History Of Chronic Renal Insufficiency Research Articles

Treatment outcomes in patients with acute thromboembolic occlusion of the superior mesenteric artery

ObjectivesThe goals of this study were to investigate the treatment outcomes of acute thromboembolic occlusion of the superior mesenteric artery (ATOS) and identify prognostic factors after treatment.MethodsThe clinical data of 62 patients with ATOS between 2013 and 2021 were retrospectively reviewed. Patients were stratified by the treatment strategy, complications and mortality were compared in different group.ResultsSixty-two consecutive patients were identified with ATOS. The median patient age was 69 years (interquartile range 58–79 years). Endovascular therapy was initiated in 21 patients, and 4 patients received conservative treatment. Open surgery was performed first in the remaining 37 patients. The technical success rates of the endovascular first group and open surgery group were 90.5% and 97.3%, respectively. One patient in the conservative treatment group had progression of ischemia to extensive bowel necrosis. There was no difference in 30-day mortality between these groups. Predictors of 30-day mortality included initial neutrophil count > 12* 103/dL, age over 60 years old and history of chronic renal insufficiency.ConclusionsEndovascular treatment or conservative treatment may be adopted in selected patients who do not exhibit signs and symptoms of bowel necrosis, and close monitoring for bowel necrosis is important. The increase in preoperative neutrophil count, age over 60 years old and history of chronic renal insufficiency were poor prognostic factors.

Chronic kidney disease and cardiovascular disease reduce survival rates after burn injury: A retrospective study over 20 years

BackgroundThe Abbreviated Burn Severity Index and comparable scores are used to assess the probability of survival in burned patients. These scores may be useful during the initial management of the patient and in addition to the clinical evaluation. As current models do not include the influence of chronic diseases, we evaluated the impact of comorbidities on survival probability, aiming to improve the existing scoring systems and survival probability accuracy further. MethodsIn this retrospective single-center study, patient data from a center for Severe Burn Injury were collected. Over a period of 20 years (2000–2019), a total of 1,193 patients were recorded. The influence of comorbidities (chronic kidney disease, diabetes mellitus type II, and cardiovascular diseases) on the survival probability was analyzed using regression models. These analyses were stratified for sex and period. ResultsPre-existing chronic kidney disease, as well as pre-existing cardiovascular disease, had a significant influence on the survival of patients. For chronic kidney disease, the influence was stronger in men than in women. Women were more likely to survive a burn injury with a history of chronic renal insufficiency. An improved Abbreviated Burn Severity Index model, which assigns an additional point for chronic kidney disease, best-described survival probability in our patient cohort. ConclusionCardiovascular disease and chronic kidney disease both have an impact on the survival probability of severely burned patients, but this impact is more severe for chronic kidney disease. An additional Abbreviated Burn Severity Index point for chronic kidney disease would be a proposed adaptation to predict the outcome of burn patients better.

Computational investigation of a novel uromodulin gene mutation (p.Y286C) in a family with autosomal dominant tubulointerstitial renal disease: A case study

Autosomal dominant tubulointerstitial kidney disease caused by a pathogenic variant in the UMOD gene (ADTKD) is a rare tubulointerstitial nephropathy characterized by hyperuricemia, gout, and slowly-progressing chronic renal insufficiency. The disease invariably progresses to end-stage renal disease (ESRD), and is believed to be one of the most common monogenic forms of kidney disease. It presents complete penetrance and inter- and intrafamilial clinical heterogeneity. The index case is a 17-year-old female who, at the age of seven began her renal function evaluation due to a family history of chronic renal insufficiency without etiological diagnosis. At this time she was already presenting with joint pain and increased serum creatinine and uric acid. Genetic testing detected a heterozygous variation in UMOD gene, c.857 A>G; p.Y286C, in two tested affected individuals but not in an unaffected family member. Here, an in silico analysis of the impact of this variant was performed, which provided support as to the deleterious nature of the variant. We also described clinical and laboratory data of 6 affected members, whose age of ESRD showed high variability, in agreement with the literature. This case provides evidence of the pathogenicity of a novel variant detected in the UMOD gene, in addition to providing clinical and laboratory data of individuals carrying this variant, highlighting the intrafamilial clinical variability.

The clinical and neuroimaging features of sporadic adult-onset neuronal intranuclear inclusion disease.

Neuronal intranuclear inclusion disease (NIID) is a rare slowly progressive neurodegenerative disorder that is characterized pathologically by the presence of eosinophilic intranuclear inclusions. NIID is a heterogeneous disease with diverse clinical manifestations, making diagnosis difficult. Here, we analyzed the clinical, pathological, and radiological features of Chinese NIID patients to improve our understanding of NIID. A total of 17 patients with sporadic NIID were recruited from the Ruijin Hospital Database between 2014 and 2021. Clinical patient information and brain MRI data were collected. All of the patients underwent standard skin biopsy procedures. The average age of onset for symptoms was 60.18 years, and the average duration of illness was 4.06 years. All patients were diagnosed with NIID due to the presence of intranuclear inclusions confirmed by skin biopsy. Tremor was the most common initial symptom. The average ages at onset and at diagnosis were both lower in patients with tremor than in patients without tremor. NIID may be a systemic disease that affects multiple organs, for one patient had a history of chronic renal insufficiency for more than 10 years. In addition to high-intensity U-fibers signals on diffusion-weighted imaging, there were several other MRI findings, such as focal leukoencephalopathy and cortical swelling. Encephalitic episodes followed by reversible leukoencephalopathy was another important imaging feature of NIID. The clinical manifestations of NIID are highly variable. Tremor may be the most common initial symptom in certain cohorts. Encephalitic episodes followed by reversible asymmetric leukoencephalopathy may also indicate this disease.

The application status of optimal medical therapy after percutaneous coronary intervention and its influence on prognosis

Objective: To investigate the application status of optimal medical therapy (OMT) in patients with coronary heart disease after percutaneous coronary intervention (PCI) and its influence on the 1-year prognosis of patients after surgery. Methods: Data of 3 812 patients diagnosed with coronary heart disease by coronary angiography and successfully completed PCI in the Department of Cardiology, TEDA International Cardiovascular Hospital from October 2016 to September 2017 were prospectively collected. The OMT status and the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE) during the hospitalization and 1, 6, and 12 months after discharge were recorded. Patients were divided into OMT group (n=1 299) and non-OMT group (n=2 289) according to their adherence to OMT after PCI. Chi-square test was used to compare the differences of MACCE between groups, and to screen for significant differences and clinically significant variables between groups. Cox regression model was used to analyze the influencing factors of MACCE after PCI. Results: Among 3 588 patients (224 cases lost to follow-up), 58.8% (2 110/3 588) used OMT during hospitalization after PCI, and 36.0% (1 293/3 588) still adhered to OMT after 12 months of follow-up. The utilization rates of OMT showed a decreasing trend, among which till the 12th month, β-blockers and ACEI/ARB showed the greatest decreasing degree, from 75.3%(2 701/3 588) and 75.1%(2 692/3 588) to 59.1%(2 122/3 588) and 53.0%(1 903/3 588). Pearson χ2 analysis showed that elderly patients, the number of amalgamative diseases, history of PCI, history of chronic myocardial infarction, history of chronic renal insufficiency, the lesion counts, lesion type, the Gensini score, adhere to the OMT and smoking during the follow-up were related to postoperative MACCE, the difference was statistically significant (P<0.05). Cox regression model showed that OMT adherence after PCI was an independent protective factor for postoperative MACCE events (HR=0.471,95%CI: 0.300-0.734, P=0.001). Conclusion: The application of OMT after PCI was suboptimal, and the application rate decreased with the lengthening of the discharge time, among which the use of ACEI/ARB and β-blockers deserved more attention. Adherence to OMT after PCI was an independent protective factor, which could reduce the incidence of postoperative MACCE and improve the prognosis of patients.

Factors Associated With Predischarge Versus Postdischarge Scheduling for Early Follow-up Appointments.

Per national guidelines, early follow-up appointments should be scheduled before discharge, but in previous research, appointments scheduled before discharge were not associated with appointment adherence. The purpose of this study was to determine whether patient, heart failure (HF), and hospital factors were associated with predischarge appointment scheduling. A secondary analysis of a medical record review included patients hospitalized for decompensated HF at 3 health system hospitals who had a scheduled office appointment post discharge at 14 days or less. Patient demographics, and social, HF, and hospital factors were studied for association with predischarge scheduling. In multivariable modeling, the odds of having an appointment scheduled predischarge were based on 3 factors: nonwhite race, history of chronic renal insufficiency, and no admission within 14 days before HF hospitalization. Appointment scheduling may be based on provider perceptions of readmission risk. Follow-up appointment scheduling practices should be based on systematic processes.

Abstract WP35: Thrombectomy Techniques and Patient Characteristics Associated With Complete TICI 3 Reperfusion After Stroke Thrombectomy

Introduction: Prior randomized trials have defined substantial reperfusion for stroke thrombectomy as TICI 2b or TICI 3. However, recent data suggest that complete TICI 3 reperfusion results in more favorable patient outcomes than partial reperfusion with TICI 2b. We have multiple effective techniques for thrombectomy, but it is not clear which are most likely to achieve TICI 3 rather than TICI 2b reperfuson. Methods: Retrospective data from 15 hospitals were used for patients age 18 or over discharged from January 2014 to May 2019 with a primary or secondary diagnosis of ischemic stroke who received a thrombectomy and achieved TICI reperfusion grade of 2b or 3. Primary outcome was TICI grade 3, defined as complete reperfusion, versus TICI 2b. Multivariate logistic regression was conducted to determine if procedure technique (retrievable stent only, distal aspiration only or a combination approach with both) was associated with achieving TICI 3 versus 2b adjusting for sex, age ≥70 vs ≤69, race/ethnicity, history of chronic renal insufficiency or diabetes, history or newly diagnosed atrial fibrillation or flutter, previous anticoagulation medication. Interaction effects between technique and clinical variables were also tested. Results: The analysis included 787 patients, 67.9% (n=534) TICI 3 and 32.1% (n=253) TICI 2b. While, main effect of procedure technique was not a significant predictor of achieving TICI 3 (p=.451), interaction effects showed superiority of the combination approach in several patient populations. Specifically, the combined approach increased the likelihood of TICI 3 compared to stent retrieval alone for older patients (Adjusted Odds Ratio (AOR) =1.79, p=.007), those with a history of diabetes (AOR=1.56, p=.045) and Asian patients (AOR=4.41, p=.010). Among AFIB/flutter patients, the combined approach also increased the odds of complete reperfusion compared to stent retriever alone (AOR=1.76, p=.005) or distal aspiration alone (AOR=1.38, p=.034). Conclusion: The combined approach of retrievable stent and distal aspiration was a significant predictor of achieving TICI 3 in certain patient subgroups including patients who were older, Asian, had a history of diabetes or history of or current AFIB/flutter.

Comparison of Baseline Characteristics and Inhospital Outcomes of Patients and Use of Bare Metal Versus Drug-Eluting Stents During Percutaneous Coronary Intervention 2005 to 2015 at a Single Tertiary Hospital

With steady growth in the use of drug-eluting stents (DES), the indications for bare metal stents (BMS) have significantly changed over the last decade. This study aims to describe trends in the use of BMS and the evolution of the population receiving them over the past 10years and determine patient characteristics associated with using BMS. Consecutive patients who underwent percutaneous coronary intervention (PCI) at the Washington Hospital Center from January 2005 through March 2015 were included. Baseline characteristics and inhospital outcomes of patients who underwent PCI with BMS versus DES were compared during 2 different time periods: from 2005 to 2010 and from 2011 to 2015. Multivariable analyses were performed for each period of time to determine independent variables associated with the choice of BMS rather than DES; 20,321 patients who underwent PCI were included in the present study. The mean age was 65.0 ± 12.5years, 65.2% were men, and 30.4% were black. BMS use peaked in 2007 (47%) but has fallen steadily since; BMS accounted for only 10% of stents used in 2015. Presentation with acute coronary syndrome or cardiogenic shock was more common in patients receiving a BMS; this was reflected in higher rates of inhospital mortality and major bleeding among patients receiving BMS versus DES. Covariables independently associated with receiving a BMS common to both time periods included black race, Hispanic ethnicity, cardiogenic shock or acute coronary syndrome, oral anticoagulation, current smoking, increasing age, lower hematocrit, and history of chronic renal insufficiency. In conclusion, there has been a precipitous decline in the use of BMS over the last decade. Newer stent technology that promises shorter duration of dual antiplatelet therapy is likely to lead to the extinction of BMS over the next decade.

Final Results from a Phase 4 Open-Label 3-Year Study Evaluating Changes in Bone Marrow (Bm) Morphology in Adult Immune Thrombocytopenia (ITP) Patients (Pts) Receiving the Thrombopoietin Mimetic Romiplostim

Introduction: Normal bm may contain reticulin, which is of unknown clinical relevance. An analysis of romiplostim ITP trials as of 2011 showed 17 reticulin cases and one collagen case; however, biopsies were not performed systematically. Reported here are final results from a prospective 3-year (y) study evaluating bm biopsies for reticulin and collagen before and after treatment with romiplostim in adult ITP pts. Methods: Eligible ITP pts had platelets Results: All pts received romiplostim and had evaluable baseline bm biopsies. Of the 50 pts in Cohort 1 [54% female, mean age 55.5 y, range 20–86 y, mean (SD) dose 4.0 (2.8) µg/kg], 39 had post-baseline bm biopsies (Table). No pts with evaluable results developed collagen or had an increase ≥2 grades from baseline in reticulin. Of the 50 pts in Cohort 2 [76% female, mean age 48.6 y, range 19–83 y, mean (SD) dose 4.3 (3.1) µg/kg], 40 had post-baseline bm biopsies. There was no evidence of collagen; 2 pts had a 2-grade increase in reticulin. Of the 69 pts in Cohort 3 [71% female, mean age 46.6 y, range 18-81 y, mean (SD) dose 4.1 (2.9) µg/kg], 58 had post-baseline bm biopsies; 7 pts had a 2-grade increase in modified Bauermeister score, with 2 of the 7 showing collagen. Of those 2, 1 had no evidence of collagen on follow-up biopsy 12 weeks later; the other refused a follow-up biopsy. The safety profile was similar to that in past trials. In Cohort 1, 4 pts died; causes were fungal sepsis in a pt with longstanding corticosteroid use, cerebral hemorrhage, pulmonary hemorrhage in a pt with pulmonary thrombosis treated with acenocoumarol, and subdural hematoma that occurred after the pt fell and sustained a head injury. In Cohort 2, 2 pts died; causes were acute renal failure in a pt with a history of chronic renal insufficiency and suicide. In Cohort 3, 1 pt died of multiple thromboses of microcirculation and failure of the heart, kidneys, and lungs. No deaths were attributed to romiplostim. One pt in Cohort 3 tested positive for neutralizing antibodies (Ab) to romiplostim at Week 30 through the Year 1 visit, but was Ab negative on a subsequent test; the last romiplostim dose was at Week 36, but the pt maintained platelet response throughout. Summary/Conclusion: An increase in modified Bauermeister score by ≥2 grades occurred in 9 of 131 pts (6.9%) treated with romiplostim; 7 had increased reticulin only and 2 also had collagen. The low incidence of both collagen and increased reticulin is consistent with results of past romiplostim studies. Table Biopsy Results 1 3 pts in cohort 1, 3 in cohort 2, and 10 in cohort 3 had biopsies at end of treatment due to early discontinuation. 2 Trichrome and silver staining results could not be obtained for all biopsies due to inadequate samples. 3 Duration-adjusted, per 100 pt-y 4 1 case: grade 0 to 2; 1 case: grade 1 to 3 5 1 case: grade 4 after 25 weeks in a pt with atypical ITP, no evidence of collagen on follow-up biopsy 12 weeks later; 1 case: grade 4 at end of treatment, pt refused follow-up biopsy 6 2 cases: collagen (as above in 5); 2 cases: grade 0 to 2; 3 cases: grade 1 to 3 Disclosures Janssens:Amgen Inc.: Membership on an entity9s Board of Directors or advisory committees, Speakers Bureau; GSK: Membership on an entity9s Board of Directors or advisory committees, Speakers Bureau; Roche: Membership on an entity9s Board of Directors or advisory committees, Speakers Bureau; Mundipharma: Membership on an entity9s Board of Directors or advisory committees, Speakers Bureau. Rodeghiero:GSK: Membership on an entity9s Board of Directors or advisory committees, Research Funding, Speakers Bureau; Amgen Inc.: Membership on an entity9s Board of Directors or advisory committees, Research Funding, Speakers Bureau; Suppremol: Membership on an entity9s Board of Directors or advisory committees, Speakers Bureau. Chong:Amgen Inc.: Research Funding; GSK: Research Funding. Pabinger:Amgen Inc.: Honoraria, Membership on an entity9s Board of Directors or advisory committees, Speakers Bureau; Boehringer Ingelheim: Honoraria, Membership on an entity9s Board of Directors or advisory committees, Speakers Bureau; Bayer: Honoraria, Membership on an entity9s Board of Directors or advisory committees, Speakers Bureau; Baxter: Honoraria, Membership on an entity9s Board of Directors or advisory committees, Speakers Bureau; Pfizer: Honoraria, Membership on an entity9s Board of Directors or advisory committees, Speakers Bureau; CSL Behring: Honoraria, Membership on an entity9s Board of Directors or advisory committees, Research Funding, Speakers Bureau. Cervinek:Alexion: Consultancy; GSK: Consultancy; Amgen Inc.: Consultancy. Wang:Amgen Inc.: Employment, Equity Ownership. Lopez:Amgen Inc.: Employment, Equity Ownership.

Safety and long‐term outcomes after percutaneous coronary intervention in patients with human immunodeficiency virus

This study aims to report the long-term outcomes after percutaneous coronary intervention (PCI) in human immunodeficiency virus (HIV+) patients. Sparse data exists regarding the risk of patients with HIV who undergo PCI. Using a case-control design, we compared baseline characteristics, procedure-related outcomes, in-hospital, and 2-year clinical outcomes of 112 consecutive HIV+ patients versus 112 HIV- controls matched for age, gender, and diabetes mellitus who underwent PCI from April 2003 to September 2011. Baseline characteristics were generally comparable, save for more African Americans and history of chronic renal insufficiency in the HIV+ vs. HIV- group (62.5% vs. 21.4%, P < 0.001) and (27.7% vs. 9.9%, P < 0.001). There was no correlation between CD4 nadir count and extent and diffuseness of coronary artery disease. The occurrence of major adverse cardiac events at 2 years was similar in both groups. Multivariable analysis for independent correlates of major adverse cardiac events at 2 years detected patients with a history of chronic renal insufficiency (OR: 2.44, 95% confidence interval: 1.02-5.83; P = 0.04) and acute myocardial infarction (OR: 2.92, 95% confidence interval: 1.39-6.15; P = 0.005) as correlates for outcome. Post-hoc analysis showed that drug-eluting stent (DES) use in the HIV+ group was beneficial. PCI in HIV+ patients is safe, with high procedural success rates, and produces similar outcomes to those seen in HIV- patients at 2 years. HIV+ patients should be treated with DES if possible.

Late rescue of proximal endograft failure using fenestrated and branched devices

Endovascular aneurysm repair (EVAR) will fail over time in a percentage of patients. Mechanical failure of the device, progression of aortic disease, or interface complications between the device and the native vasculature may contribute. Our aim was to evaluate the role of fenestrated and branched endografts as treatment options for failed devices. Between January 2001 and June 2013, 970 patients were enrolled into a physician-sponsored investigational device exemption (PSIDE) study and treated with a fenestrated/branched endograft. All patients treated for nonurgent proximal neck failure of an infrarenal endoprosthesis previously implanted during EVAR comprised the study group. Patients treated for a primary aneurysm within the PSIDE were evaluated as a comparison group to identify preoperative risk factors for failure. A retrospective review was undertaken to determine the details of the initial EVAR, whereas the prospective PSIDE database was used to assess outcomes of secondary treatment. Three-dimensional imaging techniques were used to define all morphologic measurements. Statistical analysis included comparisons between categoric variables with the χ(2) test and between continuous variables with the Wilcoxon rank sum test between patients with late failures and those with native aortic repair. Kaplan-Meier curves were used to analyze overall survival. Of 970 patients enrolled in the PSIDE, 54 (5.6%) had late failure of a prior endograft. Fenestrated/branched devices were used to address the failure in each patient. The etiology of failure was related to a proximal neck issue in all patients: type Ia endoleak in 38, stent migration in 18, neck degeneration in 28, or some combination of these factors. The endovascular rescue procedure took place a mean of 61 months after the primary procedure. The mean aneurysm diameter at reintervention was 67 mm. Patients requiring a secondary fenestrated procedure were younger at the time of their primary intervention (P = .039) and were more likely to have a history of chronic renal insufficiency (P = .05) compared with other patients in the PSIDE. Technical success rate in the study group was 85% (44 of 52). Successful stenting was achieved in 71 of 77 (92%) target vessels. Thirty-day mortality was 3.8% (two of 52). Fluoroscopy dose and operating time were longer in the rescue group (P = .07) than in the control group (P = .008). Secondary interventions were required in 36.5% (19 of 52) of patients. Our series demonstrates the risk for late failure after EVAR is greater in patients who are younger and have chronic renal impairment at the time of implantation. Branched and fenestrated repair after failed EVAR is more complex than repair in the native aorta. More research is needed to identify patients at higher risk of failure after EVAR to prevent the need for rescue in the future.

Analysis of risk factors in elderly patients with purple urine bag syndrome: A retrospective analysis in a medical center in northern Taiwan

Background: Purple urine bag syndrome (PUBS), an uncommon phenomenon that turns urine tubes or bags purple or blue, can be encountered in long-term-care facilities. A thorough literature review shows that East Asia has a high incidence of PUBS. It is important to recognize the clinical features and risk factors of this phenomenon. The aim of this study is to explore the characteristics of patients with PUBS and correlate the onset of PUBS symptoms with risk factors. Materials and Methods: We reported nine cases of clinically confirmed PUBS between January 2009 and June 2013. Pertinent clinical information was collected, including age, feeding type, renal function, type of Foley catheter, urine analysis, and bacteriological data. Results: All of patients with PUBS presented with stable vital signs without evidence of clinical infection, such as fever or chills. The mean age of the patients was 86.6 ± 10.1 years, with a preponderance of females (77%). Five PUBS patients (55%) had a history of chronic renal insufficiency. Six patients (66%) had constipation. A logistic regression univariate analysis demonstrated a statistically significant urine pH in patients with PUBS [odds ratio (OR), 3.078; P = 0.036]. Risk factors, such as gender, were found to be significant using logistic regression multivariate analysis (OR, 0.031; P = 0.021). During the follow-up, all of the patients had Foley catheters re-inserted, and all of the patients received health education. Conclusion: The incidence of PUBS in the elderly population is associated with asymptomatic bacteriuria, urine pH, and gender but not renal function, type of feeding, or type of Foley catheter used. To understand PUBS and maintain urological hygiene, it is important to educate families and health care workers about PUBS and to recognize that PUBS is not regarded as a symptom of severe disease.

Results From a Phase IV Open-Label Study Evaluating Changes In Bone Marrow Morphology In Adult Immune Thrombocytopenia (ITP) Patients Receiving Romiplostim: Analysis Of The 1- and 2-Year Romiplostim Cohorts

IntroductionReticulin is a normal and common component of the bone marrow stroma. In clinical trials of adults with chronic ITP treated with the thrombopoietin mimetic romiplostim, a small number of cases of reticulin and/or collagen in bone marrow were reported. However, bone marrow biopsies were not systematically performed in these trials. Here, we report a multicenter study of adult ITP patients that evaluated bone marrow biopsies for reticulin and collagen pre- and post-treatment with romiplostim. MethodsEligible ITP patients had platelet counts <50x109/L, received ≥1 prior ITP therapy, and no collagen in baseline bone marrow biopsies (ie, before romiplostim). Three cohorts of patients were scheduled for biopsies after 1 (Cohort 1), 2 (Cohort 2), or 3 years of romiplostim, dosed to maintain platelet counts at 50–200x109/L. Bone marrow biopsies were also performed if patients discontinued early or failed to achieve/maintain a response to romiplostim, defined as platelet counts ≤20x109/L for 4 consecutive weeks at the maximum romiplostim dose of 10 µg/kg. Reticulin and collagen formation were measured using the modified Bauermeister scale (0 no reticulin; 1 occasional fine fibers/foci fine fiber network; 2 fine fiber network; 3 diffuse fiber network, scattered coarse fibers; 4 diffuse coarse fiber network with areas of collagenization). Collagen was detected by trichrome staining and reticulin by silver staining. Cohort 1 biopsy samples were reread as the modified Bauermeister scale had not been applied as specified in the study protocol. All samples were read by 2 hematopathologists at a central bone marrow laboratory with grading discrepancies reviewed by an independent bone marrow panel. Data cutoff for this analysis was August 10, 2012. ResultsOf the 50 patients enrolled in Cohort 1 (54% female, mean age 55.5 years, range 20–86 years), 39 patients received romiplostim and had bone marrow biopsies (Table). Mean (SD) dose was 3.8 (2.9) µg/kg. No patients with evaluable results developed collagen. No patients had an increase ≥2 grades from baseline in reticulin. Of the 50 patients enrolled in Cohort 2 (76% female, mean age 48.6 years, range 19–83 years), 39 patients received romiplostim and had bone marrow biopsies (Table). Mean (SD) dose was 4.1 (3.2) µg/kg. Again, of the patients with evaluable results, none developed collagen. Two patients had a 2-grade increase in reticulin (1 patient: baseline grade 0 to 2 at year 2; 1 patient: baseline grade 1 to 3 at end of treatment). The safety profile was similar to previous trials. In Cohort 1, 3 patients died (not attributed to romiplostim); causes were fungal sepsis in a patient with longstanding corticosteroid use, cerebral hemorrhage, and pulmonary hemorrhage in a patient with pulmonary thrombosis treated with acenocumarol. In Cohort 2, 2 patients died (not attributed to romiplostim); causes were acute renal failure, in a patient with a medical history of chronic renal insufficiency, and suicide. There were no neutralizing antibodies to romiplostim or thrombopoietin in the 2 cohorts. Summary/ConclusionThere was no evidence of collagen formation after 2 years of romiplostim treatment. The incidence of increase in reticulin was low, consistent with results of previous romiplostim studies. This ongoing study will provide additional data on bone marrow changes with up to 3 years of romiplostim treatment.At completion of year 1 treatment, discontinuations included withdrew consent (n=5), non-responders (n=4), died (n=3), adverse event (n=1, severe joint pain), administration decision (n=1).At completion of year 2 treatment, discontinuations included withdrew consent (n=6), non-responders (n=2), declined biopsy (n=2), adverse events (n=2, dermatitis and suspected non-Hodgkins lymphoma), died (n=1), required alternate therapy (n=1). Disclosures:Janssens:Amgen, GSK, Mundipharma, Roche: Membership on an entity's Board of Directors or advisory committees. Rodeghiero:Amgen, GSK: Honoraria; Amgen, Eisai, GSK, LFB, Suppremol: Membership on an entity's Board of Directors or advisory committees. Chong:Amgen, GSK: Research Funding. Pabinger:CSL Behring: Research Funding; Amgen, Baxter, Bayer, Boehringer Ingelheim, CSL Behring, Pfizer: Honoraria; Amgen, Baxter, Bayer, Boehringer Ingelheim, CSL Behring, Pfizer: Membership on an entity's Board of Directors or advisory committees. Cervinek:Alexion, Amgen, GSK: Consultancy. Wang:Amgen: Employment, Equity Ownership. Lopez:Amgen: Employment, Equity Ownership.

Vegetative Plaques and Hemorrhagic Pustules

A man with a history of chronic renal insufficiency (baseline creatinine level, 2.8mg/dL) presented for evaluation of a painful forehead erythematous eruption and associated headache. (To convert creatinine to micromoles per liter, multiply by 88.4.) Three days prior to symptom onset he underwent a contrast-enhanced computed tomographic (CT) scan to evaluate abdominal pain. On the central forehead was a tender 5-cm reddish brown plaque composed of numerous coalescing vesicles and hemorrhagic pustules with intermixed serous and hemorrhagic crust. Similar vesicles and pustules were present on the nasal bridge and tip, the bilateral conchal bowls, and on the scalp (Figure, A). Two days later, the patient developed several 0.5to 1.0-cm purpuric macules and hemorrhagic vesicles on the bilateral hands and nail beds. Initial blood tests revealed a white blood cell count of 6400 cells (range, 4000 to 11 000/μL; to convert to ×109/L, multiply by 0.001). The patient denied any new medications, any known contacts with or exposures to individuals who were ill, and any history of skin disease. A punch biopsy of the forehead plaque was performed (Figure, B and C). What is your diagnosis?

Risk of contrast-induced nephropathy in patients undergoing endovascular treatment of acute ischemic stroke

Background and purposeWe report the incidence and risk factors for contrast-induced nephropathy after the use of iodinated contrast for endovascular treatment of acute ischemic stroke.MethodsA retrospective chart review was performed...

Dexmedetomidine controls twitch-convulsive syndrome in the course of uremic encephalopathy

An 85 year old man with a history of chronic renal insufficiency was admitted to the cardiothoracic intensive care unit after aortic valve replacement. His postoperative course was marked by acute oliguric renal failure for high blood urea nitrogen (BUN) and acute hyperactive delirium. At this time he also developed tremors with muscle twitching; he received no other form of sedatives. A neurology consult made the diagnosis of twitch-convulsive syndrome associated with uremic encephalopathy. While the patient was receiving the dexmedetomidine infusion, the signs of the twitch-convulsive syndrome, particularly the twitching and tremors, disappeared. Within 30 minutes of the end of the dexmedetomidine infusion, symptoms of the twitch-convulsive syndrome returned, manifesting as acute tremulousness. After several dialysis treatments, his BUN decreased and the dexmedetomidine was weaned, without return of the symptoms of twitch-convulsive syndrome.

Optimal Freeze Cycle Length for Renal Cryotherapy

To our knowledge the optimal freeze cycle length in renal cryotherapy is unknown. Ten-minute time based freeze cycles were compared to temperature based freeze cycles to -20C. Laparoscopic renal cryotherapy was performed on 16 swine. Time based trials consisted of a double 10-minute freeze separated by a 5-minute thaw. Temperature based trials were double cycles of 1, 5 or 10-minute freeze initiated after 1 of 4 sensors indicated -20C. A 5-minute active thaw was used between freeze cycles. Control trials consisted of cryoneedle placement for 25 minutes without freeze or thaw. Viability staining and histological analysis were done. There was no difference in cellular necrosis between any of the temperature based freeze cycles (p = 0.1). Time based freeze cycles showed more nuclear pyknosis, indicative of necrosis, than the 3 experimental freeze cycles for the renal cortex (p = 0.05) but not for the renal medulla (p = 0.61). Mean time to -20C for freeze cycle 1 was 19 minutes 10 seconds (range 9 to 46 minutes). In 4 of 21 trials (19%) -20C was never attained despite freezing for 25 to 63 minutes. There was no difference in immediate cellular necrosis among double 1, 5 or 10-minute freeze cycles. Cellular necrosis was evident on histological analysis for trials in which -20C was attained and in freeze cycles based on time alone. With a standard 10-minute cryoablation period most treated parenchyma 1 cm from the probe never attained -20C. Cell death appeared to occur at temperatures warmer than -20C during renal cryotherapy.

Limited Warm Ischemia During Elective Partial Nephrectomy has Only a Marginal Impact on Renal Functional Outcomes

Ischemic damage during partial nephrectomy increases with each minute of warm ischemia, leading some groups to advocate hypothermia in all cases or partial nephrectomy without vascular occlusion as a primary technique. The renal functional implications of these approaches have not been well studied in patients who undergo elective partial nephrectomy. We evaluated early and late renal functional outcomes in 1,132 patients with 2 functioning kidneys and normal preoperative serum creatinine who underwent partial nephrectomy without regional ischemia (58), with less than 30-minute warm ischemia (809) or with cold ischemia (265). The preoperative, postoperative and latest glomerular filtration rates were not significantly different in the 3 groups. At latest followup the relative decrease in renal function was less in cases without regional ischemia than in those with less than 30-minute warm ischemia and those with cold ischemia (0.5% vs 13% and 11%, respectively, p <0.001). In part this reflected selection bias since tumor size and the amount of parenchyma removed were lowest in that group (p <0.001). On multivariate analysis the percent of parenchyma preserved and the baseline glomerular filtration rate were strongly associated with the postoperative and latest glomerular filtration rates (p <0.001) but the partial nephrectomy approach was not (p >0.05). Adverse short or long-term renal functional outcomes were marginally increased in patients with 20 to 30-minute warm ischemia. However, such events were uncommon and renal failure developed in only 4 of 1,132 patients (less than 0.4%). During elective partial nephrectomy a warm ischemia time of less than 20 minutes is not associated with clinically relevant functional loss compared to that of alternative techniques. However, longer warm ischemia time may correlate with ischemic injury and should be avoided.

Radiation-Associated Kidney Injury

The kidneys are the dose-limiting organs for radiotherapy to upper abdominal cancers and during total body irradiation. The incidence of radiotherapy-associated kidney injury is likely underreported owing to its long latency and because the toxicity is often attributed to more common causes of kidney injury. The pathophysiology of radiation injury is poorly understood. Its presentation can be acute and irreversible or subtle, with a gradual progressive dysfunction over years. A variety of dose and volume parameters have been associated with renal toxicity and are reviewed to provide treatment guidelines. The available predictive models are suboptimal and require validation. Mitigation of radiation nephropathy with angiotensin-converting enzyme inhibitors and other compounds has been shown in animal models and, more recently, in patients.

7-Year Oncological Outcomes After Laparoscopic and Open Partial Nephrectomy

Open partial nephrectomy has proven long-term oncological efficacy. Long-term outcomes of laparoscopic partial nephrectomy are pending. We present the long-term outcomes of patients undergoing laparoscopic or open partial nephrectomy for a single cT1 renal cortical tumor 7 cm or less. Of 2,246 patients undergoing partial nephrectomy for a single cT1 tumor (1999 to 2008), minimum 7-year followup was available in 77 and 310, and minimum 1-year followup was available in 672 and 944 after laparoscopic and open partial nephrectomy, respectively. Survival and recurrence data obtained from medical records, radiographic reports and patient contact were analyzed retrospectively. Median followup after laparoscopic and open partial nephrectomy was 4.0 and 5.7 years, respectively. Oncological outcomes were excellent in both groups. On multivariable analysis predictors of all cause mortality included advancing age (p <0.0001), comorbidity (p <0.0001) and preoperative renal dysfunction (p = 0.0001) but not tumor size (p = 0.6) or operative approach (laparoscopic vs open partial nephrectomy, p = 0.06). Cancer recurred infrequently and only rarely caused mortality after laparoscopic or open partial nephrectomy. At 7 years metastasis-free survival was 97.5% and 97.3% (p = 0.47) after laparoscopic and open partial nephrectomy, respectively. After accounting for baseline differences between the cohorts using propensity score matching 7-year metastasis-free survival was similar after laparoscopic and open partial nephrectomy. Laparoscopic and open partial nephrectomy appear to provide similar long-term overall and cancer specific survival in patients undergoing partial nephrectomy for clinical stage T1 (7 cm or less) renal cortical tumors. Oncological outcomes at 7 years after laparoscopic and open partial nephrectomy are excellent with the majority (97%) of patients experiencing metastasis-free survival.