Higher Rates Of Renal Failure Research Articles

Incidence, risk factors and clinical outcome of multidrug-resistant organisms after heart transplantation.

Transplant recipients commonly harbor multidrug-resistant organisms (MDROs), as a result of frequent hospital admissions and increased exposure to antimicrobials and invasive procedures. To investigate the impact of patient demographic and clinical characteristics on MDRO acquisition, as well as the impact of MDRO acquisition on intensive care unit (ICU) and hospital length of stay, and on ICU mortality and 1-year mortality post heart transplantation. This retrospective cohort study analyzed 98 consecutive heart transplant patients over a ten-year period (2013-2022) in a single transplantation center. Data was collected regarding MDROs commonly encountered in critical care. Among the 98 transplanted patients (70% male), about a third (32%) acquired or already harbored MDROs upon transplantation (MDRO group), while two thirds did not (MDRO-free group). The prevalent MDROs were Acinetobacter baumannii (14%), Pseudomonas aeruginosa (12%) and Klebsiella pneumoniae (11%). Compared to MDRO-free patients, the MDRO group was characterized by higher body mass index (P = 0.002), higher rates of renal failure (P = 0.017), primary graft dysfunction (10% vs 4.5%, P = 0.001), surgical re-exploration (34% vs 14%, P = 0.017), mechanical circulatory support (47% vs 26% P = 0.037) and renal replacement therapy (28% vs 9%, P = 0.014), as well as longer extracorporeal circulation time (median 210 vs 161 min, P = 0.003). The median length of stay was longer in the MDRO group, namely ICU stay was 16 vs 9 d in the MDRO-free group (P = 0.001), and hospital stay was 38 vs 28 d (P = 0.006), while 1-year mortality was higher (28% vs 7.6%, log-rank-χ 2: 7.34). Following heart transplantation, a predominance of Gram-negative MDROs was noted. MDRO acquisition was associated with higher complication rates, prolonged ICU and total hospital stay, and higher post-transplantation mortality.

A study of clinical profile of snake bite at a tertiary care centre

Because India has long been a land of exotic snakes, snakebite is a serious occupational and rural hazard. Physicians pay very little attention to this occupational hazard despite the high morbidity and death. To study the various clinical profiles and the time interval between bite and start of treatment. Patients were categorized based on the envenomation centred by patient history and definitive bite evidence and graded (I-IV) grounded on a series of manifestations observed in association with the onset of treatment time that distinguishes a venomous from a non-venomous snake attack. Patients were obligating local inflammation owing to tourniquet use besides local innate therapies. Of the 100 patients deliberated, it was evident that there existed a minimal difference between the bites instigated by the snake type. Higher abnormal clotting was perceived on the arrival of patients (78%). While envenomation was predominantly reported to prompt primary coagulation abnormalities (84.32 %), neurotoxin manifestation was also found to occur at a lower rate (11.76 %). Both symptoms were also observed at a minimal level (3.92 %). Higher rates of renal failure were also reported and the clotting time normalization depended largely on patient admission time post-attack. In this investigation, the time gap between the bite and the commencement of therapy was not associated with the time required to normalize the coagulation abnormalities or develop a complication. The study also proposes appropriate protective and awareness measures that could save humankind and these reptiles together.

HeartMate-3 Ventricular Assist Devices Versus the Total Artificial Heart for Biventricular Support: A Single-Center Series.

The SynCardia total artificial heart (TAH) is the only device approved for biventricular support. Continuous flow ventricular assist devices (VAD) in a biventricular configuration (BiVAD) have been used with variable results. The purpose of this report was to examine differences in patient characteristics and outcomes between two HeartMate-3 (HM-3) VADs in comparison with TAH support. All patients who received durable biventricular mechanical support from November 2018 to May 2022 at The Mount Sinai Hospital (New York) were considered. Baseline clinical, echocardiographic, hemodynamic, and outcome data were extracted. Primary outcomes were postoperative survival and successful bridge-to-transplant (BTT). A total of 16 patients received durable biventricular mechanical support during the study period, of which 6 (38%) patients received two HM-3 VAD pumps as BiVAD support and 10 (62%) patients received a TAH. Overall, TAH patients had a lower median lactate ( p < 0.05) at baseline compared to those on HM-3 BiVAD support yet had higher operative morbidity, lower 6-month survival ( p < 0.05), and a higher rate of renal failure (80 vs . 17%; p = 0.03). However, survival declined to the same rate at 1 year (50%) and was largely because of extracardiac adverse events related to underlying comorbidities (particularly, renal failure and diabetes, p < 0.05). Successful BTT was achieved in 3 out of 6 HM-3 BiVAD patients and in 5 out of 10 TAH patients. In our single center experience, similar outcomes were observed among patients BTT with HM-3 BiVAD compared to those BTT on TAH support despite lower Interagency Registry for Mechanically Assisted Circulatory Support level.

Abstract 15813: Comparative Case Series of Biventricular Support Between Heartmate-3 Ventricular Assist Devices and the Total Artificial Heart: A Single-Center Experience

Introduction: Currently, only the Syncardia Total Artificial Heart (TAH) is approved for biventricular support as a bridge-to-transplant (BTT). The off-label use of continuous flow ventricular assist devices (VAD) in a biventricular configuration (BiVAD) has been used with variable results, emphasizing the need for patient selection. We report our single-center BiVAD experience in patients supported with two HeartMate-3 (HM-3) VADs in a biventricular configuration in comparison with TAH support. Methods: All patients receiving durable biventricular mechanical support at The Mount Sinai Hospital (New York, New York) were considered. Baseline clinical, echocardiographic, hemodynamic and outcome data were extracted. Outcomes of interest were postoperative survival and adverse events, and compared using non-parametric statistics. Successful BTT and post-transplant survival were descriptively evaluated. Results: From November 2018 through May 2022, a total of 6 (37.5%) patients received two HM-3 VAD pumps in a BiVAD configuration and 10 (62.5%) patients received a TAH. Overall, TAH patients had significantly higher median INTERMACS profiles (p &lt; 0.05) at baseline compared to those on HM-3 BiVAD support but lower 30-day and 6-month survival and with a significantly higher rate of renal failure (Table 1). However, survival declined to the same rate at 1-year with both forms of support and was largely due to extracardiac adverse events related to underlying comorbidities (particularly, CKD/ESRD and diabetes, p &lt; 0.05). Successful BTT has thus far been achieved in 2 (33%) HM-3 BiVAD compared to 5 (50%) TAH patients, and had similar post-transplant survival at 1-year. Conclusions: HM-3 BiVAD demonstrated lower short-term and similar long-term mortality compared to TAH support among patients in extremis. However, larger studies are needed to optimize patient selection and pursuit of mechanical support in biventricular failure.

Prognostic analysis of crescentic glomerulonephritis with acute kidney injury: a single-center cohort with 5-year follow-up.

Crescentic glomerulonephritis (CrGN) represents a severe form of glomerular injury that results in high rates of renal failure. This study aimed to investigate theinfluence of potential clinical and pathological factors on renal outcomes of CrGN; and the relationship between 3-month and 5-year follow-up as well. The cohort enrolled patients diagnosed of biopsy proven CrGN with acute kidney injury(AKI) from January 1, 2010, to January 1, 2018 in Shanghai Changzheng Hospital and followed up for 5years. A total of 56 patients were included, among whom 11 patients (19.6%) had type I, 12 (21.4%) had type II, and 33 (58.9%) had type III CrGN. Patients with type II CrGN tended to have a lower crescent score, less renal tubular damage, and lower serum creatinine than the other two types. Three-month cumulative renal survival rates of types I, II, and III CrGN were 45.5%, 66.7%, and 48.5%, respectively. Five-year cumulative renal survival rates of types I, II, and III CrGN were 27.2%, 83.3%, and 36.4%, respectively. The Kappa Consistency Test between 3-month and 5-year outcomes was 0.573(P < 0.001). Cox regression model showed that in-hospital dialysis was an indicative renal survival factor in 3months (HR 15.670, 95% CI 2.987-82.210, P = 0.001). It also showed that the crescent score had an unfavorable effect for renal survival in 5years (HR 1.750 95% CI 1.018-3.009, P = 0.043). Clinical manifestations and outcomes varied by different CrGN types. Three-month outcomes could partially reflect the 5-year outcomes. Severity of crescents was an independent risk factor for renal survival in CrGN.

Comparison of Clinical and Thrombotic Outcomes in Sars-Cov-2- Pneumonia Versus Other Viral Pneumonia in an Urban Academic Medical Center

Title: Comparison of Clinical and Thrombotic Outcomes in SARS-CoV-2- Pneumonia versus Other Viral Pneumonia in an Urban Academic Medical CenterObjective: To compare clinical and thrombotic outcomes in SARS-CoV-2 pneumonia versus other viral pneumonias.Introduction: Viral pneumonia (PNA) causes oxidative stress to the pulmonary vasculature, triggering endothelial dysfunction and activation of the coagulation cascade. Elevations in coagulation markers, including d-dimer and fibrinogen, have been observed. Recent studies indicate that SARS-CoV-2 infection causes endothelial cell injury, with activation of the coagulation cascade, and a high frequency of systemic thrombotic events. It remains unclear whether it is viral pneumonia itself, a specific viral strain (and/or viral load) that drives the clinical and thrombotic outcomes. Furthermore, limited data is available regarding clinical outcomes in a diverse patient population hospitalized with SARS-CoV-2 infection. This study is from a single urban medical center in Chicago, Illinois.Study Design: A retrospective cohort study evaluating the medical records of hospitalized adult patients admitted to University of Illinois Hospital and Health Sciences System (UIHHSS) with SARS-CoV-2 pneumonia or other viral (H1N1 or H3N2) pneumonia between 10/01/2017 and 09/01/2020.Methods: Patients were included if ≥18 years old, hospitalized, with a primary confirmed diagnosis of viral pneumonia (SARS-CoV-2, H1N1 or H3N2) based on ICD-10 code, viral diagnostic testing, diagnosis description, and appropriate clinical characteristics/imaging studies. Past medical history, inpatient medications, coagulation parameters, arterial/venous thrombotic outcomes, and other clinical outcomes (renal replacement therapy, mechanical ventilation, co-infection) were abstracted from UIHHSS electronic health record database.Results: Medical records of 257 patient with a primary diagnosis of pneumonia were reviewed, 199 patients with SARS-CoV-2 PNA (95 male, average age 58 years, 52% Hispanic, 37% non-Hispanic Black) and 58 patients with other viral PNA (24 male, average age 63 years, 21% Hispanic, 55% non-Hispanic Black; 34 with H3N2, 24 with H1N1). Coagulation parameters (maximum D-dimer, fibrinogen, INR) were similar in both groups; average D-dimer was >3x ULN. Anticoagulation therapy was similarly prescribed in both groups (SARS-CoV-2, 95% vs 84%, H1N1 or H3N2), with prophylactic dose anticoagulation prescribed most frequently (73% vs 62%) and with high average compliance rates (89% vs 83%). Admission to the intensive care unit (ICU; 32% vs 29%) and the median length of stay (10 vs 4 days) was similar in both groups. Thrombotic events (n = 6, 3%) occurred only in SARS-CoV-2 PNA patients in the ICU: 3 pulmonary embolism (PE), 1 distal lower extremity deep vein thrombosis (DVT), 2 non-ST elevated myocardial infarctions (NSTEMI). There was a significantly higher incidence of use of renal replacement therapy (8.5% vs 0%, p=0.016) and mortality (15.6% vs 3.4%, p=0.048) in the SARS-CoV-2 PNA group compared to the H3N2/H1N1 PNA group. There were no differences in the rates of mechanical ventilation, the incidence of major bleeding or co-infection. In a multivariable logistic regression analysis, age (aOR 1.07), the presence of SARS-CoV-2 PNA (aOR 11.37), and ICU admission (aOR 41.95) were significantly associated with risk of mortality during hospitalization. Race and ethnicity were not associated with mortality.Conclusion: The overall incidence of thrombotic events was low and occurred only in the SARS-CoV-2 PNA group. The low rate of venous thrombosis detected in this group, especially in the ICU setting, is likely related to the reduced use of diagnostic studies during the first COVID-19 pandemic in 2020 and to the high rates of anticoagulation prophylaxis orders and compliance. SARS-CoV-2 PNA was associated with a higher rate of renal failure and mortality compared to patients with H3N2/H1N1 viral pneumonia. There was no difference in mortality rates between Hispanic and non-Hispanic and between Black and non-Black patients. This study suggests that SARS-CoV-2 pneumonia leads to greater endothelial dysfunction than that observed in H3N2/H1N1 viral pneumonia and that race/ethnicity does not drive mortality outcomes. DisclosuresBenken: BMS: Research Funding; CareDx: Research Funding; Transplant Genomics: Research Funding; Daiichi Sankyo: Research Funding; Verici Dx: Research Funding.

Trauma and nontrauma damage-control laparotomy: The difference is delirium (data from the Eastern Association for the Surgery of Trauma SLEEP-TIME multicenter trial).

Damage-control laparotomy (DCL) has been used for traumatic and nontraumatic indications. We studied factors associated with delirium and outcome in this population. We reviewed DCL patients at 15 centers for 2 years, including demographics, Charlson Comorbidity Index (CCI), diagnosis, operations, and outcomes. We compared 30-day mortality; renal failure requiring dialysis; number of takebacks; hospital, ventilator, and intensive care unit (ICU) days; and delirium-free and coma-free proportion of the first 30 ICU days (DF/CF-ICU-30) between trauma (T) and nontrauma (NT) patients. We performed linear regression for DF/CF-ICU-30, including age, sex, CCI, achievement of primary fascial closure (PFC), small and large bowel resection, bowel discontinuity, abdominal vascular procedures, and trauma as covariates. We performed one-way analysis of variance for DF/CF-ICU-30 against traumatic brain injury severity as measured by Abbreviated Injury Scale for the head. Among 554 DCL patients (25.8% NT), NT patients were older (58.9 ± 15.8 vs. 39.7 ± 17.0 years, p < 0.001), more female (45.5% vs. 22.1%, p < 0.001), and had higher CCI (4.7 ± 3.3 vs. 1.1 ± 2.2, p < 0.001). The number of takebacks (1.7 ± 2.6 vs. 1.5 ± 1.2), time to first takeback (32.0 hours), duration of bowel discontinuity (47.0 hours), and time to PFC were similar (63.2 hours, achieved in 73.5%). Nontrauma and T patients had similar ventilator, ICU, and hospital days and mortality (31.0% NT, 29.8% T). Nontrauma patients had higher rates of renal failure requiring dialysis (36.6% vs. 14.1%, p < 0.001) and postoperative abdominal sepsis (40.1% vs. 17.1%, p < 0.001). Trauma and NT patients had similar number of hours of sedative (89.9 vs. 65.5 hours, p = 0.064) and opioid infusions (106.9 vs. 96.7 hours, p = 0.514), but T had lower DF/CF-ICU-30 (51.1% vs. 73.7%, p = 0.029), indicating more delirium. Linear regression analysis indicated that T was associated with a 32.1% decrease (95% CI, 14.6%-49.5%; p < 0.001) in DF/CF-ICU-30, while achieving PFC was associated with a 25.1% increase (95% CI, 10.2%-40.1%; p = 0.001) in DF/CFICU-30. Increasing Abbreviated Injury Scale for the head was associated with decreased DF/CF-ICU-30 by analysis of variance (p < 0.001). Nontrauma patients had higher incidence of postoperative abdominal sepsis and need for dialysis, while T was independently associated with increased delirium, perhaps because of traumatic brain injury. Therapeutic study, level IV.

Impact of bleeding on mortality in patients with acute myocardial infarction complicated by cardiogenic shock.

Acute myocardial infarction complicated by cardiogenic shock (AMICS) is associated with substantial mortality, although there are limited data available on bleeding in this critical condition. This study sought to investigate the incidence and impact of major in-hospital bleeding on all-cause mortality in patients with AMICS who undergo percutaneous coronary intervention (PCI). Between 2015 and 2017, a total of 3411 patients hospitalized within 24 h after symptom onset were prospectively enrolled in the Japan Acute Myocardial Infarction Registry (JAMIR) and followed up for a median of 293 (interquartile range, 22-375) days. AMICS developed in 335 (9.8%) patients (mean age, 71.3 ± 13.6 years). Overall, the rate of major in-hospital bleeding (Bleeding Academic Research Consortium types 3 and 5) and in-hospital mortality was 14.6% and 28.7%, respectively. The majority of major in-hospital bleeding (73.5%) occurred within 48 h after PCI. Compared to patients without major in-hospital bleeding, those with it had higher rates of renal failure, left main coronary artery culprit lesion, and intra-aortic balloon pump or extracorporeal membrane oxygenation support, and had longer door-to-device time. The cumulative incidence of 1-year all-cause mortality was significantly higher in the major bleeding group compared to the non-major bleeding group (63.8% vs. 25.5%; log-rank P < 0.001). After adjusting for confounders, major in-hospital bleeding was independently associated with increased all-cause mortality (hazard ratio, 1.70; 95% confidence interval, 1.08-2.69). These findings of JAMIR indicate that major in-hospital bleeding is associated with all-cause mortality in patients with AMICS who undergo PCI.

Concomitant tricuspid valve surgery is beneficial at the time of left-sided valve surgery.

This study evaluates the impact of secondary functional tricuspid regurgitation (TR) and concomitant tricuspid valve repair (TVr) at the time of left-sided valve operations. Adults undergoing left-sided valve operations between 2010 and 2019 at a multihospital academic institution were included. Patients were stratified into three groups: less-than-moderate TR without TVr (Group 1), moderate-or-greater TR without TVr (Group 2), and moderate-or-greater TR with TVr (Group 3). Primary outcomes included survival and hospital readmissions. Secondary outcomes included major postoperative morbidities. Multivariable logistic regression evaluated risk-adjusted mortality and readmission. About 3444 patients were included in the analysis and were stratified into Group 1 (n = 2612, 75.8%), Group 2 (n = 563, 16.3%), and Group 3 (n = 269, 7.8%). Patients with moderate or greater TR (Groups 2 and 3) had higher rates of mortality, hospital readmissions and major postoperative complications including reoperations, renal failure requiring dialysis, blood transfusions, and prolonged ventilation (all, p < .05). When assessed individually, the Group 3 had substantially higher rates of renal failure requiring dialysis, prolonged ventilation, and reoperations, although the Group 2 had higher rates of 30-day mortality (all, p < .05). These findings persisted in risk-adjusted analysis with the highest hazards for mortality (hazard ratio [HR] 1.9, 95% confidence interval [CI] 1.7-2.2) and readmission (HR 1.3, 95% CI 1.2-1.5) appreciated in the Group 2. In this analysis of 3444 patients, those with moderate-to-severe TR who did not undergo a TVr at the time of their left-sided valve operation had substantially higher risks of mortality and hospital readmissions compared with those who did undergo TV surgery.

Higher neutrophil-to-lymphocyte ratio (NLR) increases the risk of suboptimal platelet inhibition and major cardiovascular ischemic events among ACS patients receiving dual antiplatelet therapy with ticagrelor

BackgroundNeutrophil to lymphocyte ratio (NLR) has emerged as a useful and easy-to-assess prognostic tool and biomarker of cardiovascular risk. However, few studies have evaluated its role on platelet inhibition among patients on dual antiplatelet therapy (DAPT), and especially in the settings of acute coronary syndromes (ACS). We aimed at assessing the impact of NLR on platelet reactivity and the risk of major ischemic events at long-term follow-up among ACS patients on DAPT with ticagrelor. MethodsPatients on dual antiplatelet therapy with ASA + ticagrelor (90 mg/twice a day) after percutaneous coronary revascularization for ACS were scheduled for platelet function assessment 30–90 days post-discharge. Aggregation tests were performed by Multiple Electrode Aggregometry (MEA). Suboptimal platelet inhibition (HRPR-high residual platelet reactivity was defined if above the lower limit of normality (417 AU*min). The primary study endpoint was defined as the occurrence of major cardiovascular events (a composite of cardiovascular death, recurrent acute coronary syndrome, target vessel revascularization) at longest available follow-up. ResultsWe included 397 patients, that were divided according to NLR tertiles. Patients with higher NLR were older (p < .001), less frequently smokers (p = .03), with higher rates of renal failure (p = .001), previous bypass surgery (p = .05) and use of statins (p = .03) and diuretics (p = .01). Higher white blood cells count and C-reactive protein (p < .001) and lower haemoglobin (p = .001) were associated with NLR. Mean platelet reactivity and the prevalence of high platelet reactivity (HRPR) on ticagrelor were significantly associated to higher NLR tertiles values (7% vs 12% vs 14.3%, p = .04), with a significant relationship between NLR and platelet reactivity being confirmed for all the different activating stimuli.At a mean follow-up of 939 ± 581.4 days, 21.2% of the patients experienced the primary composite endpoint, with a trend for a higher risk of events across NLR tertiles (15.4% vs 24.2% vs 24.4%, p = .09), that became statistically significant after correction for baseline confounders (adjusted HR[95%CI] = 1.13[1.008–1.26], p = .036). Moreover, NLR was significantly associated to overall mortality and recurrent ACS (adjusted p = .008, p = .06 and p = .02 respectively). ConclusionsIn the present study we found that among ACS patients treated with ASA and ticagrelor after PCI, suboptimal platelet inhibition despite DAPT was significantly increased for higher values of Neutrophil-to-Lymphocyte Ratio. Moreover, mortality and the risk of recurrent major ischemic events at long-term were associated to NLR.

Bariatric Surgery in Prior Solid Organ Transplantation Patients: Is Race a Predictor of Adverse Outcomes?

PurposeMetabolic and bariatric surgery (MBS) is increasingly performed in patients with previous solid organ transplantation (PSOT). In addition, controversy remains about whether racial disparity in outcomes following MBS exists. Therefore, the aim of this analysis was to determine if race independently predicts outcomes in MBS patients with PSOT.Materials and MethodsPatients with PSOT undergoing sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) were identified in the 2017 Metabolic and Bariatric Surgery Accreditation Quality and Improvement Project (MBSAQIP) database. Patients were stratified by race (Black and White). Propensity score matching was utilized to adjust for multiple demographic variables. Multivariable logistic regression analyses were performed for overall and bariatric-related morbidity.ResultsOf 335 MBS patients with PSOT, 250 (75%) were white and 85 (25%) were black patents. Procedure-type and surgical approach (p > 0.1) were similarly distributed. Black patients were more likely (p < 0.05) to have hypertension dialysis-dependent chronic kidney disease, and be on chronic steroids). Mortality and morbidity were similar. Black patients had significantly (p < 0.05) higher rates of renal failure, pulmonary complications, and emergency department visits in unmatched analysis. After propensity score matching, 82 patients in each cohort were identified and were similar at baseline (p > 0.5). In the matched analysis, black patients had higher overall (17% vs. 10%, p = 0.12) and bariatric-related morbidity (14% vs. 7.2%, p = 0.05). In addition, black patients had significantly (p < 0.05) higher rates of postoperative pneumonias, progressive renal insufficiency, and emergency department visits. On multivariable regression analysis, black race did not independently predict overall or bariatric-related morbidity.ConclusionMBS in racial cohorts with PSOT is safe, with very low rates of overall morbidity and mortality. Black race trended toward increased postoperative morbidity. Larger cohort studies are needed to validate our findings.Electronic supplementary materialThe online version of this article (10.1007/s11695-020-04813-9) contains supplementary material, which is available to authorized users.

Sex Differences in Autoimmune Multimorbidity in Type 1 Diabetes Mellitus and the Risk of Cardiovascular and Renal Disease: A Longitudinal Study in the United States, 2001-2017.

Background: Autoimmune diseases are usually more prevalent in women. The risks of cardiovascular and renal disease in those with multiple autoimmune diseases have not been fully described. Materials and Methods: Using a national database from a large health insurer in the United States (years 2001-2017) containing ∼75 million members, we calculated age- and sex-specific co-prevalence of 12 autoimmune disorders for individuals with type 1 diabetes. We then evaluated whether concomitant autoimmune diseases were associated with renal failure, ischemic stroke, and myocardial infarction. Results: Of the 179,248 people diagnosed with type 1 diabetes, 1 in 4 had a concomitant autoimmune disease (27.03%; 95% confidence interval [CI] = 26.83%-27.24%), with hypothyroidism, rheumatoid arthritis, and celiac disease being the most common. The prevalence of autoimmune disease was 1.9 times greater in female than male patients (p < 0.001). In female patients with type 1 diabetes, one in three had another autoimmune disease (35.62%; 95% CI = 35.30%-35.94%) compared with one in five male patients (19.17%; 95% CI = 18.92%-19.42%). The risk of renal failure, ischemic stroke, and myocardial infarction increased with a greater number of concomitant autoimmune diseases (p < 0.001, test for trend for both female and male patients). Patients with type 1 diabetes who had multiple sclerosis or myasthenia gravis experienced an approximate threefold increase in risk of ischemic stroke (odds ratio [OR] = 3.57, OR = 3.22, respectively). Patients with type 1 diabetes and Addison's disease had a threefold increased risk of renal failure. Conclusions: Patients with type 1 diabetes, particularly women, frequently have coexisting autoimmune diseases that are associated with higher rates of renal failure, ischemic stroke, and myocardial infarction. Additional study is warranted, as are preventive efforts in this high-risk population.

P5524Influence of bundle branch block in the long-term outcome of patients with acute coronary syndrome

Abstract The new European Society of Cardiology guideline for ST-segment elevation myocardial infarction recommends that left and right bundle branch block should be considered equal for recommending urgent angiography in patients with suspected myocardial infarction. This consideration is not taken into account in the management of patients with coronary syndrome without ST elevation (NSTEMI). We evaluate the evolution of patients with acute coronary syndrome and long-term bundle branch block. Patients and methods We included 8771 patients admitted to two tertiary hospitals between 2003 and 2017 with an acute coronary syndrome, 5673 NSTEMI (64.3%) and 3098 STEMI (35.7%). All patients had an ECG recorded immediately upon admission. Patients were classified as having right bundle branch block (RBBB), left bundle branch block (LBBB). Long-term follow-up was performed (median 55 months) to assess mortality. Results A total of 8771 patients were included with a mean age of 66.1 years, 72.5% males, 4.1% (362) with LBBB and 5% (440) with RBBB. Patients with BBB were older, with more previous history of myocardial infarction and coronary revascularization and higher prevalence of cardiovascular risk factors. Medical treatment was similar but they were less often submitted to angioplasty. During the acute phase, patients with RBBB and LBBB presented a higher rate of heart failure than those without branch block (4.8% vs 9.1% vs 3.5%, p=0.0001); higher mortality (8.4% vs 10.5% vs 3.0%, p=0.0001); higher stroke rate (2.5% vs 1.4% vs 0.8%, p=0.001); higher rate of renal failure (8.2% vs 9.7% vs 3.9%, p=0.0001) and higher rate of reinfarction (3.0% vs 4.1% vs 1.7%, p=0.001). Patients who had a RBBB or an LBBB had a worse prognosis throughout the follow-up. Heart failure was present in 17.7% of the group with RBBB, 29.6% of LBBB and 11% in the group without branch block (p=0.0001). Mortality during follow-up was 31% in RBBB, 40.6% in LBBB and 18.7% without branch block (p=0.0001). In multivariate analysis of Cox, both RBBB (HR 1.55, 95% CI 1.23–1.98, p=0.0001) and LBBB (HR 1.48, 95% CI 1.22–1.53, p=0.001) were an independent predictors of all-cause mortality (adjustment for GRACE score, gender, treatment with betablockers, angiotensin conversor enzym inhibitors, statin and coronary revascularization). Cox regression model multivariate Conclusions The presence of RBBB or LBBB in the ECG of patients with an ACS is associated with a worse prognosis both during the hospital phase and in the long term. In addition, both bundle branch blocks are independent predictors of long-term mortality in patients with ACS.

Do anticoagulants affect outcomes of hip fracture surgery? A cross-sectional analysis

IntroductionThe management of patients with a hip fracture is affected by the use of oral anticoagulants. A cross-sectional analysis was undertaken to investigate health outcome differences in those anticoagulated compared to those not anticoagulated.MethodsPatients aged 50 years and over presenting to a large university hospital with hip fractures were identified from the service registry. Patient characteristics and health outcomes between those not anticoagulated were compared with those anticoagulated (warfarin and direct oral anticoagulants, DOAC).Results200/2307 (9%) patients were anticoagulated. 84% were on warfarin, and the rest a DOAC. Compared to those anticoagulated, there was a higher prevalence of dementia (25% vs. 18%, p = 0.02) and a lower prevalence of cardiovascular disease (54% vs. 78%, p < 0.01), atrial fibrillation (10% vs. 82%, p < 0.01), and polypharmacy (55% vs. 76%, p < 0.01). Renal function was lower in the anticoagulated group. Time to operation for those not anticoagulated and anticoagulated was a median (IQR) of 25 (15) and 27 (18) hours. There was no difference in blood transfusion and hospital mortality. Postoperative complications were similar except a higher rate of renal failure (14% vs. 19%, p = 0.04) and heart failure (1% vs. 5%, p < 0.01), and a longer length of stay [median (IQR): 14 (10) vs. 16 (12) days] in the anticoagulated group. This was no longer significant after adjustment of confounders.ConclusionThere was no statistically significant difference in health outcomes between those anticoagulated and those not after adjusting for patient characteristics. It was feasible to avoid significant delay in hip fracture surgery in those anticoagulated.

Association of neutrophil-to-lymphocyte ratio with outcomes after elective abdominal aortic aneurysm repair

Data are lacking regarding real-time prediction of postoperative complications after elective aneurysm repair. The neutrophil-to-lymphocyte ratio (NLR) has been evaluated as a predictor of outcomes after cardiac and infrapopliteal interventions and is associated with poor outcomes for critical limb ischemia. We examined NLR and outcomes after abdominal aortic aneurysm (AAA) repair. Inpatients undergoing elective AAA repair (2008 to 2015) were selected from the Cerner Health Facts database using International Classification of Disease (9th edition) procedure codes. Postoperative outcomes were identified using data from patient records within 1week after surgery. NLR was calculated by dividing the absolute neutrophil count by the absolute lymphocyte count. The receiver operating characteristic curve was analyzed to define low and high postoperative NLR groups. Chi-square analysis and multivariable logistic regression models were used to identify characteristics (demographics, diagnoses, postoperative NLR) associated with postoperative complications. Elective AAA repair occurred in 5,655 patients. Of these, we could calculate postoperative NLR for 1,908 (34%), with 1,529 undergoing endovascular repair and 379 undergoing an open repair. Compared with patients with low postoperative NLR, patients with high postoperative NLR experienced longer hospital stays (5.7 vs 2.6days, P<.0001); higher rates of in-hospital death (2.9% vs 1.4%, P=.002); higher rates of renal failure (11.6% vs 3.9%, P<.0001); cardiac problems or myocardial infarction (3.8% vs 1.2%, P=.0002); respiratory problems (13.3% vs 5.8%, P<.0001); and infection (8.9% vs 2.9%, P<.0001). The association between high postoperative NLR and adverse postoperative outcomes persisted on multivariable analysis. This included infection (odds ratio [OR], 2.59; 95% confidence interval [CI], 1.65-4.07), renal failure (OR, 2.19; 95% CI, 1.45-3.31), cardiac events (OR, 2.41; 95% CI, 1.21-4.77), and respiratory problems (OR, 1.73; 95% CI, 1.22-2.45).NLR was associated with adverse outcomes after elective endovascular and open AAA repair. An elevated NLR within 1week after surgery was strongly associated with postoperative complications, and may identify at-risk patients who require closer follow-up. Given the perilous nature of vascular surgery and the risk-benefit ratio for prophylactic aneurysm repair, future study of postoperative outcome and preoperative NLR is needed to provide clinically important risk profiles before treatment decisions.

Early and late outcomes after transcatheter versus surgical aortic valve replacement in obese patients

IntroductionData on the early and late outcome following transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) in obese patients are limited. We investigated whether TAVI may be superior to SAVR in obese patients.Material and methodsObese patients (body mass index ≥ 30 kg/m2) who underwent either SAVR or TAVI were identified from the nationwide OBSERVANT registry, and their in-hospital and long-term outcomes were analysed. Propensity score matching was employed to identify two cohorts with similar baseline characteristics.ResultsThe propensity score matching provided 142 pairs balanced in terms of baseline risk factors. In-hospital and 30-day mortality did not differ between SAVR and TAVI obese patients (4.6% vs. 3.3%, p = 0.56, and 5.2% vs. 3.2%, p = 0.41, respectively). Obese SAVR patients experienced a higher rate of renal failure (12.4% vs. 3.6%, p = 0.0105) and blood transfusion requirement (60.3% vs. 25.7%, p < 0.0001) in comparison with TAVI patients. A higher rate of permanent pacemaker implantation (14.4% vs. 3.6%, p = 0.0018), and major vascular injuries (7.4% vs. 0%, p = 0.0044) occurred in the TAVI group. Five-year survival was higher in the SAVR group compared to the TAVI patient cohort (p = 0.0046), with survival estimates at 1, 3 and 5 years of 88.0%, 80.3%, 71.8% for patients undergoing SAVR, and 85.2%, 69.0%, 52.8% for those subjected to TAVI procedures.ConclusionsIn obese patients, both SAVR and TAVI are valid treatment options, although in the long term SAVR exhibited higher survival rates.

Temporal Changes on the Risks and Complications of Posttransplantion Diabetes Mellitus Following Cardiac Transplantation.

Background Recent changes in the demographic of cardiac donors and recipients have modulated the rate and risk, associated with posttransplant diabetes mellitus (PTDM). We investigated the secular trends of the risk of PTDM at 1 year and 3 years after transplantation over 30 years and explored its effect on major outcomes. Methods Three hundred and three nondiabetic patients were followed for a minimum of 36 months, after a first cardiac transplantation performed between 1983 and 2011. Based on the year of their transplantation, the patients were divided into 3 eras: (1983-1992 [era 1], 1993-2002 [era 2], and 2003-2011 [era 3]). Results In eras 1, 2, and 3, the proportions of patients with PTDM at 1 versus 3 years were 23% versus 39%, 21% versus 26%, and 33% versus 38%, respectively. Independent risk factors predicting PTDM at one year were recipient's age, duration of cold ischemic time, treatment with furosemide, and tacrolimus. There was a trend for overall survival being worse for patients with PTDM in comparison to patients without PTDM (p = 0.08). Patients with PTDM exhibited a significantly higher rate of renal failure over a median follow-up of 10 years (p = 0.03). Conclusion The development of PTDM following cardiac transplantation approaches 40% at 3 years and has not significantly changed over thirty years. The presence of PTDM is weakly associated with an increased mortality and is significantly associated with a worsening in renal function long-term following cardiac transplantation.

IMPACT OF TYPE II DIABETES MELLITUS ON SHORT-TERM IN-HOSPITAL OUTCOMES OF SEPSIS ADMISSIONS

SESSION TITLE: Critical Care 1 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: Type II diabetes mellitus is a proinflammatory state which increases susceptibility for severe infections. Sepsis activates a proinflammatory pathway within the body causing an increased cortisol response. When left unchecked, a cytokine storm subsequently causes multiorgan failure and death. The NICE-SUGAR trial demonstrated a liberal blood sugar control to reduce mortality in critically ill patients, however subgroup analysis showed the liberal blood sugar control group to have increased incidence of infections. The prevalence of diabetes and pre-hospitalization glycemic control are considered here to be individual factors to help predict sepsis outcomes. This study seeks to examine the effects of diabetes on sepsis admissions by examining short-term in-hospital outcomes and rate of organ failure. METHODS: This retrospective cohort study utilized information from the 2012-2014 Nationwide Inpatient Sample (NIS) to identify adult patients (18+ years) with a primary diagnosis of septicemia, septicemic, bacteremia, disseminated fungal infection, disseminated candida infection, or disseminated fungal endocarditis. Selected patients were analyzed for type II diabetes mellitus. Exclusions included patients with diabetes with ketoacidosis or hyperosmolarity, diabetic coma, type I diabetes, or patients missing important clinical identifiers. RESULTS: 648,602 sepsis admissions were identified including 205,749 with type II diabetes and 442,853 without type II diabetes. Increased mortality was observed in the non-diabetic patients (13.4% vs 11.1%, p<.001, OR .81, CI .80-.82), while patients with type II diabetes had increased LOS (7.7 vs 7.6 days, p<.001), age at admission (68.7 vs 65.7 years, p<.001), and number of chronic conditions (8.0 vs 6.0, p<.001). There was no difference in total charges. Examination of organ failure rates demonstrated increased respiratory (24.6% vs 22.1%, p<.001, OR 1.15, CI 1.13-1.16), cardiovascular (7.7% vs 7.0%, p<.001, OR 1.11, CI 10.09-1.14), hepatic (3.9% vs 3.0%, p<.001, OR 1.31, CI 1.27-1.35), and hematologic (11.0% vs 9.3%, p<.001, OR 1.21, CI 1.18-1.23) organ failures in non-diabetic admissions. Septic admissions with type II diabetes were found to have higher rates of renal failure (49.4% vs 42.2%, p<.001, OR .75, CI .74-.76). There were no differences in rate of metabolic (16.8% vs 16.9%) or neurologic (2.7% vs 2.8%) organ failures between non-diabetic and diabetic admissions, respectively. CONCLUSIONS: Non-diabetic septic patients have higher mortality rates than diabetic septic patients despite increased age, LOS and number of chronic conditions in diabetics. As expected, septic patients with diabetes demonstrated higher rates of renal failure. CLINICAL IMPLICATIONS: Clinicians must be proactive with sepsis regardless of diabetic status due to high mortality. Understanding organ failure rates can aid in early monitoring and treatment during sepsis admissions. DISCLOSURES: No relevant relationships by Jacob Baer, source=Web Response No relevant relationships by Sai Guda, source=Web Response No relevant relationships by Catherine Mayer, source=Web Response

Improving Medication Safety and Cardiovascular Risk Factor Control to Mitigate Disparities in African-American Kidney Transplant Recipients: Design and Methods.

There is a lack of data analyzing the influence of cardiovascular disease (CVD) risk factor control on graft survival disparities in African-American kidney transplant recipients. Studies in the general population indicate that CVD risk factor control is poor in African-Americans, leading to higher rates of renal failure and major acute cardiovascular events. However, with the exception of hypertension, there is no data demonstrating similar results within transplant recipients. Recent analyses conducted by our investigator group indicate that CVD risk factors, especially diabetes, are poorly controlled in African-American recipients, which likely impacts graft loss. This study protocol describes a prospective interventional clinical trial with the goal of demonstrating improved medication safety and CVD risk factor control in adult solitary kidney transplant recipients at least one-year post-transplant with a functioning graft. This is a prospective, interventional, 6-month, pharmacist-led and technology enabled study in adult kidney transplant recipients with the goal of improving CVD risk factor outcomes by improving medication safety and patient self-efficacy. This papers describes the issues related to racial disparities in transplant, the details of this intervention and how we expect this intervention to improve CVD risk factor control in kidney transplant recipients, particularly within African-Americans.

Comparison of Endovascular Stent Grafts for Abdominal Aortic Aneurysm Repair in Medicare Beneficiaries

Increased renal complications have been suggested with suprarenal stent grafts, but long-term analyses have been limited. Therefore, the purpose of this study was to evaluate the effect of endograft choice on perioperative and long-term outcomes. We compared Medicare beneficiaries undergoing endovascular abdominal aortic aneurysms repair from 2005 to 2008 with endografts with infrarenal fixation and a single docking limb (AneuRx, Excluder) to those with suprarenal fixation and 2 docking limbs (Zenith), or a unibody configuration (Powerlink). Propensity score weighting accounted for differences in patient characteristics among the different graft formations, and perioperative mortality, complications, and length of stay and 4-year rates of survival, rupture, and reintervention were compared. Forty-six thousand one hundred seventy-one Medicare beneficiaries were identified including 11,002 (24%) with suprarenal fixation, 32,909 (71%) with infrarenal fixation, and 2,260 (5%) with a unibody graft. After propensity score weighting, there were no significant differences in patients' baseline clinical and demographic characteristics. The suprarenal fixation patients had higher rates of perioperative mortality (1.7% vs. 1.3%, P<0.01), renal failure (6.0% vs. 4.7%, P<0.001), and mesenteric ischemia (0.7% vs. 0.4%, P<0.01) and longer length of stay (3.4days vs. 3.0days, P<0.001) compared with patients with infrarenal fixation. Unibody grafts had higher rates of renal failure (5.9% vs. 4.7%, P<0.001), mesenteric ischemia (1.0% vs. 0.4%, P<0.001), and conversion to open repair (0.7% vs. 0.1%, P<0.001) compared to those with infrarenal fixation and single docking limbs. At 4 years, mortality remained slightly higher with suprarenal compared to infrarenal fixation (30% vs. 29%, P=0.047), although these patients had fewer conversions to open repair (0.6% vs. 0.9%, P=0.03) and aneurysm-related reinterventions (10% vs. 12%, P<0.01). At 4 years, unibody grafts had more aneurysm-related interventions compared to infrarenal fixation grafts (15% vs. 12%, P<0.01) but fewer conversions to open repair (0.4% vs. 0.9%, P=0.02). Late rupture did not differ among the groups. Compared to infrarenal fixation devices, patients who underwent EVAR with suprarenal fixation had higher perioperative mortality and renal complications but fewer reinterventions including conversion, while the unibody graft had more perioperative complications and aneurysm-related reinterventions, but fewer conversions to open repair. Although these differences could be explained by selection bias, these data suggest that further comparative effectiveness analyses should be performed to understand the outcomes following EVAR with suprarenal fixation and unibody grafts.