Episodes Of Acute Renal Failure Research Articles

Ambulatory intravenous treatment of decompensated heart failure: An effective, safe and cost-effective approach

Introduction and objectivesThe aim of this study was to evaluate the safety and efficacy of ambulatory intravenous (IV) treatment of decompensated heart failure (HF). MethodsRetrospective analysis of all episodes of decompensated HF treated with IV diuretics at the HF day hospital from January 1 to December 31, 2016. ResultsA total of 192 episodes of HF decompensation were treated in 119 patients. Mean age and ejection fraction were 75±11 years and 52±15%, respectively, 65% were women and 63% had chronic kidney disease. All patients were on baseline oral furosemide (average dose 140mg per day) and 21% on hydrochlorothiazide. The mean duration of each episode of ambulatory HF IV treatment was 3±2 days and mean dose of treatment was 240mg IV furosemide (80mg/treatment day), 25mg oral hydrochlorothiazide and 20mEq oral potassium per treatment day. It was possible to avoid hospitalization in 81% of the episodes (n=155 decompensations). This approach was associated with a decrease in direct hospital cost compared with hospitalization. The rate of complications was low: 4% (7 episodes) severe dyselectrolytemia and <1% (1 episode) symptomatic hypotension. There were no episodes of acute renal failure. ConclusionsA strategy of ambulatory IV diuretic treatment for HF decompensation could be effective and avoid hospital admission in a high number of patients, even in an elderly comorbid cohort with predominantly preserved LVEF. More importantly, this approach is safe with infrequent presence of dyselectrolytemia and symptomatic hypotension. This treatment was associated with a decrease in hospital cost.

MON-369 Calcium Gone Crazy: Recurrent Hypercalcemia in Patient with History of Hypoparathyroidism

IntroductionPatients with post-operative hypoparathyroidism mostly require Calcium supplements and Calcitriol with goal of maintaining calcium levels in low normal range. However, calcium balance can further be dysregulated by other factors including renal failure in patients with otherwise stable levels.We present a case of recurrent symptomatic hypercalcemia leading to multiple hospital visits in a patient with otherwise stable longstanding post-operative hypoparathyroidism that was precipitated after episode of Acute Renal Failure.Case Presentation71 Year old male with past medical history of Atrial fibrillation, Hypertension, Primary Hyperparathyroidism status post Parathyroidectomy (Parathyroid hyperplasia with removal of 3/12 glands) in 2003 with subsequent Hypoparathyroidism presented with lethargy and confusion few days after cardioversion attempt for atrial fibrillation. He was noted to have bradycardia and hypotension post procedure which improved subsequently. His medications included Calcitriol 0.25 mcg twice daily and Calcium Carbonate 1.25 grams twice daily. His Calcium had remained stable over the years on this regimen.On presentation, he was found to have elevated corrected calcium of 12.5 mg/dl and Acute Renal failure with Creatinine of 8.3 mg/dl which was normal 1 week prior. He underwent hydration and subsequently required few sessions of hemodialysis with improvement in kidney function and further hemodialysis was not needed. On discharge his corrected calcium was 8.6 mg/dl and Creatinine was 3.9 mg/dl. His Calcitriol and Calcium were resumed on discharge. However, 3 weeks later he presented again with lethargy and calcium was again elevated at 14.8 mg/dl. All other workup for hypercalcemia including PTHRP, Bone marrow biopsy, Serum electrophoresis were negative. Subsequently, he had 2 more admissions for hypercalcemia and 1 admission for hypocalcemia within 1 month. Finally his calcium levels stabilized with reduced dose of Calcitriol and Calcium with close weekly monitoring initially as outpatient.DiscussionIn advancing kidney disease, the kidneys are no longer able to increase urine calcium excretion, and this removes an important safety mechanism to prevent calcium excess in patients with Chronic kidney disease. In patients with hypoparathyroidism on Calcitriol and Calcium supplements, renal failure may offset the calcium balance leading to dysregulation and erratic levels with increased tendency towards hypercalcemia.ConclusionAcute Renal Failure may lead to hypercalcemia in patients with otherwise stable levels. However, limited understanding of calcium balance/ regulation in renal failure, especially in setting of hypoparathyroidism further complicates the situation and may lead to difficult titration of medications.

Recurrent Acute Renal Failure in a Patient with Aplastic Anemia–Paroxysmal Nocturnal Hemoglobinuria Syndrome: A Case Report

Acute renal failure (ARF) is one of the renal expressions in patients with aplastic anemia (AA)-paroxysmal nocturnal hemoglobinuria (PNH) syndrome following hemolytic crisis. We report the case of an AA patient who experienced recurrent episodes of ARF, in association with evidence of PNH. A 46-year-old woman with AA was admitted because of oliguria and dark urine following a urinary tract infection (UTI) caused by Candida. PNH with ARF complication was diagnosed. Hemodialysis treatment was performed nine times and her renal function recovered. However, she suffered from recurrent hemoglobinuria and acute deterioration of renal function 4 months later. The renal biopsy showed features of acute tubular necrosis, deposition of hemosiderin and positive urate stain in the proximal tubular cells, without vascular thrombosis. The patient received management by adequate hydration, diuretics and alkalization. Her renal function recovered completely. This case report shows an AA patient experiencing recurrent episodes of hemoglobinuric ARF within a short period and achieving complete recovery of renal function after hemodialysis and suitable supportive treatment. In conclusion, AA might evolve into PNH and become complicated with presentation of severe ARF. It may occur with precipitating episodes, such as the UTI in this case. Early recognition of hemoglobinuric complications and prompt treatment for precipitating disease and ARF are important to prevent progression to an irreversible adverse renal outcome.

Management of renal transplant urolithiasis: a multicentre study by the French Urology Association Transplantation Committee.

Urolithiasis is rare among renal transplant recipients and its management has not been clearly defined. This multicentre retrospective study was organised by the Comité de Transplantation de l'Association Française d'Urologie (French Urology Association transplantation committee). Statistical analysis was performed with SPSS 19 software. Ninety-five patients were included in this study. Renal transplant urolithiasis was an incidental finding in 55% of cases, mostly on a routine follow-up ultrasound examination. One half of symptomatic stones were due to urinary tract infection and the other half were due to an episode of acute renal failure. The initial management following diagnosis of urolithiasis was double J stenting (27%), nephrostomy tube placement (21%), or watchful waiting (52%). Definitive management consisted of: watchful waiting (48%), extracorporeal lithotripsy (13%), rigid or flexible ureteroscopy (26%), percutaneous nephrolithotomy (11%) and surgical pyelotomy (2%). All transplants remained functional following treatment of the stone. The main limitation is the retrospective design. The incidence of lithiasis could be higher inkidneytransplantedpatients due toa possible anatomical or metabolical abnormalities.The therapeutic management of renal transplant urolithiasis appears to be comparable to that of native kidney urolithiasis.

How to Retard Progression of Chronic Kidney Disease

End stage chronic kidney disease (CKD) requiring renal replacement therapy is related to poor quality of life and high mortality. Thus, slowing the progression of CKD is an important purpose of therapy. Some general therapeutic approaches aim to slow the decline of renal function and they can be applied in all patients with CKD - irrespective of the underlying cause of CKD. A key intervention is lowering blood pressure (target: ≤ 140/90 mmHg, and in patients with albuminuria ≤ 130/80 mmHg). Inhibitors of the renin angiotensin system preferentially should be used in case of albuminuria, depending on the diabetic status and the level of albuminuria: in diabetics with albuminuria ≥ 30 mg/d, in non-diabetics with albuminuria > 300 mg/d. Mineralocorticoid receptor blockers and endothelin receptors blockers promise novel anti-proteinuric strategies - but still validation of their positive effects on retarding CKD progression is necessary. In patients with diabetic kidney disease, glycemic control aiming for an HbA1c of ≈7.0 % has been established to slow CKD progression. Furthermore, SGLT-2 inhibition with empagliflozin may be considered as a new therapeutic approach that provides additional cardiovascular and renal protection. Finally, recent studies suggest: correction of metabolic acidosis and avoidance of episodes of acute renal failure may provide protection against the progression of CKD.

Decreased Tissue COX5B Expression and Mitochondrial Dysfunction during Sepsis-Induced Kidney Injury in Rats.

Background. Sepsis is defined as a life-threatening organ dysfunction due to a dysregulated host response to infection. Sepsis is the dominant cause of acute kidney injury (AKI), accounting for nearly 50% of episodes of acute renal failure. Signaling cascades and pathways within the kidney are largely unknown and analysis of these molecular mechanisms may enhance knowledge on pathophysiology and possible therapeutic options. Material and Methods. 26 male Wistar rats were assigned to either a sham group (control, N = 6) or sepsis group (N = 20; cecal ligature and puncture model, 24 and 48 hours after CLP). Surviving rats (n = 12) were decapitated at 24 hours (early phase; n = 6) or 48 hours (late phase; n = 6) after CLP and kidneys removed for proteomic analysis. 2D-DIGE and DeCyder 2D software (t-test, P < 0.01) were used for analysis of significantly regulated protein spots. MALDI-TOF in combination with peptide mass fingerprinting (PMF) as well as Western Blot analysis was used for protein identification. Bioinformatic network analyses (STRING, GeneMania, and PCViz) were used to describe protein-protein interactions. Results. 12 spots were identified with significantly altered proteins (P < 0.01) in the three analyzed groups. Two spots could not be identified. Four different proteins were found significantly changed among the groups: major urinary protein (MUP5), cytochrome c oxidase subunit B (COX5b), myosin-6 (MYH6), and myosin-7 (MYH7). A significant correlation with the proteins was found for mitochondrial energy production and electron transport. Conclusions. COX5B could be a promising biomarker candidate since a significant association was found during experimental sepsis in the present study. For future research, COX5B should be evaluated as a biomarker in both human urine and serum to identify sepsis.

Late Diagnosis of Familial Mediterranean Fever in Kidney Transplant Recipients

Familial Mediterranean Fever (FMF) causing AA amyloidosis and chronic renal failure is also called recurrent polyserositis. Diagnosis of FMF is established by clinical signs and sometimes by genetic analysis for MEFV mutations. We present four cases of kidney transplantation recipients (KTrs). Interestingly, FMF was diagnosed following episodes of acute renal failure, abdominal pain, and/or fever in these KTrs. When colchicine was added to their standard therapy, these events did not develop. Therefore, in cases with unknown etiologies of fever, abdominal pain, and even acute renal failure in KTrs, FMF should also be considered, particularly in certain geographic areas and ethnic groups.

Drug-related acute renal failure in hospitalised patients

IntroductionThe information available on the incidence and the characteristics of patients with acute renal failure (ARF) related to drugs is scarce. ObjectivesTo estimate the incidence of drug-related ARF in hospitalised patients and to compare their characteristics with those of patients with ARF due to other causes. Material and methodsWe selected a prospective cohort of patients with ARF during hospital admission (July 2010–July 2011). Information on patients’ demographics, medical antecedents, ARF risk factors, ARF severity according to the RIFLE classification and hospital drug administration was collected. We analysed the relationship of drugs with the ARF episodes using Spanish Pharmacovigilance System methods and algorithm. ResultsA total of 194 cases had an episode of hospital-acquired ARF. The median age of patients was 72 years [IQR 20]; 60% were men. The ARF incidence during hospitalisation was 9.6 per 1000 admissions. According to the RIFLE classification, a risk of kidney damage or kidney injury was present in 77.8% of cases. In 105 (54.1%) cases, ARF was drug-related; the drugs most frequently involved were diuretics, agents acting on the renin–angiotensin system, immunosuppressants, β-blocking agents, calcium channel blockers, contrast media and non-steroid anti-inflammatory drugs. Patients with drug-related ARF had more multi-morbidity, fewer ARF risk factors and lower mortality. ConclusionsHalf of ARF episodes during hospitalisation were drug related. Patients with drug-related ARF had higher cardiovascular morbidity than those with ARF related to other causes, but they had a lower frequency of ARF risk factors and mortality.

Insuficiencia renal aguda relacionada con medicamentos en pacientes hospitalizados

IntroductionThe information available on the incidence and the characteristics of patients with acute renal failure (ARF) related to drugs is scarce. ObjectivesTo estimate the incidence of drug-related ARF in hospitalised patients and to compare their characteristics with those of patients with ARF due to other causes. Material and methodsWe selected a prospective cohort of patients with ARF during hospital admission (July 2010-July 2011). Information on patients’ demographics, medical antecedents, ARF risk factors, ARF severity according to the RIFLE classification and hospital drug administration was collected. We analysed the relationship of drugs with the ARF episodes using Spanish Pharmacovigilance System methods and algorithm. ResultsA total of 194 cases had an episode of hospital-acquired ARF. The median age of patients was 72 years [IQR 20]; 60% were men. The ARF incidence during hospitalization was 9.6 per 1,000 admissions. According to the RIFLE classification, a risk of kidney damage or kidney injury was present in 77.8% of cases. In 105 (54.1%) cases, ARF was drug-related; the drugs most frequently involved were diuretics, agents acting on the renin-angiotensin system, immunosuppressants, β-blocking agents, calcium channel blockers, contrast media and non-steroid anti-inflammatory drugs. Patients with drug-related ARF had more multi-morbidity, fewer ARF risk factors and lower mortality. ConclusionsHalf of ARF episodes during hospitalisation were drug related. Patients with drug-related ARF had higher cardiovascular morbidity than those with ARF related to other causes, but they had a lower frequency of ARF risk factors and mortality.

Clinical outcomes of lung transplant recipients with telomerase mutations

Successful lung transplantation for patients with pulmonary fibrosis from telomerase mutations may be limited by systemic complications of telomerase dysfunction, including myelosuppression, cirrhosis, and malignancy. We describe clinical outcomes in 14 lung transplant recipients with telomerase mutations. Subjects underwent lung transplantation between February 2005 and April 2014 at 5 transplant centers. Data were abstracted from medical records, focusing on outcomes reflecting post-transplant treatment effects likely to be complicated by telomerase mutations. The median age of subjects was 60.5 years (interquartile range = 52.0-62.0), 64.3% were male, and the mean post-transplant observation time was 3.2 years (SD ± 2.9). A mutation in telomerase reverse transcriptase was present in 11 subjects, a telomerase RNA component mutation was present in 2 subjects, and an uncharacterized mutation was present in 1 subject. After lung transplantation, 10 subjects were leukopenic and 5 did not tolerate lymphocyte anti-proliferative agents. Six subjects developed recurrent lower respiratory tract infections, 7 developed acute cellular rejection (A1), and 4 developed chronic lung allograft dysfunction. Eight subjects developed at least 1 episode of acute renal failure and 10 developed chronic renal insufficiency. In addition, 3 subjects developed cancer. No subjects had cirrhosis. At data censorship, 13 subjects were alive. The clinical course for lung transplant recipients with telomerase mutations is complicated by renal disease, leukopenia with intolerance of lymphocyte anti-proliferative agents, and recurrent lower respiratory tract infections. In contrast, cirrhosis was absent, acute cellular rejection was mild, and development of chronic lung allograft dysfunction was comparable to other lung transplant recipients. Although it poses challenges, lung transplantation may be feasible for patients with pulmonary fibrosis from telomerase mutations.

Resistive Index and MELD-Na: Nephrologic Monitoring in Cirrhotic Patients Awaiting Liver Transplantation

Renal dysfunction in cirrhotic patients is primarily related to disturbances in circulatory function. In decompensated cirrhosis, ascites and water retention are associated with development of dilutional hyponatremia. The arterial resistive index (RI) is a measure of resistance to arterial flow within the renal vascular bed. Hyponatremia is an independent predictor of mortality in patients with ascites. The aim of this study was to evaluate intrarenal RI in end-stage liver disease (ESLD) patients awaiting liver transplantation (LT) and its association with renal and hepatic function as assessed by Model for End-Stage Liver Disease (MELD) and MELD-Na scores. We evaluated 40 cirrhotic patients (23 males, 17 females) awaiting LT from January 2009 to January 2012. Twenty-six of the 40 patients (65%) showed a renal RI ≥0.70, the normal value according to standard reported evaluations. Patients with RI ≥0.70 showed significantly higher MELD and MELD-Na scores as well as greater higher serum creatinine and lower serum sodium concentrations compared with subject displaying RI <0.70. The most relevant result of our study was the strong association between elevated renal RI in ESLD patients and advanced liver dysfunction, as demonstrated by MELD and MELD-Na scores, hyponatremia, ascites, and acute renal failure episodes. In conclusion, this study suggested that intrarenal RI assessment should be considered in the clinical and nephrologic monitoring of cirrhotic patients awaiting LT.

Factor IX Complex for the Treatment of Severe Bleeding After Cardiac Surgery

Previous reports have been published on the use of recombinant Factor VIIa for intractable bleeding after cardiac surgery; however, there is limited information on the use of Factor IX Complex in this population. A retrospective cohort study of adult patients who underwent cardiac surgery and experienced severe postoperative bleeding, defined as a mean chest tube output ≥300 mL/h. Primary outcomes were changes in chest tube output and blood product usage pre- and post-Factor IX Complex administration. Eleven patients received Factor IX Complex for severe postoperative bleeding. The mean dose of Factor IX Complex was 35 (13-52) units/kg. Chest tube output was significantly reduced after Factor IX Complex administration (mean pre-Factor IX Complex 381 ± 49 mL/h, mean post-Factor IX Complex 151 ± 38 mL/h; P = 0.003). Blood product usage decreased after Factor IX Complex but was not statistically significant (mean pre-Factor IX Complex 373 ± 81 mL/h, mean post-Factor IX Complex 212 ± 48 mL/h; P = 0.669). Adverse events included 1 pulmonary embolism (postoperative day 43) and 2 episodes of acute renal failure requiring dialysis (postoperative days 2 and 5). In this small group of patients, Factor IX Complex effectively controlled severe bleeding after cardiac surgery preventing the need for re-exploration.

Natural progression of renal function in the elderly: analysis of poor prognosis factors associated with chronic kidney disease.

In the last few years a debate has emerged on the range of normal renal function and the rate at which renal disease progresses in the elderly. In this review we analysed, on the basis of the results of the study Ancianos con enfermedad renal cr&oacute;nica del Hospital General de Segovia (Elderly people with chronic kidney disease of the Hospital General de Segovia), the poor prognosis factors associated with this disease: proteinuria, episodes of acute renal failure and heart failure, and the role of uric acid. Elderly people with chronic kidney disease who present these poor prognosis factors may benefit from follow-up by Nephrology.

Acute renal failure predictors in elderly patients with chronic kidney disease.

Acute renal failure (ARF) is a very common problem in the elderly and is associated with high morbidity and mortality rates. This study analysed ARF predictors in a cohort of elderly subjects and their impact on the evolution of renal function. A group of 80 elderly individuals were recruited between January and April 2006, and 56 of these who were still alive after 36 months were retrospectively studied, examining episodes of ARF, their causes, and the need for dialysis. Twelve patients (21.4%) developed ARF: 4 (33.3%) related to heart failure, 4 (33.3%) due to infection/sepsis, 2 (16.7%) due to volume depletion, and another 2 were multifactorial (16.7%). No patients required dialysis therapy. Patients with ARF were older (P=.017), had worse renal function at baseline (P=.031), higher levels of uric acid (P=.002), and lower haematocrit (P=.003). Patients with ARF had a mean baseline serum creatinine of 1.57 ± 0.59 mg/dl and peak creatinine levels during episodes of ARF averaged 4.25 ± 4.26 mg/dl (P=.035). Mean renal function at 36 months in patients with ARF had decreased (P=.024). In a logistic regression analysis (independent variables: baseline MDRD, age, gender, Charlson index, serum creatinine, urea, and uric acid), age (RR: 1.20, 1.01-1.43, P=.039), uric acid (RR: 2.65, 1.11-6.30, P=.027), and haematocrit (RR: 0.64, 0.43-0.96, P=.031) were independently associated with the development of ARF. Baseline levels of uric acid and haematocrit are independent risk factors for the development of ARF in the elderly. Although these episodes may be functional in nature and not require dialysis, this can still cause a deterioration of renal function over time.

Unusual Case of Proximal Calciphylaxis without Renal Failure

Calciphylaxis is a rare syndrome of vascular calcification with subsequent cutaneous and tissue necrosis. It usually manifests as a complication of end-stage renal failure, affecting 1 to 4% of long-term dialysis patients. Very exceptionally, it can occur without chronic renal failure. The goal of this study was to discuss an exceptional case of extensive calciphylaxis in the absence of chronic renal failure and its successful management. We present a case of a 31-year-old woman with extensive proximal, ulcerated calciphylaxis without associated chronic renal failure. Our patient had quite a few risk factors associated with the pathogenesis of calciphylaxis, such as obesity, malnutrition, and a transient episode of acute renal failure. She was successfully treated with sodium thiosulfate, extensive wound débridement (more than 30% total body surface), and subsequent skin grafts. The patient has miraculously survived this often fatal condition. Calciphylaxis can occur even in the absence of chronic renal failure. This often fatal condition can be managed successfully with a combination of aggressive wound control and the fairly newly described sodium thiosulfate therapy.

A phase I study of combined docetaxel and repeated high activity 186Re-HEDP in castration-resistant prostate cancer (CRPC) metastatic to bone (the TAXIUM trial)

Bone-seeking radiopharmaceuticals have palliative benefit in castration-resistant prostate cancer (CRPC) metastatic to bone. Recent studies have shown improvement of survival and quality of life when radiopharmaceuticals were given repeatedly or in combination with chemotherapy. We designed a phase I study combining docetaxel and (186)Re-labelled hydroxyethylidene diphosphonate (HEDP) in men with CRPC and bone metastases to evaluate toxicity. A dose escalation schedule was designed consisting of four dose levels with a standard dosage of docetaxel (75 mg/m(2) 3-weekly). (186)Re-HEDP was given in increasing activities (1,250 MBq up to 2,500 MBq) after the third and sixth cycle of docetaxel. Dose limiting toxicity (DLT) was defined as any grade 4 toxicity lasting more than 7 days or any grade 3 toxicity that did not recover within 10 days. Three patients were planned for each dose level expanding to six if a DLT occurred. Fourteen patients were recruited with a median age of 64.6 years. One DLT, grade 3 thrombocytopenia lasting >10 days, occurred at dose level 3 leading to expansion of this group to six. One of these patients had an episode of acute renal failure which resolved. Because of production problems of (186)Re-HEDP dose level 4 was not started. Combined therapy with docetaxel and (186)Re-HEDP is generally well tolerated in patients with CRPC metastatic to bone. We will conduct a randomized phase II study using three cycles of docetaxel 75 mg/m(2) 3-weekly followed by (188)Re-HEDP 40 MBq/kg body weight, followed by another three cycles of docetaxel 75 mg/m(2), followed by (188)Re-HEDP 20 MBq/kg body weight.

Emergency procedures on the descending thoracic aorta in the endovascular era

Thoracic endovascular aortic repair (TEVAR), initially developed for the treatment of degenerative aneurysms of the descending thoracic aorta, has been applied to the entire spectrum of descending thoracic aortic pathology in both the elective and emergent settings. This single center study evaluates the effectiveness of TEVAR for the treatment of acute surgical emergencies involving the descending thoracic aorta, including traumatic aortic disruption (TAD), ruptured descending thoracic aneurysm (RDTA), and acute complicated Type B dissection (cTBD). A retrospective review of the medical records of all patients undergoing emergent TEVAR at the University of Mississippi Medical Center between August 2007 and November 2010 was undertaken. Patients were studied for 30-day survival, complications, type of device used for the repair, and technical aspects of the procedure. A total of 44 patients (59% male) with an average age of 49 years (range, 16-87 years) underwent emergent TEVAR during the study period. The technical success rate was 100%, with no patient requiring emergent open surgery for conditions involving the descending thoracic aorta at our institution during the study period. The majority (73%) of the repairs were accomplished using commercially available thoracic stent grafts. Abdominal endograft proximal extension cuffs were used in 12 (38%) of the 32 patients undergoing repair of TAD. Twenty-one patients (48%) required coverage of the left subclavian artery, two (10%) of whom subsequently required subclavian artery revascularization. Procedure-related complications included two strokes, one spinal cord ischemia, one unintentional coverage of the left carotid artery, one episode of acute renal failure, and three access site injuries. One patient undergoing repair of TAD had collapse of the stent graft in the early postoperative period. He was successfully treated by placement of an additional stent graft. Seven patients (16%) died within 30 days of surgery. Three of the deaths occurred in patients who had successfully undergone repair of a TAD and died of associated injuries. Emergent TEVAR has become the treatment of choice for acute surgical emergencies involving the descending thoracic aorta. Short-term morbidity and mortality compare favorably with historic results for emergent open surgical procedures on the descending thoracic aorta. Survival is highest in patients undergoing repair of TAD. Using current endograft technology, nearly all emergent conditions of the descending thoracic aorta can be successfully treated with TEVAR.

O impacto da hemotransfusão na morbimortalidade pós-operatória de cirurgias cardíacas

To analyze the impact of blood transfusion on the incidence of clinical outcomes postoperatively (PO) from cardiac surgery. Retrospective cohort study. We analyzed 4028 patients undergoing coronary artery bypass grafting (CABG), valve (TV), or both, in Brazilian tertiary university hospital between 1996 and 2009. We compared the postoperative complications between patients with blood transfusion (n = 916) and non-blood transfusion (n = 3112). Univariate analysis was performed using the Student t test, and multivariate logistic regression bivariate (stepwise forward). Were considered significant variables with P <0.05. Patients who received blood transfusions had more infectious episodes as mediastinitis (4.9% vs. 2.2%, P <0.001), respiratory infection (27.8% vs 17.1%, P <0.001) and sepsis (6.2% vs. 2.5%, P <0.001). There were more episodes of atrial fibrillation (AF) (27% vs. 20.4%, P <0.001), acute renal failure (ARF) (14.5% vs 7.3%, P <0.001) and stroke (4.8% vs. 2.6%, P = 0.001). The length of PO hospital stay was higher in transfused (13 ± 12.07 days vs. 9.72 ± 7.66 days, P <0.001). However, mortality didn't differ between groups (10.9% vs. 9.1%, P = 0.112). The transfusion was shown to be a risk factor for: respiratory infection (OR: 1.91, 95% CI 1.59-2.29, P <0.001), AF (OR: 1.35, 95% CI 1.13-1.61, P = 0.01), sepsis (OR: 2.08, 95% CI 1.4-3.07, P <0.001), mediastinitis (OR: 2.14, 95% CI: 1.43-3.21, P <0.001), stroke (OR: 1.63, 95% CI 1.1-2.41, P = 0.014) and ARF (OR 1.8, 95% CI: 1.39-2.33, P <0.001). The blood transfusion is associated with increased risk of infectious events, episodes of AF, ARF and stroke, as well as the increased length of hospital stay but not mortality.

Defining acute renal failure

The initial management of episodes of acute renal failure is often done by clinicians who are not specialists in nephrology. Their efforts may be hampered by several factors, such as deficiencies in our understanding of acute renal failure, and consensus and anecdote forming the basis of much of our

Emergency Procedures on the Descending Thoracic Aorta in the Endovascular Era

Thoracic endovascular aortic repair (TEVAR), initially developed for the treatment of degenerative aneurysms of the descending thoracic aorta, has been applied to the entire spectrum of descending thoracic aortic pathology in both the elective and emergent settings. This single center study evaluates the effectiveness of TEVAR for the treatment of acute surgical emergencies involving the descending thoracic aorta, including traumatic aortic disruption (TAD), ruptured descending thoracic aneurysm (RDTA), and acute complicated type B dissection (cTBD). A retrospective review of the medical records of all patients undergoing emergent TEVAR at a tertiary care medical center with a level 1 trauma center between August 2007 and August 2010 was undertaken. Study endpoints included: 30-day survival, complications, type of device used for the repair and technical aspects of the procedure. A total of 42 patients (62% male) with an average age of 50 years underwent emergent TEVAR during the study period. The technical success rate was 100%, with no patient requiring emergent open surgery for conditions involving the descending thoracic aorta at our institution during the study period. The majority (71%) of the repairs were accomplished using commercially available thoracic stent grafts. Abdominal stent graft components were used in 40% of patients undergoing repair of TAD. Twenty patients (48%) required coverage of the left subclavian artery, two of whom subsequently required subclavian artery revascularization. Procedure related complications included: 1 stroke, 1 spinal cord ischemia, 1 unintentional coverage of the left carotid artery, 1 episode of acute renal failure and 2 access site injuries. Two patients undergoing repair of TAD had collapse of the stent graft in the early postoperative period. Both were successfully treated by placement of an additional stent graft. Seven patients (17%) died within 30 days of surgery. Three had successfully undergone repair of a TAD and died of associated injuries.Tabled 1Type of aortic pathologyMean age (range)Type of deviceSubclavian artery coverage30-day survivalTAD43 (16-77)Thoracic-1815 of 30 (50%)27 of 30 (90%)N = 30Abdominal-12RDTA68 (54-87)Thoracic - 73 of 7 (43%)4 of 7 (57%)N = 7cTBD67 (50-77)Thoracic-42 of 4 (50%)3 of 4 (75%)N = 4Distal aortic tear42Thoracic-101/1 (100%)N = 1Total50 (16-87)Thoracic-3020 of 42 (48%)35 of 42 (83%)N = 42Abdominal-12 Open table in a new tab Emergent TEVAR has become the treatment of choice for acute surgical emergencies involving the descending thoracic aorta. Short-term results compare favorably to published historic results for emergent open surgical procedures on the descending thoracic aorta. Survival is highest in patients undergoing repair of TAD. Using current stent graft technology, nearly all emergent conditions of the descending thoracic aorta can be successfully treated with TEVAR. Subclavian artery coverage is required in half of patients, and can be performed safely. A minority will subsequently require subclavian artery revascularization.