Dialysis-dependent Chronic Renal Failure Research Articles

CEREBRALANEURYSM SURGERY IN A PATIENT WITH CHRONIC RENAL FAILURE: PERIOPERATIVE CONCERNS AND CONFLICTS

Chronic renal failure (CRF) and associated multi-system abnormalities can adversely impact the outcome in patients undergoing high-risk aneurysm surgeries by causing hemodynamic instability, uid-electrolyte imbalance, bleeding and coagulation abnormalities, decreased anesthetic drug excretion, and dialysis-related complications. Conicts between the standard perioperative practices in aneurysm surgery and those in CRF further contribute to the management challenges. These include, using low anesthetic drug doses but achieving good brain relaxation, using a restrictive uid therapy but preventing postoperative vasospasm, and avoiding diuretics causing nephrotoxicity but reducing intracranial pressure. Ayoung male with dialysis-dependent CRF and hypertension underwent emergency craniotomy and clipping of a cerebral aneurysm. He was managed with a modied protocol of reduced heparin hemodialysis, BIS-guided use of minimum anesthetic drugs, goal-directed optimum uid therapy, maintaining hemodynamic stability, and management of post-aneurysm clipping vasospasm with hypertension. His perioperative management and related conicts are discussed

Skull fracture and epidural hematoma caused by use of a Mayfield skull clamp in an adult patient with chronic hemodialysis: a case report

BackgroundMayfield skull clamps are widely used and indispensable in current neurosurgery. Complications such as skull fractures or intracranial hematoma from using a Mayfield skull clamp have largely been reported in the pediatric population, are likely related to the relative thinness of the skull, such as in patients with hydrocephalus, and are extremely rare in adults. Here, we report a case of skull fracture and epidural hematoma caused by a Mayfield skull clamp used for posterior decompression surgery in an adult patient with chronic hemodialysis.Case presentationA 67-year-old Asian male patient with a history of dialysis-dependent chronic renal failure over 36 years suffered from severe cervical myelopathy. Neurological examination and radiographic images revealed cervical spondylotic myelopathy due to dialysis-related spondyloarthropathy. Laminoplasty was planned on patient consent. A Mayfield skull clamp was applied with the patient supine. Torque was applied to the screws with gentle care, but there was no resistance and it was not easy to reach the standard 60 lb (267 N) to 80 lb (356 N). Because a skull fracture was suspected, we canceled the surgery. Emergency head computed tomography showed depressed skull fractures underlying the single-pin sites with an associated epidural hematoma. The fractures and epidural hematoma were treated conservatively, and spontaneous resolution of the hematoma was confirmed. Cervical laminoplasty was performed successfully using a mask-type head holder on the subsequent day.ConclusionsAs a precaution for fractures and epidural hematoma in neurosurgical patients with bone fragility or a thin skull, use of a mask-type fixing device or halo ring is recommended.

Monoclonal Gammopathy with Secondary Atypical Hemolytic-Uremic Syndrome

Monoclonal gammopathy is a clonal plasma cell disorder associated with an increased risk of progression to lymphoproliferative malignancy. In children, monoclonal and oligoclonal gammopathies are rare, and their clinical relevance unrecognized. Atypical hemolytic uremic syndrome (aHUS) is a rare endotheliopathy associated with dysregulated activation of complement, microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. We present a case of aHUS that we hypothesize was triggered by monoclonal gammopathy in a child several years after cardiac transplantation. An 11 year old African-American girl with sickle trait was transferred to our cardiac center with a two week history of epigastic pain, emesis, microcytic anemia, hypergammaglobulinemia, and development of renal failure requiring dialysis. She had undergone cardiac transplantation at 7 months of age for dilated cardiomyopathy of unknown etiology and had recovered from acute cardiac rejection requiring ECMO at age 5 years. She had previously experienced at least two episodes of acute kidney injury requiring dialysis with full recovery of function reported. Renal biopsy revealed a severe collapsing glomerulopathy and a thrombotic microangiopathy. Upon transfer to our institution, her labs were notable for microcytic anemia, normal platelet count, haptoglobin, and LDH. A week later, she developed aHUS diagnosed by hemoglobin 9.5 gm/dL, haptoglobin < 30 mg/dL, LDH 314 U/L, platelets 100,000, and a predominance of schistocytes on peripheral blood smear in the setting of acute renal failure. Serum protein electrophoresis (SPEP) revealed a monoclonal spike (1g/dL), identified as IgG kappa by immunoabsorption. A second, smaller monoclonal spike was identified as IgA lambda. aHUS evaluation revealed low C3, normal C4, and 50% CD46 expression by flow cytometry. Bone marrow biopsy with flow cytometry excluded lymphoproliferative disorders. EBV did not amplify with quantitative PCR of peripheral blood, and computed tomography imaging of the body did not detect abnormal mass or lymph nodes. A trial of plasmapheresis did not improve biochemical and hematologic features of aHUS. A trial of eculizumab resulted led to normalization of platelet count and C3, increased haptoglobin, reduced need for red cell transfusion, and less frequent dialysis. Monoclonal gammopathy of unknown significance (MGUS) is rare in children, but may be more common in transplant recipients, especially after cardiac transplants in infants when thymectomy is performed. MGUS associated with secondary aHUS has been rarely reported in adults. The mechanism for aHUS was demonstrated in one case to result from affinity of the paraprotein to a binding site on complement factor H, with subsequent loss of factor H cofactor activity to inhibit alternative complement activation. We hypothesize that immune dysregulation from fluctuating levels of paraproteins during inflammation in our patient with monoclonal gammopathy resulted in recurrent, intermittent episodes of aHUS. We speculate that this was responsible for the patient's collapsing glomerulopathy and dialysis-dependent chronic renal failure. This case highlights the importance of considering monoclonal gammopathy in pediatric patients who develop recurrent kidney failure or atypical hemolytic uremic syndrome in the setting of immune dysregulation. The merit of treating the monoclonal gammopathy with Bortezumib and Rituximab is currently under consideration. Disclosures No relevant conflicts of interest to declare.

Long-Term Single-Center Outcomes of Patients With Chronic Renal Dialysis Undergoing Cardiac Surgery

The prevalence of dialysis-dependent chronic renal failure (DD-CRF) is growing worldwide. Such patients are exposed to a higher cardiovascular risk because of severe calcification and congestive heart failure caused by volume overload, with poor outcomes. This study aimed to evaluate outcomes of patients with DD-CRF who were undergoing cardiac surgery in a single institution (West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany). A retrospective evaluation of 241 consecutive patients who presented with DD-CRF and were undergoing cardiac-surgery between January 2000 and December 2017 was conducted. End points were major adverse cardiac and cerebrovascular events and long-term survival. Additionally, Cox regression multivariate analysis was performed to detect independent predictors of mortality. Follow-up was 98.3% complete through August2018. The mean age of the study cohort was 63 ± 12.2 years, and 65.1% of these patients were male. Congestive heart failure (CHF) was present in 41.5% of patients, 30.7% had a previous myocardial infarction, 9.1% had previous cardiac surgery, and 22.4% needed urgent or emergency surgery. These patients underwent isolated coronary artery bypass grafting (44.8%), isolated procedures other than coronary artery bypass grafting (17.8%), or concomitant procedures (37.3%). Early outcomes reported in-hospital mortality in 10.4%, low cardiac output syndrome in 7.1%, and stroke in 2.1% of patients, respectively. Overall mortality was recorded in 61% of patients at last follow-up. Cox regression multivariate analysis reported age 60 years or older (hazard ratio [HR], 2.36; 95% confidence interval [CI], 1.62 to 3.45; P < .001) and CHF (HR, 1.95; 95% CI, 1.37 to 2.78; P < .001) as positive predictors of death and subsequent kidney transplantation (HR, 0.35; 95% CI, 0.20 to 0.59; P < .001) as a negative predictor of death. Cardiac surgery in patients with DD-CRF is associated with high morbidity and mortality. Interestingly, overall mortality was mainly not cardiac related, and older patients or those who presented with CHF had the worst life expectancy. However, subsequent kidney transplantation positively affected long-term survival in these patients.

Pruritic Rash in an Elderly Patient with Uncontrolled Diabetes Mellitus

Acquired reactive perforating collagenosis is an uncommon skin disease that belongs to a group of dermatologic disorders characterized by transepidermal elimination of dermal material. It is highly associated with systemic disease, primarily diabetes mellitus and dialysis-dependent chronic renal failure. A 70-year-old female with 20 years of poorly controlled type 2 diabetes mellitus presented with a 6-month history of multiple pruritic erythematous papules and nodules with central hyperkeratosis, involving her right dorsal arm. Histologic examination was consistent with acquired reactive perforating collagenosis. In addition to topical treatment of the disease, the patient was referred to endocrinology for appropriate management of her underlying diabetes mellitus. Ideal treatment should involve both the endocrinologist and dermatologist. Control of the underlying systemic disease, in this case diabetes, as well topical or systemic medications can both help to improve this condition. Our patient re-established care with her endocrinologist who adjusted her medication regimen, resulting in improved hemoglobin A1c values. Our patient additionally benefited from topical betamethasone cream, ammonium lactate, and pimecrolimus application. The combined therapy led to resolution of her pruritic rash. This case highlights the importance of the skin exam by the endocrinologist, as he or she plays a unique role in identifying this rare and difficult-to-treat dermatologic disease. Early detection and prompt referral to a dermatologist are crucial in preventing progression of disease, treating the disease, and improving the patient's quality of life.

Outcomes of Dialysis-Dependent Patients After Cardiac Operations in a Single-Center Experience of 483 Patients

The aim of this study was to determine the preoperative predictors of in-hospital and medium-term mortality in patients with dialysis-dependent chronic renal failure (DD CRF) undergoing cardiac operations. Between January 1996 and June 2014, 483 consecutive patients with DD CRF underwent cardiac surgical procedures. The mean age was 65 ± 11 years, and 32. 3% were women. Isolated coronary artery bypass grafting (CABG) or isolated valve operations were performed in 39.8% and 32.3%, of patients, respectively. Combined surgical procedures (CABG with valve operations) were necessary in 20.3% of patients. Endocarditis was an indication for surgical intervention in 11% of patients. Urgent or emergent operations were performed in 49.3% of patients. The in-hospital mortality was 15.3%. Postoperative respiratory failure, gastrointestinal complications, low cardiac output, stroke, and sepsis occurred in25.7%, 12.4%, 11.8%, 5.6%, and 5.2% of patients, respectively. The independent predictors of in-hospital mortality were combined mitral and aortic valve pathologic conditions (odds ratio [OR], 3.7, 95% CI, 1. 5-9; p=0.003), chronic obstructive pulmonary disease (OR, 2.6; 95% CI, 1.1-5.9; p= 0. 03), peripheral vascular disease (OR, 2.3; 95% CI, 1.04-4; p= 0.003), left ventricular ejection fraction (LVEF) <30% (OR, 2.9; 95% CI, 1.3-6. 4; p= 0.008), and active endocarditis (OR, 2.2; 95% CI, 1.04-4.6; p= 0.04). The estimated 2-, 4-, and 6-year survival was 50.1% ± 2%, 34.3% ± 2%, and 20.3% ± 2%, respectively. Previous cerebrovascular accident, active endocarditis, previous cardiac operations, and combined aortic/mitral valve pathologic conditions were independent predictors of medium-term mortality. Patients with DD CRF undergoing cardiac operations have high perioperative and medium-term mortality, particularly in the presence of combined aortic and mitral valve pathologic conditions, active endocarditis, and poor left ventricular function.

TCTAP C-234 Early Core Valve Stenosis Due to Extensive Calcification in a Patient with Dialysis-dependent Chronic Renal Failure

TCTAP C-234 Early Core Valve Stenosis Due to Extensive Calcification in a Patient with Dialysis-dependent Chronic Renal Failure

Cardiopulmonary bypass increases the risk of vasoplegic syndrome after coronary artery bypass grafting in patients with dialysis-dependent chronic renal failure.

ObjectiveCoronary artery bypass grafting is currently the best treatment for dialysis patients with multivessel coronary artery involvement. Vasoplegic syndrome of inflammatory etiology constitutes an important postoperative complication, with highly negative impact on prognosis. Considering that these patients have an intrinsic inflammatory response exacerbation, our goal was to evaluate the incidence and mortality of vasoplegic syndrome after myocardial revascularization in this group.MethodsA retrospective, single-center study of 50 consecutive and non-selected dialysis patients who underwent myocardial revascularization in a tertiary university hospital, from 2007 to 2012. The patients were divided into 2 groups, according to the use of cardiopulmonary bypass or not (off-pump coronary artery bypass). The incidence and mortality of vasoplegic syndrome were analyzed. The subgroup of vasoplegic patients was studied separately.ResultsThere were no preoperative demographic differences between the cardiopulmonary bypass (n=20) and off-pump coronary artery bypass (n=30) group. Intraoperative data showed a greater number of distal coronary arteries anastomosis (2.8 vs. 1.8, P<0.0001) and higher transfusion rates (65% vs. 23%, P=0.008) in the cardiopulmonary bypass group. Vasoplegia incidence was statistically higher (P=0.0124) in the cardiopulmonary bypass group (30%) compared to the off-pump coronary artery bypass group (3%). Vasoplegia mortality was 50% in the cardiopulmonary bypass group and 0% in the off-pump coronary artery bypass group. The vasoplegic subgroup analysis showed no statistically significant clinical differences.ConclusionCardiopulmonary bypass increased the risk for developing postoperative vasoplegic syndrome after coronary artery bypass grafting in patients with dialysis-dependent chronic renal failure.

Brain Natriuretic Peptide on Admission as a Biological Marker of Long-Term Mortality in Ischemic Stroke Survivors

Background and Purpose: We investigated whether brain natriuretic peptide (BNP) can serve as a biological marker of long-term mortality in ischemic stroke survivors. Methods: Consecutive patients with ischemic stroke within 24 h of onset from April 2007 to December 2010 were prospectively enrolled, and admission plasma BNP levels were measured. Survivors were followed up until 1 year after stroke onset. Patients were divided into two groups: the deceased group and the surviving group. The factors associated with long-term mortality were investigated by multiple logistic regression analysis. Results: A total of 736 patients who were alive at hospital discharge were included; 130 (17.7%) patients died. On multivariate analysis, age >75 years (odds ratio, OR, 2.83; 95% CI, 1.74-4.60, p = 0.0001), dialysis-dependent chronic renal failure (OR, 5.99; 95% CI, 2.18-16.47, p = 0.0005), modified Rankin Scale score >3 at discharge (OR, 4.41; 95% CI, 2.76-7.05, p < 0.0001), and plasma BNP >100.0 pg/ml (OR, 3.94; 95% CI, 2.31-6.73, p < 0.0001) were found to be independently associated with long-term mortality. We developed a risk score from 4 variables (each variable: 1 point, total score: 0-4 points). The mortality rates were 2% with a score of 0, 9% with a score of 1, 27% with a score of 2 and 50% with a score ≥3. Conclusions: The risk score, composed of clinical parameters and BNP, may predict long-term mortality in ischemic stroke survivors.

Acquired perforating dermatosis: a clinical and dermatoscopic correlation

Acquired Perforating Dermatosis (APD) is a perforating disease characterized by transepidermal elimination of dermal material [1,2]. This disease usually develops in adulthood. APD has been reported to occur in association with various diseases, but is most commonly associated with dialysis-dependent chronic renal failure (CRF) or diabetes mellitus (DM) [1,2,3,4]. Morton et al found that APD occurs in up to 10% of patients undergoing hemodialysis [5]. Additionally, Saray et al found that sixteen of twenty-two cases with APD were associated with CRF [3].

Death or Dialysis? the Risk of Dialysis-Dependent Chronic Renal Failure after Trauma Nephrectomy

Although renal trauma is increasingly managed nonoperatively, severe renovascular injuries occasionally require nephrectomy. Long-term outcomes after trauma nephrectomy are unknown. We hypothesized that the risk of end-stage renal disease (ESRD) is minimal after trauma nephrectomy. We conducted a retrospective review of the following: 1) our university-based, urban trauma center database; 2) the National Trauma Data Bank (NTDB); 3) the National Inpatient Sample (NIS); and 4) the U.S. Renal Data System (USRDS). Data were compiled to estimate the risk of ESRD after trauma nephrectomy in the United States. Of the 232 patients who sustained traumatic renal injuries at our institution from 1998 to 2007, 36 (16%) underwent a nephrectomy an average of approximately four nephrectomies per year. The NTDB reported 1780 trauma nephrectomies from 2002 to 2006, an average of 356 per year. The 2005 NIS data estimated that in the United States, over 20,000 nephrectomies are performed annually for renal cell carcinoma. The USRDS annual incidence of ESRD requiring hemodialysis is over 90,000, of which 0.1 per cent (100 per year) of renal failure is the result of traumatic or surgical loss of a kidney. Considering the large number of nephrectomies performed for cancer, we estimated the risk of trauma nephrectomy causing renal failure that requires dialysis to be 0.5 per cent. National data regarding the etiology of renal failure among patients with ESRD reveal a very low incidence of trauma nephrectomy (0.5%) as a cause; therefore, nephrectomy for trauma can be performed with little concern for long-term dialysis dependence.

Relapsed acute promyelocytic leukemia in a hemodialysis-dependent patient treated with arsenic trioxide: a case report.

IntroductionIn the relapsed setting, arsenic trioxide remains the backbone of treatment. Scant literature exists regarding treatment of relapsed acute promyelocytic leukemia in patients with renal failure. To the best of our knowledge we are the first to report a safe and effective means of treatment for relapsed acute promyelocytic leukemia in the setting of advanced renal failure, employing titration of arsenic trioxide based on clinical parameters rather than arsenic trioxide levels.Case presentationA 33-year-old Caucasian man with a history of acute promyelocytic leukemia in remission for 3 years, as well as dialysis-dependent chronic renal failure secondary to a solitary kidney and focal segmental glomerulosclerosis and human immunodeficiency virus infection, receiving highly active antiretroviral therapy presented to our hospital with bone marrow biopsy-confirmed relapsed acute promyelocytic leukemia. Arsenic trioxide was begun at a low dose with dose escalation based only on side effect profile monitoring and not laboratory testing for induction as well as maintenance without undue toxicity. Our patient achieved and remains in complete hematologic and molecular remission as of this writing.ConclusionArsenic trioxide can be used safely and effectively to treat acute promyelocytic leukemia in patients with advanced renal failure using careful monitoring of side effects rather than blood levels of arsenic to guide therapeutic dosing.

Comments on O’Brien et al.: Prevalence and outcome of cirrhosis patients admitted to UK intensive care: a comparison against dialysis-dependent chronic renal failure patients

Dear Editor, We read with interest the article by O’Brien et al. [1] on the prevalence and outcome of patients with cirrhosis admitted to British ICUs. While the authors raise important points regarding the high mortality of decompensated cirrhosis and the increasing burden placed on critical care services by such patients, we feel their interpretation should not go unchallenged as there are several major limitations to the analysis that mitigate their bold and nihilistic conclusions. Firstly, as the authors themselves partly acknowledge, chronic renal failure is clearly not the same as hepatic failure. The outcome for patients with dialysis dependent endstage renal disease (ESRD) admitted to the ICU is surprisingly good, is better than that of patients admitted with acute kidney injury and has frequently been reported to be little different from that of the general ICU population [2]. In addition, a treatment does exist that directly addresses the underlying organ failure in ESRD, but no such equivalent is available for hepatic failure. We do not believe therefore that the authors’ argument that the two conditions are comparable for the sake of their analysis can be in anyway justified. The second shortcoming of the paper relates to its use of the Intensive Care National Audit & Research Centre (ICNARC) database. This brings with it several major problems in terms of data availability. The ICNARC and Acute Physiology and Chronic Health Evaluation II (APACHE II) models do not collect parameters that quantify either the presence or severity of liver disease. This limits the utility of these models to predict outcome in patients with liver disease, likely explaining why the ICNARC and APACHE II scores were higher for dialysis-dependent ESRD patients compared with patients with cirrhosis and significantly under-predicting mortality for this latter group. In contrast, evidence does exist that the Sequential Organ Failure Assessment (SOFA) score (which includes bilirubin as one of its parameters) performs better than APACHE II score in predicting outcome in patients with cirrhosis admitted to the ICU [3]. A further weakness of the article is the inability to identify the specific reason for ICU admission. For example, variceal bleeding is the commonest reason for ICU admission in many series [3], and ICU mortality has been demonstrated to have fallen threefold between 1980 and 2000 [4]. However, there is no way to interpret the authors’ data in the absence of specific admission data. It is undeniable that mortality in patients with cirrhosis who develop multiple organ failure is high and that the development of sepsis is a grave prognostic sign, but we would challenge the assertion that we should seek to identify earlier those patients with a poor prognosis so we can exclude them from critical care. Rather, our focus should be to more rapidly identify sepsis and organ dysfunction and admit such patients earlier to critical care units to prevent further deterioration in organ function with its associated increase in mortality risk. Such an approach, which is in direct contrast to the prognostic pessimism proposed by the authors, may then begin to deliver the improvement in outcome seen in severe sepsis in recent years [5] and produce further increases in survival in patients with cirrhosis above the 5 % reduction in mortality over time that the authors report.

Prevalence and outcome of cirrhosis patients admitted to UK intensive care: a comparison against dialysis-dependent chronic renal failure patients: Reply to comments by Mason and Yeoman

Dear Editor, We thank Drs Mason and Yeoman for their comments on our paper [1] as these raise a number of very interesting points. However, we would challenge the statement that these points mitigate against our conclusions. As mentioned in the previous reply to Drs Berry and Thompson [2], we do not wish to be seen as champions of nihilism for patients with cirrhosis; rather, our pessimistic conclusions simply reflect the data presented. Indeed, despite improvements in many aspects of critical care over the last 20 years, ICU mortality rates associated with cirrhosis remain very high. We felt that it was time for a change in the message from ‘‘we must try harder’’ to something bolder. It is very hard to advocate continuing ICU care when mortality rates exceed 85–90 %, especially as the vast majority of patients will not be eligible for transplantation. We perhaps should have added a section about optimising pre-ICU care and feel the authors’ critical care bundle suggestion has considerable merit, although whether this would have a benefit on mortality rates remains of course uncertain. However, the suggestion that cirrhosis patients be admitted earlier to the ICU is simplistic and naive given that using Hospital Episode Statistic data we identified [100,000 patients admitted to UK hospitals 2010–2011 with complications of cirrhosis (http://www. hesonline.nhs.uk). As an alternative, we would suggest borrowing another approach from sepsis studies—that of early ‘‘goal-directed therapy’’ [3], either in the emergency room or on the acute admissions ward. Indeed, a recent study has demonstrated that delayed appropriate initial empiric antimicrobial therapy is associated with increased mortality in cirrhosis [4]. As we acknowledge in our paper, the comparison with renal replacement therapy is imperfect, and we again refer to this in our reply to Drs Berry and Thompson [2], However, this hardly mitigates against our conclusion that cirrhosis patients with organ failure have an extremely poor prognosis. Rather than labour this point, we would refer these authors to the very similar overall mortality (59.2 %) seen in patients with haematological malignancies admitted to ICU [5], as mentioned in our discussion; this is a group we hope that all will agree can be regarded as having a poor prognosis. We cannot agree that using the Intensive Care National Audit & Research Centre (ICNARC) database to examine the largest cohort of ICU admissions with liver cirrhosis reported to date can be regarded as a study weakness. We acknowledge in our discussion that neither the Acute Physiology and Chronic Health Evaluation II (APACHE II) nor ICNARC score contains information directly relating to liver failure and conclude that neither score can guide decision-making; however, the area under the receiver operating characteristic curve (AUROC) of 0.8 that is seen with the ICNARC score is comparable to that obtained using Sequential Organ Failure Assessment (SOFA) and Organ System Failure (OSF) models in other studies. Equally, the fact that these scores under-predicted mortality had not been reported before, and we thought it worthy of mention. Again, we do acknowledge in the paper that mortality associated with variceal bleeding has improved over time; as such, a breakdown of mortality associated with differing reasons for admission may have proved interesting. However, the key determinants of ICU mortality in patients with cirrhosis are sepsis and organ failure [6] and, therefore, the aim of the study was to examine these in detail.

Prevalence and outcome of cirrhosis patients admitted to UK intensive care: a comparison against dialysis-dependent chronic renal failure patients: response to Berry and Thomson

Dear Editor, I thank Drs. Berry and Thompson for their comments and accept that the tone of the discussion in our article [1] was indeed negative. However, I feel that this was an accurate reflection of the data presented. I do share their concerns that the paper might be regarded as championing ‘‘therapeutic nihilism’’ in cirrhosis patients, in particular those with sepsis. This was not my intention. Rather, I feel that the onset of multi-organ failure (MOF) is such a catastrophic event in these patients that we should focus on the early phase of the illness, as indeed Drs. Berry and Thompson suggest. Whether this is in a highdependency environment or acute medical admissions unit will depend on the resources available. Regrettably, beyond supportive measures such as fluid resuscitation, nutrition, terlipressin and appropriate antibiotics, there is little to offer at present, but these measures have been demonstrated to improve outcome. I believe that hepatologists need to be more proactive and educate the acute admitting teams as these first 24 h are often crucial. The authors also make several other points I’d like to address: As I acknowledge in the paper, the comparison between renal failure and liver failure is most definitely imperfect. However, I feel that to suggest that renal failure often remains isolated from other organs is misleading given the well-established association with cardiovascular disease which remains the most common cause of death in the UK. That nutritional status is a key determinant of survival has been known for several decades, yet nutritional therapy is often overlooked and suboptimal in cirrhosis patients, and the authors are right to highlight this. However, the argument that we should disregard the severe mortality figures of MOF in cirrhosis simply because liver disease is increasing in the UK and affecting younger people is not logical and I cannot agree with this statement. The causes of this epidemic of liver disease are well documented and will require a multidisciplinary strategy involving hospital workers, addiction specialists, and those in public health, government and the food and drinks industry among others to tackle successfully. I wish to conclude on a note of optimism—as stated the survival figures are improving and increased clinical and laboratory research into this area will improve treatment yet further. However, it is difficult at present to envisage this happening in patients with established MOF, and I believe that we should focus our attention on patients at risk of organ failure as I feel the greatest gains will occur here.

Prevalence and outcome of cirrhosis patients admitted to UK intensive care: a comparison against dialysis-dependent chronic renal failure patients

Patients with decompensated liver cirrhosis who are admitted to intensive care units (ICU) are perceived, within the UK, as having a particularly poor prognosis. We performed a descriptive analysis of cirrhosis patients admitted to general critical care units 1995-2008 compared to patients admitted with pre-existing chronic renal failure. Data were obtained from the Intensive Care National Audit and Research Centre Case Mix Programme Database incorporating 192 adult critical care units in England, Wales and Northern Ireland. Cirrhosis accounted for 2.6 % (16,096 patients) of total admissions with mean age 52.5 years and male preponderance (~60 %). Hospital mortality was high (>55 %) although this improved 5 % in recent years, and median length of stay was short (2.5 days). Mortality in cirrhotics with severe sepsis requiring organ support was 65-90 %, compared to 33-39 % in those without. Conversely, patients with chronic renal failure had lower mortality (42 %) despite similar characteristics and higher acute physiology and chronic health evaluation (APACHE) II scores. The APACHE II score under-predicted mortality in cirrhotics. Cirrhosis patients exhibit worse outcomes compared to pre-existing renal failure patients, despite similar characteristics. Survival worsens considerably with organ failure, especially with sepsis. They represent a small number of admissions, albeit increasing over recent years, and, in general, have a short ICU stay. Patients with single organ failure have acceptable survival rates and mortality has improved; although we have no data on those refused ICU admission potentially causing survival bias. Given the extremely high mortality in patients with multi-organ failure, support should be limited/withdrawn in such patients.

Coronary artery bypass grafting on dialysis-dependent chronic renal failure patients: short and long-term outcomes, a 12 year experience

Coronary artery bypass grafting on dialysis-dependent chronic renal failure patients: short and long-term outcomes, a 12 year experience

Over time, high-sensitivity TnT replaces NT-proBNP as the most powerful predictor of death in patients with dialysis-dependent chronic renal failure

Background Cardiac biomarkers are emerging as a potentially powerful prognostic tool for renal-dialysis patients. The optimal biomarker and/or combination of biomarkers for predicting mortality remain uncertain. This study evaluates the prognostic value of the new high-sensitivity troponin T (TnT) assay compared to established biomarkers. Methods All patients had blood sampled for prospective assessment of the prognostic value of traditional risk markers including albumin and CRP, and cardiac biomarkers BNP, NT-proBNP, TnT and TnI. Patients were closely monitored clinically. Mortality and morbidity outcomes were documented for a national morbidity and mortality database. Stored samples were subsequently used to measure TnT with a new high-sensitivity assay. Results After a median of 30 months from blood collection, NT-proBNP was the most powerful predictor of all-cause mortality, along with albumin. After a median of 46.7 months the new high-sensitive TnT assay was the only cardiac biomarker predictive of all-cause mortality. TnT was detectable in all dialysis patients using the high-sensitive TnT assay with a cut-point of 24.15 ng/L below which all patients survived. Conclusions The new hs-TnT is the most powerful biomarker for prognostic classification for all-cause mortality of all the commonly used biomarkers for our renal-dialysis population. Our study also suggests that cardiac biomarkers have a different prognostic ability for different time frames with NT-proBNP being a better predictor for early mortality and troponin for later mortality.

Chronic Renal Failure: Another Complication of this Interminable Condition?

Two patients on dialysis for chronic renal failure and hyperparathyroidism were referred for total parathyroidectomy. The first was a 32-year-old man, who had pre-operative methylene blue infusion. Four coloured parathyroid glands were readily identified and excised. Histology confirmed three hyperplastic parathyroids and a thyroid nodule containing a 12-mm diameter incompletely excised papillary carcinoma. This had clearly taken up the methylene blue and masqueraded as a hyperplastic parathyroid. A 20-year-old man with similar renal and endocrine pathophysiology underwent a total parathyroidectomy. Three definite hyperplastic parathyroid glands were encountered and excised and, in lieu of a definite fourth, various small nodules were excised from the environs of his very nodular thyroid. Histology confirmed three parathyroids, reporting all the nodules as thyroid tissue except one, which was a lymph node replaced by papillary thyroid carcinoma. Both patients subsequently had a total thyroidectomy (and completion parathyroidectomy), radio-iodine, and thyroxine replacement/suppression. Both specimens showed multiple foci of papillary thyroid carcinoma. The first patient remains well and cancer-free after 8 years, and the second is well after 4 months. My interest changed from identifying methylene blue as a potential cause of ‘false-positive’ parathyroid localisation, to associating dialysis-dependent chronic renal failure with multifocal thyroid papillary carcinoma. This is difficult to rationalise, as neither of the patients had been transplanted or immunosuppressed. My yearly average return of approximately 50 operative thyroid specimens has yet to comprise any other with occult multifocal papillary carcinoma. However, my interest is piqued: I wonder what the proportion would be in the thyroids of patients with dialysis-dependent chronic renal failure? EDITORIAL COMMENT The hypothesis proposed by these two cases is that patients with chronic renal failure on dialysis have an increased likelihood of developing multifocal papillary carcinoma of the thyroid. Two rare conditions can occur synchronously but is there a true association? Have any of our readers observed a similar relationship?

Aortic Valve Replacement in a Dialysis-Dependent Jehovah's Witness: Successful Use of a Minicircuit, Microplegia, and Multimodality Blood Conservation Technique

We present the first reported case of an aortic valve replacement operation without blood transfusion in a 62-year-old Jehovah's Witness with dialysis-dependent chronic renal failure, severe anemia, severe aortic stenosis, and symptomatic angina with minimal exertion after an accident in which she suffered fractures of both her right arm and leg. She underwent successful valve replacement surgery after preoperative stabilization of her fractures and high-dose erythropoietin and iron supplement therapy preoperatively and postoperatively. The intraoperative blood conservation technique included a novel approach with a miniature cardiopulmonary bypass circuit and microplegia with limited hemodilution. High-risk valve surgery in patients who are Jehovah's Witnesses can be successful with a carefully planned multimodality blood conservation strategy.