History Of Chronic Kidney Disease Research Articles

Impaired heart rate variability triangular index predicts stroke and systemic embolism in patients with atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation Introduction Despite the broad use of oral anticoagulants, stroke remains one of the most serious complications in atrial fibrillation (AF) patients. Stroke has been linked to disturbances of the autonomic nervous system as both share similar risk factors. Therefore, impaired cardiac autonomic function may indicate an enhanced stroke risk. Purpose We hypothesized that impaired cardiac autonomic function, quantified by means of heart rate variability (HRV), might be useful in predicting stroke in patients with AF. Methods We enrolled 1,933 patients with a documented history of AF from the multicenter Swiss-AF cohort study who were either in sinus rhythm (SR-group, n=1130) or AF (AF-group, n=803) on a 5-minute resting ECG recording. HRV triangular index (HRVI), standard deviation of normal-to-normal intervals, root mean square root of successive differences of normal-to-normal intervals, mean heart rate, 5-min total power and power in the high frequency, low frequency and very low frequency range were calculated. We constructed cox regression models to analyze the predictive power of HRV parameters for the composite endpoint stroke or systemic embolism. Results Mean age was 71±8 years in the SR group and 75±8 in the AF group, 28% of the total study cohort were female. 36 patients in the SR group (3.2%) and 58 patients in the AF group (6.5%) experienced a stroke or systemic embolism during a follow-up time of 4.0±1.3 years. In patients with sinus rhythm, HRVI <15 was the only HRV parameter independently associated with stroke or systemic embolism (hazard ratio 2.94; 95% confidence interval 1.3-6.8; p=0.011) after adjustment for multiple clinical confounders (age, sex, AF type, history of hypertension, history of diabetes, history of chronic kidney disease, prior stroke or transient ischemic attack, intake of oral anticoagulation, antiarrhythmics or betablockers). In the AF group, no HRV parameter was associated with the composite endpoint. Conclusions HRVI measured during SR on a single 5-minute ECG recording is an independent predictor of stroke or systemic embolism in AF patients. HRV analysis may help to improve risk stratification in AF patients.

P195 A CASE REPORT OF TYPE TWO KOUNIS SYNDROME

Abstract A 81–years old female presented to the emergency department of our hospital with dyspnea and chest pain. She had a history of chronic kidney disease and left bundle brunch block (LBBB) never further investigated. Non diagnostic ECG was performed in the setting of pre–existing LBBB. HS–T–Troponin level was significantly elevated (986 ng/L). A transthoracic echocardiogram (TTE) revealed inferior and posterior wall hypokinesis. NSTEMI was diagnosed and coronary angiography via the femoral artery revealed subocclusive stenosis of the right coronary artery (RCA) and 80% stenosis of left anterior descending artery (LAD). Coronary stent positioning was performed for the RCA culprit lesion and staged complete revascularization was planned. After two days, the patient experienced sharp pain in the right groin and a femoral pseudoaneurysm was diagnosed by Ultrasound Color Doppler. Subsequently anemia suggested the development of retroperitoneal hematoma but it was excluded by contrast CT. Unfortunately, the patient developed acute chest pain, wheezing and erythematous pruritic rash 10 minutes after injection of contrast medium agent. The ECG didn’t show any new ischemic abnormalities in the setting of pre–existing LBBB. The peak CK–MB level was significantly elevated (87 ng/mL). New onset apical region akinesia and anterior wall hypokinesia were detected on TTE. Acute coronary syndrome (ACS) was suspected consistent with symptoms, new onset wall motion abnormalities and CK–MB elevations. The patient was diagnosed with allergic reaction and coronary vessel spasm secondary to contrast agent injection in pre–existing atherosclerotic plaque. Due to the high probability of an hypersensitivity reaction to the contrast medium agent we did not perform a new coronary angiography to confirm the diagnosis. Promethazine, Urbason and Nitroglicerin were administered with clinical improvement. The next day we observed recovery of the anterior and apex wall motion abnormalities consistent with coronary vessel spasm. Take Home Message We presented the case of an allergic reaction leading to the release of inflammatory mediators responsible of coronary vessel spasm causing acute myocardial infarction. It can also be induced by injection of contrast medium like in the presented case. Therefore, clinicians and radiologist should recognize this rare but critical disease to ensure prevention and appropriate management.

MO323: Effects of Patient Frailty and Comorbidity on Duration of Hospitalisation as an Outcome Among Adults With Acute Kidney Injury

Abstract BACKGROUND AND AIMS Acute kidney injury (AKI) is commonly associated with an adverse outcome in hospitalised patients. Frailty and comorbidity are risk factors for acute kidney injury. The aim of this study was to assess the strength of association between frailty and comorbidity as modifiers for duration of hospitalisation (LOS) as an outcome among inpatients with acute kidney injury in our institution. METHOD A retrospective observational study as part of a service assessment of adult inpatients, in a 1-month period, during the pre-pandemic phase was conducted to evaluate for changes needed to existing care pathways in our institution. AKI was identified with the help of the national algorithm endorsed by NHS England, which is incorporated in hospital reporting systems. Clinical frailty and comorbidity were estimated using the Rockwood Clinical Frailty Scale (CFS) and the Charlson comorbidity index (CCI). Pairwise correlations between LOS, CFS and CCI were estimated and tested for statistical significance using Bonferroni-adjusted significance levels. Ordinary least-squares linear regression was used to assess the prediction of LOS using CFS and CCI in separate models. RESULTS In 148 patients in our cohort, the mean age was 76.4 [95% confidence interval (95% CI) 74.1–78.8] years. Of these, 54% were male, 24.3% were diabetic, 29.7% had at least one criterion for prior vascular disease and 16.2% had a history of cancer. A total of 22.3% had a prior history of chronic kidney disease. In terms of severity at presentation, 67.6% had stage 1 AKI, 18.9% had stage 2, and 13.5% had stage 3 AKI. The mean CCI was 5.4 (95% CI 5.06–5.81) and the mean RFI was 4.6 (95% CI 4.3–5.0). 50% were both at least moderately frail (CFS ≥ 5) and had a CCI of >5. The mean duration of hospitalisation was 8.7 days. Spearman's correlation coefficient constant for CFS with LOS was 0.23 and was 0.11 with CCI, with only the correlation between LOS and CFS being statistically significant at the 5% level after Bonferroni correction. As expected, there was a statistically significant correlation between CCI and CFS (0.49). Beta coefficients for ordinary least-squares linear regression individual models with LOS as the outcome variable were 0.69 (95% CI 0.18–1.19; P < .007) for CFS and 0.27 (95% CI –0.16 to 0.70; P = .22) for CCI. CONCLUSION Compared with patient comorbidity, clinical frailty has a stronger and statistically significant association with the duration of hospitalisation among hospitalised adults with AKI. This study quantifies the magnitude of factors over and above those resulting from patient comorbidity that are contributory to frailty in adult inpatients with AKI. Further studies are required to improve understanding of how clinical frailty affects duration of hospitalisation in patients with AKI, to help inform future clinical care pathways and improve duration of hospitalisation as a clinical outcome.

Analysis of age-based stratified renal involvement in Tianjin first batch of 430 patients with Omicron variant of novel coronavirus infection

To investigate the incidence and clinical characteristics of renal involvement with Omicron coronavirus infection in age-based stratified patients. The first batch of 430 convalescent patients with Omicron coronavirus treated in Tianjin First Central Hospital from January 21, 2022 to March 7, 2022 were enrolled in this study. The baseline information, vaccination status and laboratory examination information of patients were extracted in order to analyze the incidence of renal involvement in age-based stratified patients. Multivariate Logistic regression analysis was conducted to determine the risk factors of renal involvement in different age groups. Excluding those younger than 1 year old and those with a history of chronic kidney disease, a total of 421 patients were included. There were 184 males and 237 females with an average age of (36.65±21.28) years. The types of renal involvement included pathological tubular urine (28.9%), proteinuria (16.9%), renal hematuria (14.7%), a slight decrease of estimated glomerular filtration rate (eGFR, 9.3%), renal glycosuria (0.5%). According to their age, all patients were divided into three groups: 113 cases of ≤ 18 years old, 244 cases of 19-59 years old and 64 cases of ≥ 60 years old. Significant difference was founded in the incidence of renal involvement among the three groups. The incidence of proteinuria, pathological tubular urine and slight decline of eGFR in the ≥ 60 years old group were significantly higher than those in the ≤ 18 years old group [28.1% (18/64) vs. 8.0% (9/112), 42.2% (27/64) vs. 19.6% (22/112), 34.9% (22/63) vs. 6.2% (7/113), respectively, all P < 0.01]. The incidence of slight decline of eGFR was significantly higher than that in 19-59 years old group [34.9% (22/63) vs. 4.1% (10/243), P < 0.01]. Multivariate Logistic regression analysis showed that age was significantly correlated with renal involvement after adjusting for the baseline situation, serological indexes and Omicron infection related indexes [odds ratio (OR) = 1.059, 95% confidence interval (95%CI) was 1.021-1.097, P = 0.002]. Compared with the group ≤ 18 years old, the risk of renal involvement in the group ≥ 60 years old was significantly increased (OR = 26.245, 95%CI was 1.357-507.458, P = 0.031). Age ≥ 60 years old was an independent risk factor for renal involvement with Omicron coronavirus infection. Although a low incidence of severe cases in Tianjin first batch of 430 patients with Omicron coronavirus infection, there is still a high incidence of renal involvement. Advanced age is the risk factor of renal involvement. We should pay more attention to the renal involvement of elderly with Omicron coronavirus infection.

E-42 | Early Outcomes and Peri-procedural Complications of Transcatheter Mitral Valve Repair in Patients with Chronic kidney disease

Transcatheter Mitral Valve Repair (TMVr) has been established as an alternative treatment option to open heart surgery in patients with severe symptomatic mitral regurgitation. We performed a systematic review and meta-analysis to compare the early outcomes and periprocedural complications of TMVr in patients with or without history of chronic kidney disease (CKD).

Self-reported chronic kidney disease and the risk of all-cause and cause-specific mortality: outcome-wide association study of 54 causes of death in the National Health Interview Survey

BackgroundA diagnosis of chronic kidney disease has been strongly associated with cardiovascular disease and mortality in a number of studies, but the association with specific causes of death has not been assessed in detail. We analysed the association between chronic kidney disease and all-cause mortality and 54 causes of death in the National Health Interview Survey, a prospective study of 210,748 US adults.MethodsWe used multivariable Cox regression models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause and cause-specific mortality associated with self-reported chronic kidney disease. Men and women aged 18–84 years were recruited between 1997 and 2004 and followed up for mortality through December 31, 2006.ResultsDuring an average of 6 years follow-up, 9564 deaths occurred. A history of chronic kidney disease vs. no chronic kidney disease was associated with increased risk of all-cause mortality (HR = 2.69, 95% CI: 2.38–3.04), and mortality from septicemia (5.65, 2.84–11.25), viral hepatitis (10.67, 2.43–46.95), other infectious parasitic diseases (10.58, 3.59–31.21), total cancer (1.48, 1.05–2.09), lung cancer (1.94, 1.10–3.44), kidney cancer (4.74, 1.81–12.41), diabetes mellitus (8.57, 5.60–13.11), circulatory disease overall (3.36, 2.70–4.18) and 11 specific circulatory diseases with the strongest associations observed for primary hypertension/renal disease (13.60, 6.42–28.84), hypertensive heart/renal disease (10.72, 2.47–46.49), and other diseases of circulatory system (7.36, 3.22–16.81). Elevated risk was also observed for alcoholic liver disease (5.63, 1.90–16.66), other chronic liver disease (4.41, 1.74–11.17), kidney failure (13.07, 8.23–20.77), and five other causes of death.ConclusionsA history of chronic kidney disease was associated with increased risk of all-cause mortality and 27 out of 54 causes of death. Further studies are needed to clarify associations with less common causes of death.

In-hospital mortality, length of stay, and hospitalization cost of COVID-19 patients with and without hyperkalemia

BackgroundHyperkalemia (HK) may be associated with poor clinical outcomes among COVID-19 patients. This study aimed to describe the prevalence of HK and evaluate the associations between HK and in-hospital mortality, intensive care unit (ICU) admission, length of hospital stay (LOS), and hospitalization cost among COVID-19 inpatients. MethodsA retrospective cohort study was conducted using a large hospital discharge database (PINC AI Healthcare Database) for COVID-19 inpatients discharged between April 1 and August 31, 2020. HK was defined with discharge diagnosis and potassium binder use. ResultsOf 192,182 COVID-19 inpatients, 12% (n = 22,702) had HK. HK patients were more likely to be older (median age 67 vs 63 years), male (63% vs 50%), black (30% vs 22%), and have a history of chronic kidney disease (45% vs 16%) or diabetes mellitus (55% vs 35%) than non-HK patients (all p<.001). A significantly higher proportion of patients with HK had in-hospital mortality (42% vs 11%, p<.001) than those without HK; this was persistent after adjusting for confounders (adjusted odds ratio [aOR] 1.69, 95% confidence interval [CI]1.62-1.77). Patients with HK were also more likely to be admitted to ICU (aOR 1.05, 95% CI 1.01-1.09), incur higher cost of care (adjusted mean difference $5,389) and have longer LOS (adjusted mean difference 1.3 days) than non-HK patients. ConclusionsPresence of HK was independently associated with higher in-hospital mortality, LOS, and cost of care among COVID-19 inpatients. Detecting and closely monitoring HK are recommended to improve clinical outcomes and reduce LOS and healthcare cost among COVID-19 patients.

Involvement of blood lncRNA UCA1 in sepsis development and prognosis, and its correlation with multiple inflammatory cytokines.

BackgroundSepsis is a highly life‐threatening disease. Long non‐coding RNA urothelial carcinoma associated 1 (lncRNA UCA1) participates in the processes of inflammation and organ injury in several diseases, whereas its role in sepsis patients is still unclear. The aim was to explore the clinical value of lncRNA UCA1 in sepsis patients.MethodsOne hundred seventy‐four sepsis patients and 100 age and gender‐matched controls were enrolled. LncRNA UCA1 in peripheral blood mononuclear cell samples was examined, and the level of inflammatory cytokines in serum samples was assessed.ResultsLncRNA UCA1 was highly expressed in sepsis patients compared with controls. LncRNA UCA1 was positively correlated with tumor necrosis factor‐α, interleukin (IL)‐6, IL‐17, intercellular adhesion molecule 1, and vascular cell adhesion molecule 1 in sepsis patients, while it was not correlated with these inflammatory cytokines in controls. lncRNA UCA1 upregulation was related to raised APACHE II score and SOFA score in sepsis patients. Moreover, lncRNA UCA1 was increased in sepsis deaths compared with sepsis survivors and was independently correlated with increased 28‐day sepsis mortality risk. Further receiver operating characteristic curves presented that lncRNA UCA1 had a good value to predict 28‐motality risk, while its combination with other independent factors (including age, history of chronic kidney disease, G+ bacterial infection, Fungus infection, C‐reactive protein, and APACHE II score) exerted a great predictive value for 28‐day mortality risk.ConclusionLncRNA UCA1 is upregulated and correlates with multiple pro‐inflammatory cytokines, terrible disease severity, and poor prognosis in sepsis patients.

Correlation between Acute Kidney Injury and Inflammatory markers in Coronavirus Disease 2019

Background and Objectives: Coronavirus Disease 2019 (COVID-19) particularly when severe may commonly present with Acute Kidney Injury and may show elevated blood levels of inflammatory markers. Current study aims at determining the correlation between AKI and raised inflammatory markers in COVID-19.&#x0D; Materials and Methods: Medical records of 250 patients admitted in COVID-19 isolation intensive care unit of Farooq Hospital, Westwood Branch, Lahore between 1st July, 2021 and 30th September, 2021 were retrospectively reviewed and data comprising of demographic, clinical and laboratory parameters was collected. Patients with confirmed diagnosis of COVID-19 from Real Time Polymerase Chain Reaction (RT-PCR) were included in the study while those with incomplete medical records or known history of Chronic Kidney Disease (CKD) were excluded. Statistical analysis of collected data was then made and p value &lt; 0.05 was considered statistically significant.&#x0D; Results: Among 176 patients who fulfilled the inclusion criteria, most (138(78.4%)) were males with mean age of 51.26±15.20 years. Diabetes Mellitus was most common comorbidity observed in 70(39.8%) patients and mean length of hospital stay was 8.46±4.12 days. AKI was found in 91(51.7%) patients while remaining 85(48.3%) patients didn’t have AKI. All four inflammatory markers: C-Reactive Protein (CRP), D-dimers, ferritin and procalcitonin (PCT) were found significantly raised in COVID-19 patients having AKI compared with non-AKI group (p &lt; 0.05).&#x0D; Conclusions: Raised inflammatory markers in patients having severe COVID-19 are associated with increased risk of AKI.

New-Onset Atrial Fibrillation and Early Mortality Rate in COVID-19 Patients: Association with IL-6 Serum Levels and Respiratory Distress.

Background and objectives: COVID-19 is associated with an aberrant inflammatory response that may trigger new-onset cardiac arrhythmias. The aim of this study was to assess the mortality risk in hospitalized COVID-19 patients according to IL-6 serum levels and new-onset atrial fibrillation (AF) according to PaO2/FiO2 stratification. Materials and Methods: 175 COVID-19 patients (25 new-onset AF, 22 other types of AF and 128 no-AF) were included in this single-center, retrospective study; clinical and demographic data, vital signs, electrocardiograms and laboratory results were collected and analyzed. The primary outcome of the study was to evaluate the mortality rate in new-onset AF patients according to IL-6 serum levels and PaO2/FiO2 stratification. Results: The incidence of new-onset AF in the study population was 14.2%. Compared to the no-AF group, new-onset AF patients were older with a positive history of chronic kidney disease and heart failure, had higher IL-6, creatinine and urea serum levels whereas their platelet count was reduced. After PaO2/FiO2 stratification, 5-days mortality rate was higher in new-onset AF patients compared to patients with other types of AF and no-AF patients, and mortality risk increases 5.3 fold compared to no-AF (p = 0.0014) and 4.8 fold compared to other forms of AF (p = 0.03). Conclusions: New-onset AF is common in COVID-19 patients and is associated with increased IL-6 serum levels and early mortality. Further studies are needed to support the use of IL-6 as an early molecular target for COVID-19 patients to reduce their high rate of mortality.

Transient And Persistent Acute Kidney Injury In Children Hospitalized With Decompensated Heart Failure

Transient And Persistent Acute Kidney Injury In Children Hospitalized With Decompensated Heart Failure

Outcomes Of Intermittent Hemodialysis During Support With Ventricular Assist Devices: A Potential Bridge To Heart/kidney Transplantation?

Introduction Severe renal dysfunction is a contraindication for receiving ventricular assist devices (VADs). Hence, patients with end-stage heart failure (ESHF) and severe renal dysfunction who are not candidates for heart/kidney transplantation (HT/KT) may only be considered for either intermittent hemodialysis (IHD) or hospice. However, there is little evidence about the outcomes of patients with ESHF who are initiated on IHD after VAD implantation. Methods We reviewed the medical charts of all patients in our center who received IHD after VAD implantation. We considered IHD <6-hour sessions 3-4 times weekly, excluding continuous renal replacement therapy (CRRT). Continuous variables were expressed in means and standard deviations, or medians and p25-p75, according to their distribution. Categorical variables were represented in absolute numbers and percentages. Results Eleven patients (54.1 [±9.9] years of age, 6 [54.6%] women, and 6 [54.6%] African American) underwent VAD implantation as destination therapy (40%) or bridge to transplant (60%) and received IHD. Seven (63.6%) of them received HeartMate II, whereas the other patients were supported with HVAD HeartWare, and HeartMate 3 systems. By the time of VAD implantation, nine (81.8%) patients had history of chronic kidney disease with a median GFR was 60 (45-60) mL/min/1.73 m2 and a mean creatinine was 1.2 (±0.4) mg/dL. The mean outpatient furosemide-dose equivalent prior VAD implantation was 106 (±59.7) mg/day. Ten patients started IHD prior to discharge after VAD placement with a median time from VAD implantation to initiation of IHD was 26 (17-50) days. Another patient was initiated on IHD as outpatient within a year after receiving a VAD. Eight (72.7%) patients died during a follow-up of 886.7 (±762.1) days after initiation of IHD with a median survival time of 838 days. Three patients were bridged to transplantation: 2 HT/KT, and 1 HT (recovered renal function). Details about the timeline of events can be found in Fig 1. Conclusions Intermittent hemodialysis helped to bridge 2 VAD patients to HT/KT, and another to HT and recovery of renal function. Larger studies could provide valuable insight into this potential strategy to widen the options of advanced heart failure therapies for patients with ESHF. Severe renal dysfunction is a contraindication for receiving ventricular assist devices (VADs). Hence, patients with end-stage heart failure (ESHF) and severe renal dysfunction who are not candidates for heart/kidney transplantation (HT/KT) may only be considered for either intermittent hemodialysis (IHD) or hospice. However, there is little evidence about the outcomes of patients with ESHF who are initiated on IHD after VAD implantation. We reviewed the medical charts of all patients in our center who received IHD after VAD implantation. We considered IHD <6-hour sessions 3-4 times weekly, excluding continuous renal replacement therapy (CRRT). Continuous variables were expressed in means and standard deviations, or medians and p25-p75, according to their distribution. Categorical variables were represented in absolute numbers and percentages. Eleven patients (54.1 [±9.9] years of age, 6 [54.6%] women, and 6 [54.6%] African American) underwent VAD implantation as destination therapy (40%) or bridge to transplant (60%) and received IHD. Seven (63.6%) of them received HeartMate II, whereas the other patients were supported with HVAD HeartWare, and HeartMate 3 systems. By the time of VAD implantation, nine (81.8%) patients had history of chronic kidney disease with a median GFR was 60 (45-60) mL/min/1.73 m2 and a mean creatinine was 1.2 (±0.4) mg/dL. The mean outpatient furosemide-dose equivalent prior VAD implantation was 106 (±59.7) mg/day. Ten patients started IHD prior to discharge after VAD placement with a median time from VAD implantation to initiation of IHD was 26 (17-50) days. Another patient was initiated on IHD as outpatient within a year after receiving a VAD. Eight (72.7%) patients died during a follow-up of 886.7 (±762.1) days after initiation of IHD with a median survival time of 838 days. Three patients were bridged to transplantation: 2 HT/KT, and 1 HT (recovered renal function). Details about the timeline of events can be found in Fig 1. Intermittent hemodialysis helped to bridge 2 VAD patients to HT/KT, and another to HT and recovery of renal function. Larger studies could provide valuable insight into this potential strategy to widen the options of advanced heart failure therapies for patients with ESHF.

Clinical Predictors of Lung Transplant Outcomes in Patients with Scleroderma Compared with Pulmonary Fibrosis

Purpose Primary Graft Disfunction (PGD) is the leading cause of early morbidity and mortality after lung transplant. We sought to identify risk factors for PGD and survival in patients with scleroderma undergoing lung transplant compared to patients with pulmonary fibrosis. Methods This was a single center retrospective cohort study, of patients that underwent lung transplantation for scleroderma or pulmonary fibrosis from 2007 to 2020. Propensity scores were used to match the scleroderma group with the pulmonary fibrosis group based on lung allocation score and age at lung transplant. Univariable analyses identified factors associated with the development of PGD 72 hours posttransplant, and six-month survival. Survival rates were compared using Kaplan-Meier analysis. Results We compared 104 patients with scleroderma to 389 patients with pulmonary fibrosis who underwent lung transplant. After propensity matching, compared with pulmonary fibrosis, scleroderma patients had reduced 90-day survival (99.0% vs 90.2%, p=0.007). However, there was no statistically significant difference in 1 year (84.4% vs 79.1%, p=0.23) or 5-year survival (64.9% vs 52.9%, p=0.98). Scleroderma patients were more likely to have PGD 72 hours posttransplant (29.4% vs 11.8%, p=0.01). Scleroderma patients who developed PGD had higher volumes of intraoperative transfusion of blood products (p=0.02), plasma (p=0.04), platelets (p=0.03), but not red blood cells (p=0.28). Preoperative history of chronic kidney disease (p<0.001) and postoperative Acute Kidney Injury [AKI] (p=0.028) were also associated with the development of PGD. Donor factors for developing PGD in scleroderma patients were traumatic brain injury as cause of donor death (p=0.015) and donor history of smoking (p=0.02). Risk factors for 6-month mortality were postoperative right ventricular dysfunction (p=0.02) or dilation (p=0.003), stroke (p=0.02), atrial fibrillation (p=0.01), PGD (p<0.001), AKI (p=0.005) and decreased glomerular filtration rate 3 months posttransplant (p=0.04). Conclusion Scleroderma had higher rates of post lung transplant PGD compared to pulmonary fibrosis. Kidney function plays a prominent role in the risk of developing PGD and mortality in this population. Despite reduced 90-day posttransplant survival in scleroderma patients, 1- and 5-year survival rates were similar. Primary Graft Disfunction (PGD) is the leading cause of early morbidity and mortality after lung transplant. We sought to identify risk factors for PGD and survival in patients with scleroderma undergoing lung transplant compared to patients with pulmonary fibrosis. This was a single center retrospective cohort study, of patients that underwent lung transplantation for scleroderma or pulmonary fibrosis from 2007 to 2020. Propensity scores were used to match the scleroderma group with the pulmonary fibrosis group based on lung allocation score and age at lung transplant. Univariable analyses identified factors associated with the development of PGD 72 hours posttransplant, and six-month survival. Survival rates were compared using Kaplan-Meier analysis. We compared 104 patients with scleroderma to 389 patients with pulmonary fibrosis who underwent lung transplant. After propensity matching, compared with pulmonary fibrosis, scleroderma patients had reduced 90-day survival (99.0% vs 90.2%, p=0.007). However, there was no statistically significant difference in 1 year (84.4% vs 79.1%, p=0.23) or 5-year survival (64.9% vs 52.9%, p=0.98). Scleroderma patients were more likely to have PGD 72 hours posttransplant (29.4% vs 11.8%, p=0.01). Scleroderma patients who developed PGD had higher volumes of intraoperative transfusion of blood products (p=0.02), plasma (p=0.04), platelets (p=0.03), but not red blood cells (p=0.28). Preoperative history of chronic kidney disease (p<0.001) and postoperative Acute Kidney Injury [AKI] (p=0.028) were also associated with the development of PGD. Donor factors for developing PGD in scleroderma patients were traumatic brain injury as cause of donor death (p=0.015) and donor history of smoking (p=0.02). Risk factors for 6-month mortality were postoperative right ventricular dysfunction (p=0.02) or dilation (p=0.003), stroke (p=0.02), atrial fibrillation (p=0.01), PGD (p<0.001), AKI (p=0.005) and decreased glomerular filtration rate 3 months posttransplant (p=0.04). Scleroderma had higher rates of post lung transplant PGD compared to pulmonary fibrosis. Kidney function plays a prominent role in the risk of developing PGD and mortality in this population. Despite reduced 90-day posttransplant survival in scleroderma patients, 1- and 5-year survival rates were similar.

Evolution of Kidney Disease in Single Ventricle Patients After Cardiac Transplantation

<h3>Purpose</h3> Unlike Fontan-associated liver disease, the impact of heart transplant (HT) on Fontan associated kidney disease has not been well described. In this single center study, we sought to characterize the natural history of chronic kidney disease in a small cohort of Fontan patients from listing to follow up after HT. <h3>Methods</h3> We conducted a retrospective review of pediatric patients at our institution with prior Fontan palliation that underwent HT between 2000-2020. We collected demographic information, data regarding baseline renal function/anatomic abnormalities, presence of protein losing enteropathy/liver disease/renal insufficiency/diabetes, and cardiac hemodynamics. Estimated glomerular filtration rate (eGFR) was calculated based on serum creatinine (Cr) using the Cr-based "Bedside Schwartz" formula which was used to determine the stage of kidney disease. We trended data at listing, at transplant, and then at post-transplant follow-up visits (90 days, 180 days, then annually). <h3>Results</h3> Fourteen patients with prior Fontan palliation who underwent HT were identified. At listing, 10 out of 14 patients were noted to have a normal eGFR (GFR ≥ 90). By transplant, four of these patients declined to Stage 2 kidney disease (GFR 60 - 90, not inclusive). All four normalized by 1 year follow-up. The <b>4</b> patients with eGFR < 90 at listing all had further decline in renal function by the time of HT. Post-transplant, 2 normalized, 1 remained with eGFR <90, and 1 required dialysis. The progression of eGFR of all the patients is summarized in the figure below. <h3>Conclusion</h3> In this small single center series, Cr based eGFR at listing and at transplant appear to be risk factors for progressive renal insufficiency in Fontan patients undergoing HT. The predictive value of other pre-transplant variables is limited by our population size. Cr-based eGFR calculations may help identify Fontan patients at increased risk for a decline in renal function post HT who may benefit from enhanced longitudinal renal surveillance.

The Impact of Left Ventricular Assist Device Infections on Clinical Outcomes

<h3>Purpose</h3> Infection is a leading cause of morbidity for patients with left ventricular assist devices (LVAD). We assessed the risks and associated mortality of LVAD infections. <h3>Methods</h3> A single center, retrospective study of patients with durable LVADs was performed. Patient demographics, clinical characteristics, and outcomes were evaluated and LVAD infections classified per ISHLT 2011 guidelines. <h3>Results</h3> Of 241 LVAD implants between January 2007 and December 2020, 134 (56%) had documented infection; 56 (42%) LVAD specific, 47 (35%) LVAD related, and 31 (23%) non-LVAD infections (Table). Body mass index (BMI), age, and history of chronic kidney disease (CKD) or diabetes (DM) were similar among the different infection groups. In univariate analyses, receiving antibiotics for infection at the time of LVAD placement, duration of index hospitalization, and duration of LVAD support differed significantly among those with and without infection. In multivariable analysis, only length of index hospitalization increased the risk of developing LVAD specific or related infections (p<0.001). Mortality at 3 years was 28% for those with LVAD specific infections, 42% for LVAD related, 45% for non-LVAD, and 39% for those without infection (p = 0.533). When adjusting for age, BMI, CKD, DM, length of index hospitalization, and duration of LVAD support, there was no difference in mortality at 3 years among the different infection groups (Figure). <h3>Conclusion</h3> Infection is a frequent complication for LVAD patients and a continuing problem despite advances in devices. However, having an infection was not independently associated with increased 3-year mortality in our cohort.

Risk factors for progression of Urolith Associated with Obstructive Urosepsis to severe sepsis or septic shock

IntroductionTo analyze the risk factors for progression of urolith associated with obstructive urosepsis to severe sepsis or septic shock, we had done the retrospective cross-sectional study, which would facilitate the early identification of high-risk patients.Materials and methodsDatas were retrospectively reviewed from 160 patients, suffering from obstructive urosepsis associated with urolith between December 2013 and December 2019. There were 49 patients complicating by severe sepsis (severe sepsis group), 12 patients complicating by septic shock (septic shock group), and 99 patients without progressing to severe sepsis or septic shock (sepsis group). The data covered age, gender, BMI (body mass index), time interval from ED (emergency department) to admission, WBC count (white blood cell count), NLR (neutrophil/lymphocyte ratio), HGB (hemoglobin), etc. Datas were analyzed by univariate analyses and multivariate logistic regression analysis. The corresponding nomogram prediction model was drawn according to the regression coefficients.ResultsUnivariate analysis showed that the differences of age, the time interval from ED to admission, history of diabetes mellitus, history of CKI (chronic kidney disease), NLR, HGB, platelet count, TBil (total bilirubin), SCr (serum creatinine), ALB (albumin), PT (prothrombin time), APTT (activated partial thromboplastin time), INR (international normalized ratio), PCT (procalcitonin), and positive rate of pathogens in blood culture were statistically significant (P < 0.05). Multivariatelogistic regression analysis showed that age, SCr, and history of CKI were independent risk factors for progression to severe sepsis, or septic shock (P < 0.05).ConclusionsAged ≥ 65 years, SCr ≥ 248 mol/L, and history of CKI were independent risk factors for progression of urolith associated with obstructive urosepsis to severe sepsis or septic shock. We need to pay more attention to these aspects, when coming across the patients with urolithic sepsis.

Etiology, clinical characteristics, and outcome of infective endocarditis: 10-year experience from a tertiary care center in Pakistan.

This study was conducted to assess the clinical characteristics, causative agents, complications, and outcomes of infective endocarditis (IE) among patients presenting to our tertiary care center over the last decade. This retrospective cohort study included all adult patients admitted to the Aga Khan University Hospital with the diagnosis of IE over a ten-year period from 2010 to 2020. Outcomes variables included complications during hospitalization, surgical intervention, mortality, and length of stay. We identified a total of 305 cases out of which 176 (58%) were males and 129 (42%) were females. The mean age of the patients was 46.9±18.8 years. 95 (31%) had prosthetic valves in place. Staphylococcus aureus was isolated in 54 (39%) patients followed by coagulase-negative Staphylococcus in 23 (17%). Echocardiography revealed vegetations and abscesses in 236 (77%) and 4 (1%) patients, respectively. The most common valvular complication was mitral valve regurgitation found in 26 (9%) patients, followed by tricuspid valve regurgitation in 13 (4%) patients and aortic valve regurgitation in 11 (3%) patients. Furthermore, 81 (27%) patients suffered from heart failure and 66 (22%) from a stroke during hospitalization. The mean hospital length of stay was 10.4 ± 10.6 days. 64 (21%) patients required surgical repair and the overall mortality rate was 25%. Prosthetic valve endocarditis (OR = 3.74, 95% CI = 2.15-6.50, p<0.001), chronic kidney disease (OR = 2.51, 95% CI = 1.15-5.47, p=0.036), previous stroke (OR = 2.42, 95% CI = 1.18-4.96, p=0.026), and ischemic heart disease (OR = 3.04, 95% CI = 1.50-6.16, p=0.003) were significantly associated with an increased risk of mortality. In conclusion, our study provided valuable data on the clinical characteristics and outcomes of patients with IE in a developing country. S. aureus was the most common causative agent. Heart failure and stroke were the most common complications. The presence of prosthetic valves, history of chronic kidney disease, ischemic heart disease and previous stroke were associated with a significantly increased risk of mortality. Surgical management was not associated with improved outcomes.

Relation Between Renin-Angiotensin-Aldosterone System Inhibitors and COVID-19 Severity.

Background: Angiotensin-converting enzyme 2 (ACE2) receptor serves as a receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus causing COVID-19, to enter the lungs. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) may increase the expression of ACE2, resulting in concerns that patients with COVID-19 who are receiving these agents may be at increased risk of severe disease. This study was conducted to further investigate the effects of ACEIs and ARBs on the severity of COVID-19 in hospitalized hypertensive patients.Methods: The study was a retrospective observational study. The medical records of all adult hypertensive patients who were hospitalized at Dammam Medical Complex (DMC) between March 1, 2020, and December 31, 2020, due to COVID-19 were reviewed. The hypertensive patients who were receiving ACEIs or ARBs were compared with the other hypertensive patients who were not on ACEIs or ARBs.Results: A total of 148 hypertensive patients were included in the analysis. They consisted of 106 male and 42 female patients (72% and 28%, respectively). Nearly half of the patients were Saudi (75 patients, 50%). A total of 81 patients were in the ACEI/ARB group, and 67 patients were in the control group. There were no differences between the two groups in age, diabetic status, history of chronic kidney disease, initial blood pressure measurements, and initial oxygen requirements, but the control group contained fewer female patients (18% versus 37%) and Saudi patients (36% versus 63%) than the ACEI/ARB group (p-values = 0.017 and 0.002, respectively). The use of ACEIs or ARBs was associated with significant reductions in ICU admission (9% versus 31%, p-value = 0.001), need for intubation (7% versus 28%, p-value = 0.002), and death (2% versus 24%, p-value = 0.000). A significant negative association between the use ACEIs or ARBs and mortality was also observed in the multivariate analysis after the adjustment for the possible confounders, with an odds ratio (OR) of 0.087 and a 95% confidence interval (CI) of 0.017-0.449.Conclusions: ACEIs and ARBs have no adverse effects on the clinical prognosis of COVID-19 patients with hypertension. Their use might be even beneficial and protective, but future larger studies are needed to confirm these effects. In the meanwhile, they should be continued in COVID-19 hypertensive patients unless their use is contraindicated for other reasons (e.g., hypotension, hyperkalemia, or acute kidney injury (AKI)).

Prescription Patterns of Novel Antihyperglycemic Medications.

Glucagon-like peptide-1 agonists (GLP-1a) and sodium-glucose cotransporter-2 inhibitors (SGLT-2i) are recommended in carefully selected patients with type 2 diabetes. This study will assess prescription of these medications and investigate predictors of prescription. This retrospective cross-sectional study included 31,354 patients. Data including sociodemographic descriptors, clinical histories, medications, and health insurance providers were extracted from a health system's administrative databases. Variables to be associated with prescription of a GLP-1a or SGLT-2i were assessed using a multivariable logistic regression model. Mean age was 62.58 years and 40.8% identified as African American. Only 3.4% were prescribed a GLP-1a and 2.1% received a SGLT-2i. Logistic regression demonstrated lower odds of receiving either medication in the highest age-group (70 to 79 years) (GLP-1a: odds ratio [OR] 0.44, P < .01, SGLT-2i: OR 0.39, P < .01) and in African Americans (GLP-1a: OR 0.64, P < .01, SGLT-2i: OR 0.28, P < .01). Atherosclerotic cardiovascular disease was not associated with GLP-1a prescription (P = .54) and conferred lower odds of being prescribed SGLT-2i (OR 0.68, P < .01). History of chronic kidney disease conferred lower odds of receiving GLP-1a and was not associated with the odds of receiving SGLT-2i. Prescription of GLP-1a and SGLT-2i medications was low as compared with existing literature. Advanced age and African American race were negatively associated with prescription of these medications. Contrary to guideline recommendations; atherosclerotic cardiovascular disease and chronic kidney disease were not positively associated with prescription.

The Brief Case: Corynebacterium amycolatum in a Relapsing Urinary Tract Infection of a Feline Patient.

Over an 11-month period, seven isolates of Corynebacterium amycolatum were cultured from urine collected via cystocentesis from a feline patient with relapsing urinary tract infection (UTI). The 11-year-old, castrated male, domestic short-haired cat presented with a history of chronic kidney disease, episodic vomiting and diarrhea, hypercalcemia, obstructive urolithiasis, and grade III parasternal systolic heart murmur. In addition to placing a left-sided subcutaneous ureteral bypass (SUB), we performed a perineal urethrostomy to treat the urinary tract obstruction. Urine sampled 10 months after SUB placement yielded growth of Trueperella abortisuis (&gt;105 CFU/mL) and C. amycolatum (200 CFU/mL; this isolate was not saved). The patient was treated with amoxicillin-clavulanate (62.5 mg PO q12h; 21 days). The urine sampled on days 13 and 26 post treatment (pt) yielded no bacterial growth.