Dialysis-dependent Renal Failure Research Articles

Volume-outcome relationships for transcatheter aortic valve replacement-risk-adjusted and volume stratified analysis of TAVR outcomes

ObjectivesThis purpose of the study was to evaluate TAVR outcomes at low, intermediate and high volume institutions. BackgroundFor the care of complex patients, volume-outcome effect is well described. The initial US TAVR experience was limited to a few centers of excellence. The impact of institutional volume on outcomes after TAVR has not been systematically studied. MethodsWithin the Banner Health system, TAVR is performed at 3 institutions-a low volume, an intermediate volume and a high volume institution. 181 consecutive patients undergoing TAVR within these 3 institutions were the study cohort. To adjust for bias and confounders between the 3 groups, risk-adjusted multivariate logistic regression and propensity score analysis was performed. The primary endpoint was a composite of mortality, dialysis-dependent renal failure, cerebrovascular accident, need for new permanent pacemaker and readmission within 30days. ResultsThe primary endpoint was reached in 38.8% of patients at the high volume institution and 76.2% of patients at the low volume institution (p<0.01). Having a TAVR procedure at a larger volume institution was an independent predictor of having improved outcomes (OR 0.33, 95% CI 0.16–0.68; p=0.003). These improved outcomes after the TAVR procedure noted at the large volume institution were seen in the most complex patients: age ≥80years, BMI >30, diabetes, hypertension, prior CAD, CKD and NYHA class III/IV heart failure. ConclusionsHigh-risk patients undergoing TAVR at a large volume institution have better 30-day outcomes compared to outcomes at intermediate and low volume centers.

Laparoscopic Sleeve Gastrectomy in Kidney Transplant Candidates: a Case Series.

Patients with a body mass index (BMI) >35kg/m2 who need kidney transplant present with increased postoperative mortality and reduced kidney graft survival compared to patients with a lower BMI. For this reason, obese patients are often excluded from the transplantation waiting list. The aim of this study was to evaluate the feasibility and the results of laparoscopic sleeve gastrectomy (LSG) for obese patients awaiting a kidney transplant. This was a retrospective study on patients with dialysis-dependent renal failure (DDRF) operated on at two first-level bariatric centers in Paris (France). All the patients were contraindicated for kidney transplantation due to the presence of morbid obesity. Nine DDFR patients with a mean BMI of 45.9kg/m2 underwent LSG for the treatment of obesity. Furthermore, all patients presented with hypertension and sleep apnea and six out nine were diabetics. In the immediate postoperative period, all patients were transferred to the intensive care unit (mean stay of 2.1days). The only major adverse event was a delayed weaning from mechanical ventilation in one patient. The mean hospital stay was 5.5days (3-12). The total weight loss (TWL) was 27.1, 33.6, and 39.5kg at 6, 12, and 18months, respectively. One patient underwent renal transplantation 18months after LSG, and the other five patients were actively listed for kidney transplantation. According to the results of this small sample series, LSG seems to be an effective and safe procedure in DDRF patients with concomitant obesity and can increase access to transplantation.

Nephron-sparing management (distal ureterectomy with reimplantation of ureter) for carcinoma of distal ureter: A single-center experience

ObjectiveRadical nephroureterectomy with bladder-cuff excision has been the traditional treatment for upper tract urothelial carcinoma because of its high rate of recurrence. However, given the morbidity of nephrectomy and the risk of developing chronic kidney disease or dialysis-dependent renal failure, the nephron-sparing approach may be preferable in selected patients. Materials and methodsA total of 118 patients who received unilateral distal ureterectomy with reimplantation at a single center in Taiwan were included, using surgical code numbers, from March 2006 to December 2014. A total of 82 patients were excluded due to nonmalignancy and 17 due to concomitant bladder cancer. Finally, 19 patients with primary, solitary, unilateral ureter lesions and confirmed to have ureter malignancy (urothelial carcinoma, n=18; squamous cell carcinoma, n=1) were included. ResultsOf the 19 patients (13 males and 6 females) included, the mean age was 69.3±10.7 years. Tumor pathological staging was Tis (n=1), Ta (n=3), T1 (n=2), T2 (n=6), and T3 (n=5). Histopathology grading was low grade (n=3) and high grade (n=13). No local recurrence was noted; nine patients had bladder recurrence (47.4%), three had distant metastasis (15.8%), and two had progression and finally underwent radical nephroureterectomy (10.5%). The mean time to bladder recurrence was 12.4 months (3–24 months); the mean follow-up time was 28.1 months (1–90 months). The 5-year overall survival rate was 73.7% (14/19); four patients were lost to follow-up, and one patient expired. The mean 5-year progression-free survival was 67.74%. The mean preoperative creatinine level was 1.61 mg/dL, and at 12 months after operation it was 1.56 mg/dL (p=0.95). ConclusionIn selected patients, distal ureterectomy with reimplantation, in our experience, is a feasible option for distal ureter tumor. Favorable postoperative outcomes with a low local recurrence rate, a low rate of progression to nephroureterectomy, and renal function preservation may prove the value of this modality and should be taken into consideration in suitable patients.

Intracardiac Infection at the Tip of Hemodialysis Catheter: Life threatening Morbidity

Endocarditis and intracardiac infection have been increased recently especially in dialysis dependent renal failure patients. This is usually intractable infection to broad spectrum Antibiotic therapy and in most cases surgical intervention was necessary. We have presented 45 years old man with intracardiac infection at the tip of dialysis catheter that after catheter removal intracardiac infection was removed.

A Young Patient with Refractory Multiple Myeloma and Dialysis-Dependent Renal Failure has been Cured by Non-Cryopreserved Autologous Stem Cell Transplantation Followed by Live-Related Kidney Transplantation

Management of patients with multiple myeloma having dialysis-dependent renal failure, particularly if the disease is refractory to several lines of therapy, is a difficult task. Cure of such patients represents a real challenge to the treating team. In late November 2009, the diagnosis of multiple myeloma was made in a young patient who had been receiving regular hemodialysis for end-stage renal disease. His myeloma was refractory to four lines of therapy and it responded partially to the fifth line of treatment. Thereafter, the patient received a noncryopreserved autologous hematopoietic stem cell transplantation which brought his myeloma under more optimal control. One year later, he received live-related kidney transplantation. During his subsequent follow-up for fifty four months post-renal transplantation at King Fahad Specialist Hospital in Dammam, Saudi Arabia, no complication has been encountered. As the case is complicated, the literature review will be detailed in order to discuss the various aspects related to care of the patient presented.

Anti-glomerular basement membrane disease: Case series from a tertiary center in North India.

Anti-glomerular basement (anti-GBM) disease is an uncommon disorder with a bimodal age of presentation. Patients presenting with dialysis-dependent renal failure have poor renal outcomes. There is limited data regarding the clinical presentation and outcomes of anti-GBM disease from India. We conducted this prospective study to analyze the clinical presentation and outcomes of anti-GBM disease at a large tertiary care hospital in North India over 1½ years. Subjects with a biopsy proven anti-GBM disease (light microscopic examination showing crescents and immunofluorescence examination showing linear deposition of IgG) with or without positive anti-GBM antibodies in serum were included in the study and followed-up for at least 12 months. All the patients were treated with steroids, cyclophosphamide, and plasma exchange. A total of 17 patients (nine males) were included. The mean age at presentation was 39.11 ± 16.58 (range 11–72) years. Twelve patients (70%) presented with rapidly progressive glomerulonephritis (RPGN), 4 (23.5%) presented with Goodpasture syndrome, while 1 (5.8%) had nephritic syndrome, 7 (41%) were hypertensive, and 14 (82.3%) required dialysis at the time of presentation. Four patients (23.5%) had associated anti-neutrophil cytoplasmic antibody positivity (anti-myeloperoxidase antibodies in all). Fourteen (87.5%) patients had crescentic glomerulonephritis, while 5 (31.25%) showed necrotizing (n = 4) or granulomatous (n = 1) in the vasculitis. Of 16 patients who received treatment, four (23.25%) achieved complete remission. In this single-center study, the majority of anti-GBM disease patients presented with RPGN and had crescentic glomerulonephritis on biopsy with poor treatment outcome.

Evaluation of renal lesions and clinicopathologic correlation in rheumatoid arthritis.

The most common causes of renal disease in rheumatoid arthritis (RA) are glomerulonephritis (GN), amyloidosis, tubulo-interstitial nephritis, and drug toxicity. Our aim was to evaluate the clinicopathologic correlation of renal lesions and to assess the course and prognosis of renal disease in patients with RA. We conducted a prospective observational study in all adult patients with RA between July 2010 and June 2015. The total number of patients studied was 90, with a female:male ratio of 2.3:1. Mean follow-up duration was 30 ± 6.5 months. About 54 patients (60%) were asymptomatic. The most common symptom was edema legs (30%), followed by oliguria (10%). About 18 patients (20%) presented with the nephrotic syndrome, 15 patients (16.6%) with nephritic syndrome, and 30 (33%) with asymptomatic urinary abnormalities. Chronic kidney disease (CKD) was seen in 48 of 90 patients (53%).The most common renal pathology noted was mesangioproliferative GN followed by membranous nephropathy (MN). IgM with C3 deposits was the most common immunofluorescence pattern observed. Among the patients who had glomerular diseases, complete remission was seen in nine patients, partial remission in 15, and persistent proteinuria in 14. Duration of RA and a high erythrocyte sedimentation rate correlated significantly with persistent proteinuria. Only one patient in the glomerular disease group progressed to dialysis-dependent renal failure. On followup, 11 out of 48 CKD patients showed a significant decrease in estimated glomerular filtration rate and worsened to the next stage of CKD. Renal disease in RA presents with varied renal pathology. MN was seen frequently and was not associated with gold or penicillamine usage. Relatively high incidence of CKD was noted. Hence, it is important to monitor renal function abnormalities periodically in these patients.

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.

Results of Protocol-based Perioperative Management in Off-Pump Coronary Artery Bypass Grafting for Patients with Non-dialysis-dependent Chronic Kidney Disease.

BackgroundRecent studies have demonstrated the benefits of off-pump coronary bypass grafting over the on-pump technique in patients with chronic kidney disease (CKD). To further reduce the risk of acute kidney injury and the need for renal replacement therapy, even in patients undergoing off-pump coronary artery bypass grafting, we adopted protocol-based perioperative management for patients with CKD.MethodsFrom December 2012 to March 2015, 265 patients underwent isolated off-pump coronary artery bypass grafting. To analyze renal function in a stable condition, we excluded 12 dialysis-dependent end stage renal failure and 10 emergency or urgent cases. Among the remaining 243 patients, 208 patients had normal kidney function (normal group), and 35 patients had CKD (CKD group). Minimizing contrast exposure, ensuring adequate hydration, using strict drug dosage adjustment, and optimizing hemodynamic status were key elements of the protocol for the CKD group.ResultsThe risk of acute kidney injury was about ×3 higher in the CKD group than in the normal group (p=0.01). Estimated glomerular filtration rates and serum creatinine levels deteriorated until the third postoperative day in the CKD group. However, by adopting protocol-based perioperative management, this transient renal dysfunction recovered to preoperative levels by the fifth postoperative day without requiring renal replacement therapy in all cases.ConclusionOff-pump coronary bypass surgery combined with this protocol-based perioperative management strategy in patients with non-dialysis-dependent CKD could mostly be performed without renal replacement therapy.

Citrate Extended High Cut‐Off Hemodiafiltration for Renal Recovery in Patients With Multiple Myeloma

We proposed a combination of convective and diffusive transport mechanisms as high cut-off (HCO) post-dilution hemodiafiltration dialysis technique to optimize serum immunoglobulin free light chains (FLCs) removal which may improve dialysis dependent renal failure in patients with multiple myeloma. To reduce bleeding risk regional citrate anticoagulation was successfully used for the first 7 h followed by 1 h anticoagulant-free hemodiafiltration to avoid citrate accumulation. We retrospectively assessed the effect of FLCs reduction on the renal outcome of 28 patients treated with 133 citrate extended post-dilution HCO (Theralite 2100; Gambro, Lund, Sweden) hemodiafiltration sessions between 2010 and 2016. Renal recovery was demonstrated in 61% of all patients. Twenty-three patients achieved more than 50% reduction of FLCs concentrations and 88% of those became dialysis independent. Our experience supports the extended citrate HCO hemodiafiltration as a good treatment strategy that enable a sustained reduction in serum FLCs concentration and recovery of renal function.

Incidence of Infection and Inhospital Mortality in Patients With Chronic Renal Failure After Total Joint Arthroplasty

BackgroundPatients with chronic renal failure (CRF) may require total joint arthroplasty (TJA) to treat degenerative joint disease, fractures, osteonecrosis, or amyloid arthropathy. There have been conflicting results, however, regarding outcomes of TJA in patients with chronic renal disease. The aim of this case-controlled study was to determine the outcome of TJA in patients with CRF, with particular interest in the incidence of infections and inhospital mortality. MethodsWe queried our electronic database to determine which patients among the 29,389 TJAs performed at our institution between January 2000 and June 2012 had a diagnosis of CRF. A total of 359 CRF patients were identified and matched for procedure, gender, age (±4 years), date of surgery (±2 years), and body mass index (±5 kg/m2) in a 2:1 ratio to 718 control patients. ResultsThe incidence of infection and inhospital mortality was not significantly different between the nondialysis CRF patients and controls, whereas it was significantly higher in dialysis-dependent end-stage renal failure patients compared to controls. Of the 50 CRF patients receiving hemodialysis, 10 (20%) developed surgical site infection, of which 4 (8%) were periprosthetic joint infection, and 4 (8%) died during hospital stay. The odds ratio for infection in the dialysis group was 7.54 (95% confidence interval: 2.83-20.12) and 10.46 (95% confidence interval: 1.67-65.34) for the inhospital mortality. ConclusionWe conclude that end-stage renal failure patients receiving hemodialysis have higher postoperative infection and inhospital mortality rates after an elective TJA procedure, whereas nondialysis CRF patients have similar outcomes compared with the general TJA population.

Reversal of Dialysis Dependent Renal Failure After Renal Artery Stenting: A Case for Intervention

Reversal of Dialysis Dependent Renal Failure After Renal Artery Stenting: A Case for Intervention

COMBINED HEART-KIDNEY TRANSPLANTATION

Combined heart-kidney transplantation may be performed in carefully selected patients with end-stage heart disease and renal failure. There are two types of combined transplantation of heart and kidney: 1) simultaneous heart-kidney transplantation (SHKT) from the same donor; 2) staged transplantation of heart and kidneys from two genetically different donors. The ISHLT registry in 2014 reported an increase in the number of SHKT over the years: from 22 in 1994 to 97 in 2012. World experience demonstrated excellent results of SHKT. Recipients of SHKT had superior survival, lower rates of acute cardiac and renal rejection compared to heart recipients. This article discusses the indications for simultaneous or staged heart-kidney transplantation in patients with dialysis-independent or dialysis-dependent renal failure, results and posttransplant survival of SHKT recipients. The author describes his own experience of 2 staged combined heart-kidney transplantations.

The Noninvasive Urinary Polyomavirus Haufen Test Predicts BK Virus Nephropathy in Children After Hematopoietic Cell Transplantation: A Pilot Study.

After hematopoietic cell transplantation (HCT), polyoma-BK virus is associated with hemorrhagic cystitis and also with polyomavirus nephropathy (PVN). However, the true burden of post-HCT PVN is unknown because kidney biopsies are avoided due to their bleeding risk. The novel, noninvasive urinary PV-Haufen test detects PVN in kidney transplant recipients with greater than 95% positive/negative predictive values. We hypothesized that the detection of PV-Haufen in voided urine samples-a positive PV-Haufen test-was also clinically significant after HCT. We examined 21 suitable urine samples from 14 patients (median age, 15 years; 71.4% male) who were selected from repositories for having varying degrees of BK viremia (range, 0-1.0 × 10 copies/mL), hemorrhagic cystitis (present/absent), and data on kidney function. Urine samples were obtained at a median of 88 days post-HCT. The PV-Haufen were detected in 5 of 14 patients (35.7%) and 7 of 21 (33.3%) urine samples, with histologic confirmation of PVN in 1 autopsy specimen. After a median of 285 days post-HCT, patients with PV-Haufen had an increased risk of dialysis-dependent renal failure (P < 0.05). All 3 dialysis-dependent patients had PV-Haufen and died. The presence of urinary PV-Haufen was not significantly correlated with hemorrhagic cystitis. From the 16 urines collected during BK viremia, 43.8% were PV-Haufen-positive, and 56.2% were negative. The PV-Haufen were not present in the 5 urines from patients without concomitant BK-viremia. In this proof-of-concept study, a positive PV-Haufen test was only seen in some patients with BK viremia and was not associated with hemorrhagic cystitis. The detection of PV-Haufen suggests underlying PVN with an increased risk of kidney failure and dialysis.

Long Term Survival and Continued Complete Response of Vemurafenib in a Metastatic Melanoma Patient with BRAF V600K Mutation.

Introduction. BRAF kinase inhibitors such as Vemurafenib have shown improvement in overall survival, progression-free survival, and response rates in patients with metastatic melanoma with BRAF V600K mutation. However, there were no cases of complete remission reported in patients with V600K mutation before. Case Presentation. A 53-year-old man with metastatic melanoma and dialysis dependent end stage renal failure was treated safely with Vemurafenib for a BRAF V600K mutation positive melanoma and the case was reported elsewhere. After a long follow-up of the same patient treated with Vemurafenib, a complete radiological response was observed and the renal functions remained stable throughout the treatment. Main toxicities reported were grade 1 photosensitivity and skin cancers. Vemurafenib was discontinued but patient remains disease free 12 months after stopping treatment and the clinical review is ongoing. Conclusion. This is the first reported case of complete radiological response to a BRAF inhibitor in metastatic melanoma with BRAF V600K mutation and remains disease free even after discontinuation of treatment. This also shows clinical safety of Vemurafenib in end stage renal failure and highlights the need for closer look at the subgroup of patients with BRAF V600K mutation and its tumour biology.

Abstract 17889: A Randomized Controlled Trial of Moderate Glucose Control After Complex Pediatric Cardiac Surgery

Introduction: Infants and children after cardiac surgery may develop hyper- or hypoglycemia, associating with higher nosocomial infection or neurological morbidities. Hypothesis: The hypothesis of this perspective randomized control study is moderate glucose control may improve clinical outcomes. Methods: We randomly assigned children(≤3 years of age) who were admitted to the pediatric cardiac intensive care unit (PICU) after cardiopulmonary bypass surgery into either moderate glucose control group (target blood glucose: 110-143mg per deciliter) or conventional glucose control group (target level below 200mg per deciliter). The primary outcome was the rate of nosocomial infection in PICU. Second outcomes include hospital mortality, duration of mechanical ventilation and PICU stay, and a composite morbidity variable included events of requiring extracorporeal membrane oxygenation, delayed sternal closure, dialysis-dependent renal failure and hypoglycemia. Results: A total of 593 patients underwent randomization: 293 to moderate glucose control group and 300 to conventional glucose control group. The baseline data were balanced between these two groups. Mean 72 hours time-weighted blood glucose average was lower in the moderate control group than in the conventional group (129.9±22.1 mg per deciliter vs. 138.8±28.6 mg per deciliter, p&lt;0.001). Although no statistically significance reached, there is a trend that nosocomial infection occurred less in moderate glucose group (17 (5.80%) vs. 29 (9.67%), P=0.054). Duration of mechanical ventilation was shorter in the moderate control group (18 (range, 4-300) hours vs 22 (range 3-771) hours, p=0.046). Hypoglycaemia (blood glucose ≤65mg per deciliter) which occurred in 7(2.39%) patients in the moderate group versus 8 (2.67%) in the conventional group, was statistically similar between groups. Other secondary outcomes did not differ significantly between groups. Conclusions: With moderate glucose control, although the major clinical outcomes did not change, this randomized control study showed shorter ventilation time after pediatric cardiac surgery, substantially benefit for patients with complex congenital cardiac anomalies.

Effects of dialysis modality on blood loss, bleeding complications and transfusion requirements in critically ill patients with dialysis-dependent acute renal failure.

Blood loss and bleeding complications may often be observed in critically ill patients on renal replacement therapies (RRT). Here we investigate procedural (i.e. RRT-related) and non-procedural blood loss as well as transfusion requirements in regard to the chosen mode of dialysis (i.e. intermittent haemodialysis [IHD] versus continuous veno-venous haemofiltration [CVVH]). Two hundred and fifty-two patients (122 CVVH, 159 male; aged 61.5±13.9 years) with dialysis-dependent acute renal failure were analysed in a sub-analysis of the prospective randomised controlled clinical trial-CONVINT-comparing IHD and CVVH. Bleeding complications including severity of bleeding and RRT-related blood loss were assessed. We observed that 3.6% of patients died related to severe bleeding episodes (between group P=0.94). Major all-cause bleeding complications were observed in 23% IHD versus 26% of CVVH group patients (P=0.95). Under CVVH, the rate of RRT-related blood loss events (57.4% versus 30.4%, P=0.01) and mean total blood volume lost was increased (222.3±291.9 versus 112.5±222.7 ml per patient, P <0.001). Overall, transfusion rates did not differ between the study groups. In patients with sepsis, transfusion rates of all blood products were significantly higher when compared to cardiogenic shock (all P <0.01) or other conditions. In conclusion, procedural and non-procedural blood loss may often be observed in critically ill patients on RRT. In CVVH-treated patients, procedural blood loss was increased but overall transfusion rates remained unchanged. Our data show that IHD and CVVH may be regarded as equivalent approaches in critically ill patients with dialysis-dependent acute renal failure in this regard.

Moderate Versus Deep Hypothermia With Unilateral Selective Antegrade Cerebral Perfusion for Acute Type A Dissection

Despite improved results with surgical therapy for acute type A aortic dissection (ATAAD), there remains a lack of consensus regarding the optimal method of cerebral protection and circulation management during ATAAD. The purpose of this study is to determine whether in the setting of antegrade cerebral perfusion, moderate hypothermic circulatory arrest (MHCA) provides equivalent cerebral and visceral protection as deep hypothermic circulatory arrest (DHCA) for patients undergoing emergent ATAAD repair. A review of the Emory aortic surgery database from 2004 to 2014 identified 288 patients who underwent ATAAD with right axillary artery cannulation, unilateral selective antegrade cerebral perfusion (uSACP), and hypothermic circulatory arrest (HCA). In all, 88 patients underwent HCA at 24 °C or lower (DHCA), and 206 patients underwent HCA at more than 24 °C (MHCA). Major adverse outcomes of death, stroke, temporary neurologic dysfunction, and dialysis-dependent renal failure were examined. The groups were well matched for age and major comorbidities. The DHCA patients underwent HCA at lower temperatures (DHCA 21.6 ± 3.1 °C vs MHCA 27.4 ± 1.6 °C, p < 0.01). There were no significant differences in cardiopulmonary bypass, cross-clamp, or HCA times. Mortality was 14.6% for DHCA patients, and 9.2% for MHCA patients (p = 0.17). There was no significant difference in stroke, temporary neurologic dysfunction, or dialysis-dependent renal failure. There was no association with either MHCA plus uSACP or DHCA plus uSACP and any of the major adverse outcomes (p > 0.05). Moderate HCA with uSACP is an effective circulation management strategy that provides excellent cerebral and visceral protection during emergent ATAAD repair. In the setting of antegrade cerebral perfusion, deep hypothermia does not provide any additional benefit.

Older patients with ANCA-associated vasculitis and dialysis dependent renal failure: a retrospective study

BackgroundANCA-associated vasculitis (AAV) with renal involvement is not uncommon in older individuals. Unfortunately, this can be catastrophic requiring hemodialysis (HD) and may lead to end stage renal disease (ESRD). However, more than 50 % of patients with AAV who require HD initially have renal recovery and discontinue HD. The aim of this study was to describe a retrospective cohort of older patients with AAV and severe renal involvement which required hemodialysis.MethodsBetween 1995 and 2013 a total of 30 patients with histologic evidence of pauci-immune glomerulonephritis who required HD were evaluated at a single university center. The association of demographic and clinical parameters with age was assessed. Older age of disease onset was defined as age ≥60 years. The risk of developing ESRD at 3 months was examined using univariate logistic regression analysis.ResultsAmong 30 patients with AAV who required HD, the mean age of disease onset was 59 ± 17 years (range 22-88 years). Twelve patients were in the older age group, and 18 were in the younger group. Three months after diagnosis, 43 % of the cohort had ESRD with a statistically similar proportion of older (n = 9, 50 %) versus younger (n = 4, 33 %) patients (p = 0.367). Most patients (93 %) received immunosuppressive therapy. There was not a statistically significant association between age and ESRD.ConclusionsThese data suggest that age alone does not predict renal recovery among individuals on HD due to AAV. Renal recovery is a realistic expectation and outcome, if patients are treated, even among older patients with AAV who require HD initially.

Prognostic Factors After Distal Bypass Grafting in Dialysis and Nondialysis Patients With Critical Limb Ischemia

The aim of this study was to elucidate efficacy of distal bypass grafting (DBG) for critical limb ischemia (CLI) and to detect predictors involved with life expectancy in hemodialysis patients (HD) and nonhemodialysis patients (NHD). Between September 2006 and August 2011, 188 consecutive ASO patients with CLI underwent 223 DBG for limb salvage (LS). Sixty-two percent (117 patients) had dialysis-dependent renal failure. All bypasses were performed using vein grafts, which included 43% of paramalleolar bypass grafting and 57% of pedal bypass grafting. Primary and secondary graft patency, LS, and amputation-free survival rates (AFS) 5 years after surgery were estimated using the Kaplan-Meier method and compared between two groups. Multivariable analysis by Cox proportional hazard ratio (HR) was performed to explore the independent determinants in each group. Five-year primary and secondary graft patency rates were 52%, 74% in HD and 73% and 84% in NHD, respectively, showing significant difference was seen in primary patency (P < .05) but not in secondary patency. LS rate was 90% in HD and 99% in NHD 5 years after surgery (P = .042). Only 38.5% of patients in HD were ambulatory before surgery compared with 70.5 % NHD group (P < .01). Seventy percent of HD surviving patients, however, regained their ambulatory status only then 12 months after surgery compared with 85% of NHD surviving patients. AFS was 29% in HD and 67% in NHD 5 years after surgery (P < .01). Multivariable analysis showed four statistically significant predictors of AFS in HD: history of congestive heart disease (HR, 2.296; 95% confidence interval [CI], 1.457-3.618) nonambulatory status at baseline (HR, 2.081; 95% CI, 1.244-3.481); history of infrainguinal bypass (HR, 2.564; 95% CI, 1.429-4.598); and β-blocker user (HR, 2.074; 95% CI, 1.248-3.436). Two factors that independently predicted AFS in NHD were identified: history of congestive heart disease (HR, 3.270; 95% CI, 1.236- 8.655) and statin use (HR, 0.184; 95% CI, 0.052-0.645). Although DBG achieved agreeable LS rates against CLI in both groups, there were distinct differences in prognosis after DBG between the groups. Extremely poor prognostic patients were included in HD, leading patient selections appropriate to surgery in HD are necessary.