and facility 44%, and mean HC $36,010 (SD $63,331). After covariate adjustment, the mortality rate of ACVD patients with RI was 24% vs 11% (P&lt;0.001) for those without RI; LOS ≥7 days 50% vs 29% (P&lt;0.001); and facility discharge 62% vs 51% (P&lt;0.001). In subgroup analysis, adjusted HC were significantly greater in patients with acute RI (78% vs 43%; P&lt;0.001). The frequency of hemodialysis (HD) in all ACVD patients was 2.3%. Notably, HD was associated with LOS ≥7 days (61% vs 30%; p&lt;0.001), increased mortality rate (25% vs 12%; p&lt;0.001), and HC (76% vs 44%; p&lt;0.001). However, there was no difference in disposition to facility (57% vs 52%; p&lt;0.350). Conclusions: Acute or chronic RI was present in 9% of patients with ACVD. RI was associated with significantly greater risks of in-patient mortality, LOS, and discharge to a facility. In subgroup analyses, the overall HC were greater in patients with acute RI. Patients undergoing HD experienced a similar negative impact on all outcome parameters except for disposition status. The negative impact of RI on vital outcome parameters in ACVD patients should be considered, i.e., when indicating the administration of contrast for imaging.

Renal Function Recovery with Total Artificial Heart Support.

Heart failure patients requiring total artificial heart (TAH) support often have concomitant renal insufficiency (RI). We sought to quantify renal function recovery in patients supported with TAH at our institution. Renal function data at 30, 90, and 180 days after TAH implantation were analyzed for patients with RI, defined as hemodialysis supported or an estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m. Between January 2008 and December 2013, 20 of the 46 (43.5%) TAH recipients (age 51 ± 9 years, 85% men) had RI, mean preoperative eGFR of 48 ± 7 ml/min/1.73 m. Renal function recovery was noted at each follow-up interval: increment in eGFR (ml/min/1.73 m) at 30, 90, and 180 days was 21 ± 35 (p = 0.1), 16.5 ± 18 (p = 0.05), and 10 ± 9 (p = 0.1), respectively. Six patients (30%) required preoperative dialysis. Of these, four recovered renal function, one remained on dialysis, and one died. Six patients (30%) required new-onset dialysis. Of these, three recovered renal function and three died. Overall, 75% (15 of 20) of patients' renal function improved with TAH support. Total artificial heart support improved renal function in 75% of patients with pre-existing significant RI, including those who required preoperative dialysis.

Renal safety of intravenous gadolinium-enhanced magnetic resonance imaging in patients awaiting liver transplantation.

Renal dysfunction in cirrhosis carries a high morbidity and mortality. Given the potential risk of contrast-induced nephropathy associated with iodinated intravenous contrast used in computed tomography (CT), alternate contrast modalities for abdominal imaging in liver transplant candidates need to be examined. The purpose of this study was to examine the renal safety of magnetic resonance imaging (MRI) with gadolinium in patients awaiting liver transplantation. The study involved a retrospective analysis of 352 patients of abdominal MRI with low-dose gadobenate dimeglumine (MultiHance) (0.05 mmol/kg) in patients with cirrhosis and without renal replacement therapy at a single center during the period from 2007 to 2013. For each case, serum creatinine before and within a few days after the MRI were compared. In addition, the patients were analyzed for the development of nephrogenic systemic fibrosis (NSF), a reported complication of gadolinium in chronic kidney disease. The pre-MRI serum creatinine values ranged from 0.36 to 4.86 mg/dL, with 70 patients (20%) having values ≥ 1.5 mg/dL. A comparison of the pre- and post-MRI serum creatinine values did not demonstrate a clinically significant difference (mean change = 0.017 mg/dL; P = 0.38), including those patients with a pre-MRI serum creatinine ≥ 1.5 mg/dL. In addition, no cases of NSF were noted. In conclusion, our findings suggest that MRI with low-dose gadobenate dimeglumine (MultiHance) is a nonnephrotoxic imaging modality in liver transplant candidates, and its use can be cautiously expanded to liver transplant candidates with concomitant renal insufficiency.

Abstract 494: The Impact of Renal Insufficiency on Carotid Artery Disease Regression in an Academic Medical Center

Introduction: In the United States, 3% of adults are affected by carotid artery disease, and the prevalence is higher in patients with concomitant renal insufficiency. Ischemic events are also more common in patients with renal insufficiency and significantly contribute to morbidity and mortality. Despite the prevalence of carotid artery disease in individuals with renal insufficiency, only a few studies have examined the rate of carotid disease progression in this high risk group, and the mechanisms underlying disease progression are largely unknown. Hypothesis: Patients with any stage of renal insufficiency will have an accelerated rate of carotid artery atherosclerotic progression compared to patients with normal renal function. Methods: Retrospective chart review was performed on 171 consecutive patients referred to Cooper University Hospital for non invasive evaluation of carotid artery disease. Severity of carotid artery disease was evaluated with carotid doppler, and each patient had at least two carotid doppler studies performed at least 6 months apart. The sample was divided into 2 groups - [Group 1] GFR &gt; 60 and [Group 2] GFR &lt;60. Demographics, comorbidities, medications, serum creatinine, MDRD GFR and ultrasound analysis (proximal peak systolic velocity (PSV), and proximal end diastolic velocity (EDV)) were recorded. The average change in the PSV between studies for the 2 groups were calculated and compared. None of the patients in the sample were on dialysis. Results: Preliminary results revealed carotid artery disease regression in both groups; however, patients with any stage of renal insufficiency had less carotid artery disease regression compared to patients with normal renal function. Conclusions: Renal insufficiency negatively impacts the rate of carotid artery disease regression in patients with carotid artery disease. These results suggest that patients with renal insufficiency may require more aggressive follow-up and/or earlier invasive interventions of carotid artery disease. Current monitoring and treatment standards should be improved to adequately address the needs of this high risk subgroup.

MP41-11 NSAIDS FOR ACUTE UROLITHIASIS: UNDERUTILIZED ANALGESICS WITH POTENTIAL FOR COST SAVINGS

You have accessJournal of UrologyStone Disease: Medical Therapy1 Apr 2015MP41-11 NSAIDS FOR ACUTE UROLITHIASIS: UNDERUTILIZED ANALGESICS WITH POTENTIAL FOR COST SAVINGS Courtney K. Rowe, Deborah S. Hess, James S. Hwong, Francisco J. Gelpi-Hammerschmidt, Benjamin I. Chung, and Steven L. Chang Courtney K. RoweCourtney K. Rowe More articles by this author , Deborah S. HessDeborah S. Hess More articles by this author , James S. HwongJames S. Hwong More articles by this author , Francisco J. Gelpi-HammerschmidtFrancisco J. Gelpi-Hammerschmidt More articles by this author , Benjamin I. ChungBenjamin I. Chung More articles by this author , and Steven L. ChangSteven L. Chang More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1639AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Multiple studies have shown that non-steroidal anti-inflammatory drugs (NSAIDs) are effective analgesics for renal colic. However their use is often overly cautioned and curtailed even in patients with normal kidney function. The objectives of this study are to evaluate for underutilization of NSAIDs for renal colic in eligible patients, and to assess for differences in total hospital costs or length of stay between those who received NSAIDs and those who did not. METHODS The Premier Hospital Database was used to identify a sample of emergency room visits between 2003 and 2013 by adult patients with a primary diagnosis of kidney or ureteral stones (ICD9 592.0, 592.1, and 274.11). Patients with concomitant renal insufficiency (ICD9 581, 582, 583, 585, 586, 587, 589) were excluded. Patient level billing data were reviewed using regular expression matching to identify those who were administered NSAIDs on hospital day one. Univariate and multivariate analysis of total narcotic use, length of stay, and cost of hospitalization were performed. Total narcotic use was standardized to morphine equivalents, and accrued costs were normalized to 2013 values. Results were controlled for year, gender, race, Charlson Comorbidity Index (CCI), marital status, insurance provider, hospital setting, teaching hospital status, hospital size, and hospital region. RESULTS A weighted sample of 741,898 emergency room visits for urolithiasis were identified. Of these, 371,394 (50.1%) received NSAIDs. Nearly all NSAIDs were administered intravenously (98.3%), and patients who received NSAIDs were more likely to be young with a low CCI (p<0.001). Patients in the Western and Southern U.S. were more likely to receive NSAIDs compared to their counterparts in the Northeast and Midwest (p=0.046). Though NSAID use was associated with increased use of total morphine equivalents, total length of stay with was nearly one day less and associated with an average savings of $462 (Table 1). CONCLUSIONS At only 50% use, NSAIDs are underutilized for the treatment of renal colic. Because they offer tangible benefits including decreased hospital costs and shortened lengths of stay, they should be considered in all eligible adult patients who present to the emergency department with renal colic. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e503-e504 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Courtney K. Rowe More articles by this author Deborah S. Hess More articles by this author James S. Hwong More articles by this author Francisco J. Gelpi-Hammerschmidt More articles by this author Benjamin I. Chung More articles by this author Steven L. Chang More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Abstract 11924: Phenotypes of Heart Failure Identified via Cluster Analysis Do Not Recapitulate Hemodynamic Profiles: Insights From the ESCAPE Trial

Background: Heart failure (HF) classification criteria do not adequately describe disease state. We used cluster analysis to identify distinct phenotypes of patients in the pulmonary artery catheter (PAC) arm of the ESCAPE trial, and examine association of clusters with hemodynamic profiles. Methods: Cluster analysis was performed on baseline clinical variables and PAC measurements in a cohort of 172 subjects from the ESCAPE trial, a randomized study examining PAC versus usual care in advanced systolic HF patients. ANOVA examined association between patient clusters and clinically determined hemodynamic profiles (warm/cold/wet/dry); association with clinical outcomes was assessed using Cox proportional hazards models. Results: Four HF clusters were identified with the following general characteristics: Cluster 1(n=75): Male Caucasians with ischemic cardiomyopathy, multiple comorbidities, lowest BNP levels; Cluster 2 (n=33): Females with non-ischemic cardiomyopathy, few comorbidities, most favorable hemodynamics; Cluster 3 (n=29): Young African American males with non-ischemic cardiomyopathy, most adverse hemodynamics and advanced disease; Cluster 4 (n=25): Older Caucasians with ischemic cardiomyopathy, concomitant renal insufficiency, and highest BNP levels. We noted no association between hemodynamic profiles and clusters (P=0.70). Cluster 4 patients had the highest risk of all adverse clinical outcomes, whereas cluster 2 had the lowest. Compared to patients in cluster 4, patients in other clusters had 45-70% lower risk of all-cause mortality. Conclusions: Using a novel approach that clusters patients according to similar clinical variables and PAC measures, we identified 4 clinically relevant phenotypes of HF patients, with no discernable relationship to hemodynamic profiles. Our analysis suggests that HF classification can be enhanced by simultaneous considerations of etiology, comorbid conditions, and biomarker levels.

N-terminal pro-brain natriuretic peptide is a useful prognostic marker in patients with pre-capillary pulmonary hypertension and renal insufficiency.

N-terminal pro-brain natriuretic peptide (NT-proBNP) is a routinely used prognostic parameter in patients with pre-capillary pulmonary hypertension (PH). As it accumulates in the presence of impaired renal function, the clinical utility of NT-proBNP in PH patients with concomitant renal insufficiency remains unclear. In a retrospective approach, patients with pre-capillary PH (group I or IV) and concomitant renal insufficiency at time of right heart catheterization (glomerular filtration rate (GFR) ≤60 ml/min/1.73 m2) were identified out of all prevalent pre-capillary PH patients treated at a single center. Forty patients with renal insufficiency (25.8%) were identified and matched regarding hemodynamic parameters with a control group of 56 PH patients with normal renal function (GFR >60 ml/min/1.73 m2). Correlations of NT-proBNP levels with hemodynamic and prognostic parameters (time to clinical worsening and overall survival) were assessed. Overall, GFR correlated inversely with NT-proBNP and had the strongest influence on NT-proBNP levels in a stepwise multiple linear regression model including hemodynamic parameters and age (r2 = 0.167). PH patients with renal insufficiency had significant higher levels of NT-proBNP (median: 1935 ng/l vs. 573 ng/l, p = 0.001). Nevertheless, NT-proBNP correlated with invasive hemodynamic parameters in these patients. Using higher cut-off values than in patients with preserved renal function, NT-proBNP levels were significantly associated with time to clinical worsening (>1660 ng/l, p = 0.001) and survival (>2212 ng/l, p = 0.047) in patients with renal insufficiency. Multivariate Cox’s proportional hazards analysis including established prognostic parameters, age and GFR confirmed NT-proBNP as an independent risk factor for clinical worsening in PH patients with renal insufficiency (hazard ratio 4.8, p = 0.007). Thus, in a retrospective analysis we showed that NT-proBNP levels correlated with hemodynamic parameters and outcome regardless of renal function. By using higher cut-off values, NT-proBNP seems to represent a valid clinical marker even in PH patients with renal insufficiency.

Heart and Combined Heart–Kidney Transplantation in Patients With Concomitant Renal Insufficiency and End-Stage Heart Failure

In patients with end-stage heart failure (ESHF) who are candidates for isolated heart transplant (HRT), dialysis dependence (DD) is considered an indication for combined heart-kidney transplantation (HKT). HKT remains controversial in ESHF transplant candidates with nondialysis-dependent renal insufficiency (NDDRI). Using United Network for Organ Sharing data, we examined the cumulative incidences of transplant and mortality in patients with DD and NDDRI waitlisted for HKT or HRT. In all groups, 3-month waitlist mortality was dismal: 31% and 21% for HRT- and HKT-listed patients with DD and 12% and 7% for HRT- and HKT-listed patients with NDDRI. Five-year posttransplant survival was improved in HKT recipients compared with HRT recipients for both patients with DD (73% vs. 51%, p<0.001) and NDDRI (80% vs. 69%, p<0.001). Likewise, multivariable analysis associated HKT with better outcomes than HRT in HKT-listed patients, although both improved survival. These data argue strongly for HKT in ESHF transplant candidates with DD. However, in patients with NDDRI, HKT must be weighed against the possibility of renal recovery with isolated HRT. Whether HRT (followed by a staged kidney transplant in patients who do not recover renal function after HRT), as opposed to HKT, maximizes organ benefit for patients with NDDRI and ESHF requires assessment. Nevertheless, given their dismal waitlist outcomes and excellent posttransplant results, we suggest that patients with DD and NDDRI with ESHF be considered for early listing and transplant.

Three-Dimensional Guided Renal Denervation to Treat Drug-Resistant Arterial Hypertension in a Patient With Renal Insufficiency

HomeHypertensionVol. 60, No. 4Three-Dimensional Guided Renal Denervation to Treat Drug-Resistant Arterial Hypertension in a Patient With Renal Insufficiency Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessLetterPDF/EPUBThree-Dimensional Guided Renal Denervation to Treat Drug-Resistant Arterial Hypertension in a Patient With Renal Insufficiency Thorsten Lewalter and Turgut Brodherr Thorsten LewalterThorsten Lewalter Isar Heart Center Munich, Munich, Germany Search for more papers by this author and Turgut BrodherrTurgut Brodherr Isar Heart Center Munich, Munich, Germany Search for more papers by this author Originally published20 Aug 2012https://doi.org/10.1161/HYPERTENSIONAHA.112.201467Hypertension. 2012;60:e33Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2012: Previous Version 1 To the Editor:A 68-year–old diabetic women was transferred to our department for renal denervation to treat drug-resistant arterial hypertension. A known diabetic nephropathy deteriorated after an abdominal computed tomography scan in the external hospital with an increase of the serum creatinine (baseline, 1.3 mg/dL; 5 days after computed tomography, 2.1 mg/dL; at admission to our hospital, 1.4 mg/dL). To reduce or even eliminate the amount of necessary contrast medium during the denervation procedure we decided to perform a 3D guided ablation procedure.For this purpose, the external abdominal computed tomography scan was used to reconstruct the 3D anatomy of the renal arteries. The impedance-based NavX system (St Jude), used routinely in arrhythmia ablation, was used to create a virtual anatomy of both renal arteries by touching the vessel walls. For image fusion, critical anatomic landmarks like, for example, an orifice of the renal arteries or areas of vessel bifurcation, were determined by comparing the position of the catheter in the native x-ray and the 3D image based on computed tomography anatomy. A decapolar steerable electrode catheter in the renal venous system served as the local reference catheter (Figure A and B, video).Download figureDownload PowerPointFigure. Anterolateral view (A) and posterior view (B) of the 3D image of the renal artery (red), the renal vein (blue), and kidney parenchyma (gray). The reference decapolar catheter is positioned in a side branch of the renal vein. The ablation catheter can be located in the proximal portion of the renal artery. The green dots indicate ablation spots.To perform the ablation, a cooled tip 7F quadripolar radiofrequency ablation (IBI/St Jude) catheter with a flow of 17 mL/min and a maximum of 10 watts was used in a power-controlled mode (IBI/St Jude RF generator). In the right renal artery 11 ablation points and in the left 13 ablation points were delivered in a spiral manner from the distal until the proximal portion of both renal arteries. To check the distal catheter position once for the fusion process, a single contrast medium injection was performed in each renal vein (7 mL for the left and 8 mL for the right), leading to a total contrast medium volume of 15 mL for the entire procedure. To reduce the risk of vasospasm, we performed the procedure in deep sedation (propofol infusion). No creatinine increase could be detected after the ablation procedure. A postprocedural Doppler sonography of both renal arteries revealed no evidence for a stenotic process. At 3 months after the procedure, a drop in the mean systolic blood pressure of 9 mm Hg and in the mean diastolic pressure of 4 mm Hg in a 24-hour measurement could be documented.To our knowledge, this is the first report about a cooled tip renal denervation using a 3D nonfluoroscopic guiding system. This approach allows an ablation requiring only a minimal amount of contrast medium. Even a procedure without any contrast medium appears feasible with this technique. Therefore, this approach is of special interest in patients with drug-resistant arterial hypertension and concomitant renal insufficiency with the aim of reducing their exposure to contrast medium to a minimum.Thorsten LewalterTurgut BrodherrIsar Heart Center MunichMunich, GermanyFootnotesLetters to the Editor will be published, if suitable, as space permits. They should not exceed 1000 words (typed double-spaced) in length and may be subject to editing or abridgmentThe online-only Data Supplement is available with this article at http://hyper.ahajournals.org/lookup/suppl/doi:10.1161/HYPERTENSIONAHA.112.201467/-/DC1. Previous Back to top Next FiguresReferencesRelatedDetailsCited By Tölle M and van der Giet M (2013) Renale Denervation als Therapieoption, CardioVasc, 10.1007/s15027-013-0022-1, 13:1, (38-44), Online publication date: 1-Feb-2013. Xiao Y, Zhou S and Liu Q (2012) Ablation Points of Renal Sympathetic Denervation: The More, the Better?, Hypertension, 60:6, (e47-e47), Online publication date: 1-Dec-2012. October 2012Vol 60, Issue 4 Advertisement Article InformationMetrics © 2012 American Heart Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.112.201467PMID: 22914794 Originally publishedAugust 20, 2012 PDF download Advertisement SubjectsArrhythmiasCatheter Ablation and Implantable Cardioverter-DefibrillatorHypertensionTreatment

Surgical management of aortic root abscess: A 13-year experience in 172 patients with 100% follow-up

The study objective was to evaluate the outcomes of surgery for active infective endocarditis with aortic root abscess formation. Between July 1996 and June 2009, 1161 patients underwent operation for aortic valve endocarditis, of whom 172 had aortic root abscess. The infected valve was native in 96 patients and prosthetic in 76 patients. Patients' mean age (± standard deviation) and logistic EuroSCORE-predicted risk of mortality were 62 ± 13 years and 23.1% ± 26%, respectively. Surgery was emergent in 96 patients (58%). The abscess involved the aortic annulus in 90 patients (52%), the intervalvular fibrous body in 81 patients (47%), and the mitral annulus in 21 patients (12%). Surgery consisted of radical resection of the abscess, reconstruction of the annulus with patches, and valve replacement. Estimated mean follow-up was 4.0 ± 0.3 years (range, 0-8.2 years). Thirty-day mortality was 25% (n = 43) (prosthetic valve endocarditis vs native valve endocarditis, 35.5% vs 16.7%, P = .005). Independent predictors of mortality were sepsis (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.2-10.7), renal insufficiency (OR, 3.3; 95% CI, 1.1-9.5), concomitant coronary artery bypass grafting (OR, 2.8; 95% CI, 1.1-7.0), and prosthetic valve endocarditis (OR, 2.4; 95% CI, 1.1-5.6). Survival at 1 and 5 years was 55% ± 4% and 50% ± 4%, respectively, and predicted by concomitant mitral endocarditis (OR, 3.2; 95% CI, 1.3-8.2), sepsis (OR, 2.7; 95% CI, 1.6-4.5), renal insufficiency (OR, 1.9; 95% CI, 1.1-3.4), and age (OR, 1.05; 95% CI, 1.02-1.07). Endocarditis recurred in 15 patients (8.7%) at a mean of 1.8 ± 2.4 years postoperatively (39 days to 6 years). The surgical treatment of aortic root abscess remains a challenge with relatively high perioperative morbidity and mortality, although long-term survival is satisfactory.