History Of Renal Insufficiency Research Articles

Integrated Chinese and Western medicine for stable angina pectoris of coronary heart disease: a real-world study including 690 patients.

We aimed to evaluate the effects of integrated Chinese and Western medical therapeutic modalities on clinical prognosis in a population with stable angina pectoris (SAP) of coronary heart disease (CHD). In a prospective cohort study, 732 patients with SAP of CHD hospitalized in the Integrated Cardiology Unit of the China-Japan Friendship Hospital From October 2020 to October 2021 were included. The patients were divided into integrated treatment and conventional treatment groups according to whether they had been taking Chinese medicine for more than 6 months per year. The occurrence of composite cardiovascular events (CVEs), including cardiac death, non-fatal myocardial infarction, revascularization, stroke, all-cause death, and readmission due to angina attack, heart failure, or malignant arrhythmia, was recorded during follow-up. The effects of different treatment modalities on prognosis were evaluated using univariate and multifactorial logistic regression. Logistic regression models were evaluated using receiver operating characteristic (ROC) curves. In sensitivity analysis, the correlation between treatment modality and outcome events was corrected by rematching the two groups of patients using the propensity score matching (PSM) method. The data from 690 patients were included in the analysis, with 327 patients in the integrated treatment group and 363 patients in the conventional treatment group. CVEs occurred in 19 patients (5.8%) in the integrated treatment group and 37 patients (10.2%) in the conventional treatment group. The proportion of outcome events was significantly lower in the combination treatment group than in the conventional treatment group (P = 0.037). Covariate correction by multimodal multifactorial logistic regression revealed a lower risk of CVEs in patients receiving integrated therapy compared with conventional therapy (OR = 0.246, 95% CI = 0.097-0.622, P = 0.003). Moreover, a history of renal insufficiency (OR = 3.991, 95% CI = 1.164-13.684, P = 0.028) and a higher Gensini score (OR = 1.039, 95% CI = 1.028-1.050, P < 0.001) were risk factors for the development of CVEs. Model evaluation showed that C-statistic = 0.955 and area under the ROC curve (AUC) = 0.955. After PSM correction, the results still showed that integrated Chinese and Western medical treatment reduced the occurrence of CVEs in patients compared with Western treatment alone (OR = 0.339, 95% CI = 0.131-0.874, P = 0.025). Integrated treatment based on Chinese and Western medicine might improve the prognosis and reduce the risk of CVEs in this disease population. China Clinical Trials Registry, ChiCTR1800017891, Registered 20 August 2018, http://www.chictr.org.cn/showproj.aspx?proj = 30170.

Long-term follow-up in patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention.

Long-term follow-up after primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI) beyond 5 years is poorly described. There are no risk-stratification systems available for routine use. This retrospective, academic, two-centre analysis included consecutive patients who presented with acute STEMI between March 2008 and December 2019. In total, 5263 patients underwent pPCI; all patients were included in the analysis only once. Baseline characteristics were gathered from prospective local registries and based on initial hospitalization. The study enrolled 5263 patients who had been treated with pPCI; it found that cardiovascular mortality was the most frequent cause of death (65.0%) on long-term follow-up to 12 years. Myocardial infarction associated mortality was 27.2%. Cardiovascular mortality was dominant, including in the landmark analysis beyond 1 year. Multivariate analysis identified significant predictors for long-term cardiovascular mortality: age, history of diabetes mellitus, history of renal insufficiency, history of heart failure, Killip class, and successful pPCI at presentation. A predictive model was built to evaluate the risk of cardiovascular death with a high discrimination value (C-statistic = 0.84). Cardiovascular diseases remain the leading cause of long-term mortality after pPCI in the Central European population. Our novel predictive model provides risk stratification; it could identify patients who would experience the greatest benefit from aggressive secondary prevention measures.

Resuscitation Using ECPR During In-Hospital Cardiac Arrest (RESCUE-IHCA) Mortality Prediction Score and External Validation.

The aim of this study was to develop and validate a score to accurately predict the probability of death for adult extracorporeal cardiopulmonary resuscitation (ECPR). ECPR is being increasingly used to treat refractory in-hospital cardiac arrest (IHCA), but survival varies from 20% to 40%. Adult patients with extracorporeal membrane oxygenation for IHCA (ECPR) were identified from the American Heart Association GWTG-R (Get With the Guidelines-Resuscitation) registry. A multivariate survival prediction model and score were developed to predict hospital death. Findings were externally validated in a separate cohort of patients from the Extracorporeal Life Support Organization registry who underwent ECPR for IHCA. A total of 1,075 patients treated with ECPR were included. Twenty-eight percent survived to discharge in both the derivation and validation cohorts. A total of 6 variables were associated with in-hospital death: age, time of day, initial rhythm, history of renal insufficiency, patient type (cardiac vs noncardiac and medical vs surgical), and duration of the cardiac arrest event, which were combined into the RESCUE-IHCA (Resuscitation Using ECPR During IHCA) score. The model had good discrimination (area under the curve: 0.719; 95% CI: 0.680-0.757) and acceptable calibration (Hosmer and Lemeshow goodness of fit P=0.079). Discrimination was fair in the external validation cohort (area under the curve: 0.676; 95% CI: 0.606-0.746) with good calibration (P=0.66), demonstrating the model's ability to predict in-hospital death across a wide range of probabilities. The RESCUE-IHCA score can be used by clinicians in real time to predict in-hospital death among patients with IHCA who are treated with ECPR.

Correlation between metabolic syndrome and adverse events after internal fixation of femoral intertrochanteric fracture in the elderly

To explore the effect of metabolic syndrome on 15 days postoperative adverse events of femoral intertrochanteric fractures with internal fixation. From January 2011 to June 2019, 986 elderly patients with intertrochanteric fracture were treated with internal fixation, including 312 males and 674 females, with an average age of(77.71± 7.58) years old. And there were 97 patients with metabolic syndrome and 889 patients without metabolic syndrome. Through the electronic medical record system, the patient's age, gender, fracture type, cause of trauma, body mass index, smoking history, preoperative comorbidities, preoperative bloodtransfusion, operation timing, ASA classification, anesthesia method, internal fixation type, operation duration, and 15 days postoperative adverse events, which include surgical site infection, acute heart failure, acute respiratory failure, pulmonary infection, acute renal failure, DVT, embolism in important organs, urinary tract infection, death, and blood transfusion after surgery were collected. The differences of preoperative and intraoperative baseline datas and 15 days postoperative adverse events between the two groups were compared and analyzed by t text or univariate χ2 test. Adjusted for the preoperative and intraoperative mixed factors with P<0.05, and 15 days postoperative adverse events with P<0.05 were then analyzed by multivariate unconditional Logistic regression analysis to further study the independent effects of metabolic syndrome on 15 days postoperative adverse events. There were statistical differences in age, body mass index, history of cardiac insufficiency, history of COPD, history of renal insufficiency, operation timing, ASA classification, operation duration, surgical site infection, acute heart failure, DVT, urinary tract infection and blood transfusion between two groups (P<0.05). Adjusted for the preoperative and intraoperative mixed factors, multivariate unconditional logistic regression analysis showed that metabolic syndrome could increase the infection rate of the surgical site [OR=3.785, 95%CI (1.086-13.188), P= 0.037], DVT incidence rate[OR=2.265, 95%CI(1.096-4.682), P=0.027], urinary tract infection rate[OR=2.703, 95%CI (1.049-6.963), P=0.0390], and blood transfusion rate [OR=1.811, 95%CI (1.142-2.870), P=0.012]. Elderly patients with intertrochanteric fracture with metabolic syndrome had higher postoperative surgical site infection rate, DVT incidence rate, urinary tract infection rate, and postoperative blood transfusion rate. Therefore, the orthopedic treatment team should give more attentionand optimize the treatment plan during the perioperative period with the cooperation of internal physician and anesthesiologist.

A Rare Case of Metformin Associated Lactic Acidosis in a Type 2 Diabetic Patient With No Known Contraindications for Metformin Prescription - a Diagnostic Conundrum!

Introduction: Metformin is a biguanide drug primarily inhibits hepatic gluconeogenesis and improves insulin sensitivity. Lactic acidosis is a rare complication of metformin. The incidence of Metformin-associated lactic acidosis (MALA) is 6.3 per 100,000 patient-years. Metformin raises lactate levels by inhibiting the conversion of lactate and pyruvate into glucose, shunting towards anaerobic glycolysis. Although, MALA is a reported side effect, metformin is still identified as the drug of choice for Type 2 DM. Here we present a case of MALA in a Type 2 Diabetic patient to shed light on this controversial dilemma. Case Presentation: A 56-year-old African-American male with Type 2 DM and diabetic retinopathy presented after a fall and generalized weakness. Upon arrival, his blood sugar was 22 mg/dL. Patient was vitally stable with signs of dehydration. Home medications includes Metformin 1000 mg twice daily and Glipizide. Laboratory results showed an anion gap metabolic acidosis of 18 mmol/L, Lactic acid was 6.5 mmol/L with repeat of 7.6 mmol/L. Creatinine was 6.0 mg/dL with a BUN of 89 mg/dL. Baseline creatinine from 1 year prior was 1.3–1.5 mg/dL with GFR of 52 mL/min. Hemoglobin A1c was 5.9%. Sodium bicarbonate infusion in 5% dextrose in water. The patient clinically improved with closure of the anion gap and resolution of the metabolic acidosis. Metformin level was 10 mcg/mL. He was discharged on basal insulin and discontinued Metformin and Glipizide. Discussion: Metformin is the first line treatment of Type 2 DM due to its safety. The most common adverse events of Metformin include nausea, bloating, and diarrhea. MALA is a rare, yet serious side effect with a reported mortality of 45%. Higher mortality was associated with increased age, lower arterial pH, and need for mechanical ventilation and vasopressor medicationsThe following criteria should raise concern for MALA in patients with history of Metformin use; elevated lactate level, high anion gap, severe acidosis, low serum bicarbonate level and a history of renal insufficiency. Our patient met the above criteria. The treatment approach for MALA includes adequate supportive measures and correction of acidosis with the acceleration of lactic acid metabolism. Ultimately, if there is no improvement with the aforementioned strategies, then the next step is elimination of the offending agent by renal excretion or dialysis. Fortunately our patient improved with intravenous hydration and did not require advanced intervention. This case highlights the importance of the early recognition of MALA in a patient with unexplained anion gap acidosis and history of Metformin use as even with no risk factors, an episode of gastroenteritis can be enough to impair renal function which increases the risk of MALA. More importantly, it is crucial to educate patients to withhold Metformin in the setting of acute illness and volume contraction to prevent MALA.

METFORMIN ASSOCIATED LACTIC ACIDOSIS

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Metformin is the most commonly used oral hypoglycemic agent to treat Type 2 Diabetes Mellitus owing to its favorable safety profile. Although metformin is renally cleared, drug levels generally remain within the therapeutic range and lactate concentrations are not substantially increased when used in patients with mild to moderate chronic kidney disease. However, the situation is different when a patient has acute renal insufficiency with progressively worsening kidney function. Here, we present a case of severe Metformin-associated lactic acidosis. CASE PRESENTATION: A 66-year-old Hispanic man with type-2 diabetes on metformin, hypertension, coronary artery disease and chronic back pain presented to our hospital with 2 days of altered mental status and worsening back pain. Initial physical examination was unremarkable except for tachycardia with a heart rate of 156. In the emergency department, laboratory abnormalities included initial blood sugar of 62, creatinine of 11, anion gap of 41 and lactate of 18, bicarbonate of 6 and pH of 6.7 on arterial blood gas. The patient worsened after transfer to critical care unit with acute development of hypoxia and hypotension and had to be intubated and started on mechanical ventilation and vasopressors. Differential diagnosis at this point was broad and it was thought that hypotension, acidemia, and severe metabolic derangement could be consistent with septic shock vs metformin-associated lactic acidosis. Patient was started on broad spectrum antibiotics and a nephrology consult was obtained and the patient was dialyzed within few hours after the placement of temporary dialysis catheter. Patient's pH improved to 7.2 after 1 session of dialysis and vasopressors requirement went down as well. The patient was extubated on day 4 and renal function improved over the coming days as well. DISCUSSION: The overall incidence of lactic acidosis in metformin users is generally low and varies across studies from approximately 3-10 per 100,000 person-years [1]. The overall mortality rate of Metformin associated lactic acidosis is 25.4% according to the study by Renda et al. [2]. Mortality is associated with the extent of acidosis while acute renal failure is associated with a low mortality. It is crucial to maintain a high suspicion of this complication in the differential diagnosis at the earliest stage for patients with metabolic acidosis and history of metformin use. CONCLUSIONS: Lactic acidosis resulting from metformin toxicity should be suspected in any patient who has all of the following five criteria: (1) a history of metformin use; (2) a markedly elevated lactate level (> 15 mmol/L) with a large anion gap (> 20); (3) severe acidemia (pH 7.1); (4) a very low serum bicarbonate level (< 10 mmol/L); and (5) a history of renal insufficiency. Education of both patients and providers to avoid metformin when there is a risk of renal failure is crucial. Reference #1: https://jamanetwork.com/journals/jama/article-abstract/2084896 Reference #2: https://www.ncbi.nlm.nih.gov/pubmed/23436666/ DISCLOSURES: No relevant relationships by Anam Hassan, source=Web Response No relevant relationships by Muhammad Hasham Sarwar, source=Web Response

A Curious Case of Confusion in a Patient With Cirrhosis

A Curious Case of Confusion in a Patient With Cirrhosis

Postoperative bleeding after laparoscopic Roux en Y gastric bypass: predictors and consequences.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a common, safe and effective bariatric procedure. Bleeding is a significant source of postoperative morbidity. We aimed to determine the incidence, outcomes, and predictors of postoperative bleeding after LRYGB. LRYGB patients included in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015 dataset were identified. Preoperative and intraoperative factors were tested for associations with bleeding using univariable and multivariable logistic regression analysis. Outcomes of length of stay, in-hospital mortality, 30-day mortality, discharge disposition, and 30-day complications among patients with and without clinically significant postoperative bleeding were compared using multivariable regression. In the 43,280 LRYGB patients included in this analysis, postoperative bleeding occurred in 652 (1.51%) patients. Of these, 165 (25.3%) underwent a re-operation and 97 (14.9%) underwent an unplanned endoscopy for 'bleeding'. Postoperative bleeding was associated with a longer median postoperative length of stay (4 vs. 2 days), higher in-hospital mortality (1.23 vs. 0.04%), higher 30-day mortality (1.38 vs. 0.15%), discharge to an extended-care facility (3.88 vs. 0.6%), and higher rates of major complications (all P < 0.05). Independent predictors of postoperative bleeding included; a history of renal insufficiency (OR 2.55, 95% CI 1.43-4.52), preoperative therapeutic anticoagulation (OR 2.44, 95% CI 1.69-3.53), and revisional surgery (OR 1.45, 95% CI 1.06-1.97). Intraoperative associated factors included conversions (OR 3.37, 95% CI 1.42-7.97), and drain placement (OR 1.40, 95% CI 1.18-1.67). Robotic approaches resulted in independently lower postoperative bleeding rates (OR 0.50, 95% CI 0.32-0.77). Postoperative bleeding occurs in 1.5% of patients undergoing a LRYGB and is associated with significantly increased morbidity and mortality. We have identified patient and operative factors that are independently associated with postoperative bleeding.

Gastric Mucosal Calcinosis

Background: Gastric mucosal calcinosis (GMC) is a rarely encountered disease characterized by calcific deposition in the gastric mucosa which was known to be associated with organ transplantation, end-stage renal disease, hypercalcemia, hyperphosphatemia, gastric neoplasia, medications such as antacids containing aluminum, sucralfate and bismuth, and so on. We describe incidentally found 23 cases of GMC. Methods: We identified 23 cases of GMC from July 2004 to June 2011 from pathology department records. All available inpatient and outpatient medical records including laboratory data were reviewed. Results: 23 cases (9 male and 14 femal: median age of 65.2, range 34-85) were found incidentally by upper gastrointestinal endoscopic biopsy. The microscopic examination showed multifocal basophilic calcific material just beneath the surface epithelium. 14 patients (60.9%) were taking tripotassium dicitrato bismuthate in variable duration from one week to four years, 5 patients (21.7%) were taking aluminum containing antacid and 2 patient (8.7%) were taking both of them. 1 patient (4.3%) showed hypercalcemia with increased parathyroid hormone. The patients had no history of renal insufficiency, organ transplantation or gastric malignancy and had variable symptoms according to other comorbid gastrointestinal diseases, in example, gastritis, gastroesophageal reflux disease, and functional dyspepsia. The endoscopic findings were hyperemia, edema, chalky or salty-white plaque in common and other frequently accompanying feature was spontaneous bleeding. However, endoscopic finding of 2 pateints (8.7%) showed gastric polyp which confirmed GMC pathologically. There was no difference of endoscopic findings between different etiologies. Follow up endoscopy which was available in 8 patients (34.8%) from two months to two years after stopping offending medication showed disappearance of previous noted GMC. Conclusion: Gastric mucosal calcinosis can develop in normal tissue because of altered serum or mucosal biochemical environment associated with therapeutic measures and can be reversed after abstinence of the offending medication.

Effect of Ischemia Duration and Door-to-Balloon Time on Myocardial Perfusion in ST-Segment Elevation Myocardial Infarction: An Analysis From HORIZONS-AMI Trial (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction).

This study sought to investigate the effect of treatment delay on microvascular reperfusion in ST-segment elevation myocardial infarction (STEMI) patients from the large, multicenter, prospective HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trial. Despite restoration of epicardial blood flow during primary percutaneous coronary intervention (PCI), one-third of patients do not obtain myocardial perfusion due to impairment in the microvascular circulation. We examined the effect of symptom onset-to-balloon time (SBT) and door-to-balloon time (DBT) on myocardial reperfusion during primary PCI in STEMI, utilizing resolution of ST-segment elevation (STR) and the myocardial blush grade (MBG). The primary analysis was the relationships between SBT ≤2, >2 to 4, and >4 h and DBT ≤1, >1 to 1.5, >1.5 to 2, and >2 h with MBG and STR. Clinical risk was assessed using a modified version of the Thrombolysis In Myocardial Infarction risk score for STEMI. In 2,056 patients, absent microvascular perfusion (MBG 0/1) and STR (STR <30%) after primary PCI was significantly more common in patients with longer SBT, in patients with both low and high clinical risk profiles. By multivariable analysis, SBT (p < 0.0001), anterior infarction (p < 0.0001), reference vessel diameter (p = 0.005), lesion minimum lumen diameter (p < 0.0001), hyperlipidemia (p = 0.03), and current smoking (p = 0.001) were independent predictors of MBG 0/1, whereas SBT (p = 0.007), anterior infarction (p < 0.0001), and history of renal insufficiency (p = 0.0002) were independent predictors of absent STR. DBT (p < 0.0001) was an independent predictor of MBG 0/1. MBG 0/1 and STR<30% identified patients with increased 3-year mortality. The present study suggests that delay in mechanical reperfusion therapy during STEMI is associated with greater injury to the microcirculation.

Renal failure following hospitalization for heart failure.

The purpose of the study is to evaluate the number of patients with heart failure readmitted for renal failure to IU Health Bloomington within 30 days of hospital discharge in 2010, and to determine whether there are factors that might have been identified before the original discharge that would have prevented the readmission. The goal of the research is to identify factors from previous admissions of patients with heart failure that would have possibly predicted a subsequent admission for renal failure, so that interventions can be developed to prevent such readmissions. The results from this study are applicable to all primary care settings. A retrospective descriptive design was employed. Subjects were patients diagnosed with heart failure in 2010 and subsequently readmitted with renal failure within 30 days of their previous hospital admission. A retrospective chart review was completed extracting the variables blood urea nitrogen levels upon patients' discharge and readmission, serum creatinine levels upon discharge and readmission, weight in kilograms upon discharge and readmission, total intake and output during the first hospitalization, diuretic medication dosage, history of renal failure, history of renal insufficiency, and death. Renal failure may be a predictable complication of heart failure. Although there are varying secondary pathophysiologies, which could account for readmission with renal failure and the severity of the renal failure, more attention should be paid to the variables identified in this study. Case managers can play a crucial role in identifying potential patients with renal failure and, where possible, collaborating with other health care providers to proactively preventing renal complications in patients with heart failure.

0120: B-type Nt-proBNP as a marker for contrast induced nephropathy in patients with primary percutaneous coronary intervention for ST segment elevation myocardial infarction

Contrast induced nephropathy (CIN) after Percutaneous Coronary Intervention (PCI) for ST segment elevation myocardial infarction (STEMI) is frequent and associated with mortality and long term renal impairement. Improving risk stratification of such patients by early markers is needed. To assess the association between Nt-proBNP, as an integrated biomarker for altered ventricular dysfunction and renal function, and the development of CIN. From the (RICO) survey, consecutive patients undergoing a PCI for a STEMI were included. Patients with cardiogenic shock or severe kidney disease were excluded. Serum creatinine (Cr) was measured at admission and 48h after PCI. CIN was defined as a rise in Cr >26.5µmol/L or >50% from baseline. Nt-proBNP was assessed on admission. Among the 1243 patients included, CIN occurred in 130 (10.4%) patients. Patients who developed CIN had a 5 fold increase in Nt-proBNP levels when compared with patients without CIN (1275(435-4022) vs 247(79-986) pg/ml, p<0.001). Hospital mortality was markedly higher in patients with CIN (6.9% vs 1.1%, p<0.001). Nt-proBNP levels were univariate estimate for CIN as well as age, hypertension, diabetes, smoking, prior stroke, history of renal insufficiency, heart rate, altered LVEF, anemia, CRP, and eGFR<30 ml/min/1.73m 2 . By multivariate analysis, Nt-proBNP levels remains strongly associated with the occurrence of CIN even after adjustment for risk factors, treatments, clinical, and biological variables (OR(95%CI): 1.91(1.40-2.60), p<0.001). From this large contemporary prospective study, our work suggests that Nt-proBNP levels at admission could help to identify patients at risk of CIN beyond traditional risk factors.

Pulmonary hemorrhage associated with Henoch-Schöenlein purpura in an adult patient primary diagnosed of IgA nephropathy.

We describe a case of IgA nephropathy (IgAN) followed by pulmonary hemorrhage associated with Henoch-Schöenlein purpura (HSP) in an adult female. The patient had a history of renal insufficiency and persistent hematuria and proteinuria, without any extra-renal involvement. She was diagnosed with IgAN 7years before the onset of HSP and had received immunosuppressive therapy for 6years. One year after discontinuing oral prednisolone and mizoribine, she suffered a pulmonary hemorrhage. She presented with exacerbated urinary findings, and palpable purpura, resulting in the diagnosis of HSP. Intravenous pulse methylprednisolone followed by oral prednisolone (1mg/kg/day) and a monthly intravenous cyclophosphamide pulse resolved the pulmonary hemorrhage. In a review of 36 HSP patients complicated with pulmonary hemorrhage, 27.8% of the patients perished [Rajagopala et al., Semin Arthritis Rheum 42:391-400, 1]. While the most efficient therapeutic strategies for these patients have yet to be determined, we speculate that an aggressive therapy of pulse methylprednisolone combined with immunosuppression agents is likely to bring about the best outcome in cases with pathological conditions similar to our patient's. On the other hand, discontinuance of immunosuppressive therapy might have resulted in the aggravation of the disease, hence we should examine patients carefully not to miss the cue.

Urinary Iodine Excretion After Contrast Computed Tomography Scan

Patients who undergo radiographic studies with contrast receive an enormous bolus of iodine. This can delay subsequent use of radioactive iodine (RAI) therapy because the iodine can compete for uptake. There is a paucity of literature on the minimum interval between contrast administration and RAI therapy. To better characterize how long it takes for the iodine load from an intravenous contrast bolus to clear from the body. A prospective cohort of 21 adults undergoing intravenous contrast CT studies at a tertiary academic medical center; exclusion criteria included history of thyroid disease or thyroidectomy, history of renal insufficiency, pregnancy, and other contrast administration within 1 year. Morning urine samples were taken before the scan for analysis and then every 2 weeks thereafter for 12 weeks. RESULTS The median baseline iodine level was 135 μg/L (range, 29-1680 μg/L), and median peak level was 552 μg/L (range, 62-6172 μg/L). Median time for urinary iodine level to normalize was 43 days, with 75% of subjects returning to baseline within 60 days, and 90% of subjects within 75 days. Baseline iodine level was a significant predictor of postcontrast iodine levels. Age, sex, weight, and estimated glomerular filtration rate were not significant. These results may be used for guidance on the timing of RAI use following contrast exposure. The practice at our institution is to wait 2 months and then check a 24-hour urinary iodine level. This alleviates concerns about contrast use in patients with thyroid carcinoma interfering with adjuvant radioiodine therapy.

Abstract 227: Aldosterone Antagonists in Post-Acute Myocardial Infarction Use, Predictors, and Temporal Trends of a Class I Recommendation

Objectives: To measure the use of guideline-recommended aldosterone antagonist therapy in eligible patients with post-MI and reduced ejection fraction (EF), temporal trends, and characteristics associated with use. Background: Current guidelines recommend the initiation of aldosterone antagonist therapy post-AMI for those with an EF ≤ 40% with heart failure or diabetes prior to hospital discharge, in the absence of contraindications. We explored the relationship between this Class IA recommendation issued in 2004 (STEMI)/2007 (NSTEMI) and its implementation into practice. Methods: Data from the AHA’s Get with the Guidelines-CAD national database were analyzed for 81,570 post-AMI patients from 219 hospitals between January 1, 2006 and December 29, 2009 of whom 11,255 (13.8%) were eligible for aldosterone antagonist therapy. Results: Among eligible patients, 1023 (9.1%) were prescribed an aldosterone antagonist at discharge. There was wide variation in use among hospitals (0% to 40.0) with no hospital treating even half their eligible patients. Patient and hospital characteristics independently associated with prescription of aldosterone antagonists were history of diabetes, heart failure, or coronary revascularization. Conversely, patients less likely to have an aldosterone antagonist prescribed had a history of renal insufficiency, were smokers, and had higher EF. Larger hospital size was associated with higher aldosterone antagonist use. Prescription of an aldosterone antagonist increased in the study population from 6.0% to 13.4% from January 2006 to December 2009 (p&lt;0.001). Conclusions: Fewer than one in ten post-MI patients eligible for an aldosterone antagonist, were discharged with this Class IA recommended therapy. Although rates of utilization are rising modestly over time, compliance continues to be extremely low. This discrepancy between evidence based therapy and actual prescribing patterns suggests the need for specific targeted performance improvement efforts.

Phase I Analysis of the Safety and Pharmacodynamics of the Novel Broad Spectrum Histone Deacetylase Inhibitor (HDACi) PCI-24781 in Relapsed and Refractory Lymphoma.

Abstract 2726Poster Board II-702 Background:PCI-24781 is a novel oral pan-HDACi with potent preclinical anti-tumor activity in lymphoma cell lines and models and has previously demonstrated safety and clinical benefit in solid cancers (Undevia et al, ASCO 2008). In lymphoma cell lines, PCI-24781 was causes increased oxidative stress and NF-κB inhibition that results in caspase-dependent apoptosis (Evens et al, Clin Ca Res 2009). Based in part on this encouraging pre-clinical data, a phase I/II clinical trial was designed for patients with relapsed/refractory lymphoma. Methods:The primary objective of the phase I component of this protocol was to determine the maximum tolerated dose (MTD) for testing in the phase II portion of the trial. PCI-24781 was given orally twice daily at escalating doses of 30–60mg/m2 on a 4-week cycle on two treatment schedules: 5 days/week x 3 weeks (schedule 1) or 7 days/week every other week (schedule 2). A standard 3+3 phase I dose escalation scheme was used. Tubulin and histone acetylation were measured in peripheral blood mononuclear cells (PBMCs). Data presented here consists of the completed phase I dose escalation component of the clinical trial. Results:25 pts enrolled with 7 pts continuing on treatment. The median age was 63 years, while the median number of prior treatments was 3. The histologies included: diffuse large B-cell lymphoma (DLBCL) (9), follicular lymphoma (FL) (4), Hodgkin lymphoma (3), CLL/SLL (2), mantle-cell lymphoma (2), nodal peripheral T-cell lymphoma (2), and cutaneous T-cell lymphoma (1). The best tolerated doses were 30 mg/m2 on schedule 1 and 45 mg/m2 on schedule 2, both with no adverse events (AEs) > grade 2. AEs ≥ grade 3 were thrombocytopenia (n=4) and diarrhea (n=1) and thus were dose limiting. One DLBCL pt with a history of renal insufficiency and renal involvement by lymphoma experienced a serious AE of renal failure, which was deemed possibly related to PCI-24781. Of note, no pericarditis, pericardial effusion, or QT prolongation were seen at any dose level of PCI-24781. Twelve pts were evaluable for response. Two confirmed responses have been seen (1 complete remission (CR), 1 partial remission (PR)), while six patients had stable disease (SD) with the median length of SD being 15 weeks (range, 6–17+). The longest duration of response (CR) was 8 cycles (32+ weeks). Both responses were seen in FL (2/4); one patient (PR) had received prior CHOP, R-ESHAP, and autologous transplant, while the other patient (CR) was rituximab-refractory and had failed 5 prior therapies. Pharmacodynamic monitoring revealed a dose-dependent increase in tubulin acetylation at 4 hours following the first dose, however this did not correlate with response or toxicity. Conclusion:PCI-24781 is a well tolerated pan-HDACi, including complete absence of prolonged QT abnormalities. Preliminary clinical benefit in heavily pre-treated relapsed/refractory lymphoma patients was documented in the phase I portion of this study. Accrual will continue to the phase II component of the clinical trial. Disclosures:Off Label Use: This is a non-FDA approved agent. Balasubramanian:Pharmacyclics: Employment. Sirisawad:Pharmacyclics: Employment. Mani:Pharmacyclics: Employment. Guerra:Pharmacyclics: Employment. Szakacs:Pharmacyclics: Employment. Loury:Pharmacyclics: Employment. Buggy:Pharmacyclics: Employment. Hamdy:Pharmacyclics: Employment, Equity Ownership.

Risk of acute renal failure among breast cancer patients and chemotherapy treatment of breast cancer patients with a history of renal insufficiency in a commercially-insured population in the United States

e22104 Background: Risk of acute renal failure (ARF) among breast cancer (BC) patients may increase with nephrotoxic chemotherapy and other exposures, but this risk is not well characterized. Furthermore, among patients who present with renal insufficiencies (RI) at cancer diagnosis, subsequent treatment patterns are not well described. Methods: We performed a retrospective cohort study using a large national commercial claims database. The cohort included all women diagnosed with BC from 2000 to 2007 who were 18–64 years at diagnosis with no history of cancer (n=13,296). We defined a diagnosis of BC as at least one inpatient or two outpatient claims more than 30 days apart with an ICD-9 code of 174. Among patients with no history of RI (n=13,150), we calculated the cumulative incidence (CI) of ARF_the proportion with at least one inpatient or two outpatient claims with an ICD-9 code of 584 or 586 in the first year following cancer diagnosis. Treatment for BC patients with a history of RI (n=146) was also assessed. Results: Among BC patients with no history of RI, 0.3% were diagnosed with ARF within a year after cancer diagnosis. The CI of ARF was higher in patients with metastases: 0.7% for any metastasis, 2.3% for bone metastasis, and 0.1% for no metastasis. The CI of ARF among patients undergoing radiation or mastectomy was similar to the overall rate (0.3%) but was higher in patients receiving nephrotoxic chemotherapy (1.0%) or intravenous bisphosphonates (IV BPs) (2.1%). The CI of ARF was higher in patients with congestive heart failure (1.4%), diabetes (0.9%), and/or hypertension (0.8%) at cancer diagnosis compared to patients without these comorbidities (0.2%). Among BC patients with a history of RI, 7.5% were administered nephrotoxic chemotherapy, 30.1% received potentially nephrotoxic chemotherapy, and 1.4% were given IV BPs. Conclusions: Breast cancer patients who present with comorbidities, develop metastases, or are given nephrotoxic chemotherapy or IV bisphosphonates are at higher risk of acute renal failure in the first year after breast cancer diagnosis. More research is warranted on the treatment of breast cancer patients with a history of renal insufficiency. [Table: see text]

Peritoneal Dialysis Masking Symptoms of an Insulinoma Uncovered During the Perioperative Period: A Case Report

A 61-year-old male with a chronic history of renal insufficiency treated with peritoneal dialysis (PD) was discovered to be asymptomatic for an occult insulinoma after peripheral revascularization. The patient's near continuous provision of glucose in the PD fluid acted to conceal symptoms of an insulinoma which was revealed when PD was interrupted. The patient had delayed emergence from general anesthesia resolving with glucose administration, precipitating insulinoma work up.

Glomerular hyperfiltration and metabolic syndrome: results from the FIrenze-BAgno A Ripoli (FIBAR) Study

Metabolic syndrome (MS) has been associated with microalbuminuria and kidney disease. In the present cohort study, different methods for the estimation of glomerular filtration rate (GFR) on the basis of serum creatinine were compared with respect to their association with MS and their predictive value for incident diabetes mellitus. The present analysis was performed on the cohort of subjects enrolled in the FIBAR study, a screening program for diabetes. GFR was estimated (eGFR) using three different methods: Cockroft-Gault (CG) formula, using actual body weight (CAW), CG formula using ideal body weight (CIW), and Modification of Diet in Renal Disease formula (M). The study was performed on 2,694 nondiabetic subjects, without history of renal insufficiency or serum creatinine at baseline >1.5 mg/dl. Mean follow-up was 27.8 +/- 11.5 months. Elevated eGFR, estimated with different methods, was associated with increased prevalence of most components of MS; however, an association between elevated clearance and MS was observed only when using CAW, which overestimates filtration in obese subjects. During follow-up, 40 new cases of diabetes were recorded (0.5/100 patient*years). After adjusting for age and sex, the HR (with 95% confidence intervals) for diabetes for patients in the highest quintile of eGFR was 1.14 [0.44-2.99], 0.89 [0.31-2.51], and 1.01 [0.42-2.41] for formula CAW, CIW, and M, respectively (all p > 0.7). Elevated eGFR, estimated through methods which do not produce a systematic overestimate in obese subjects, is not associated with the diagnosis of MS, and does not predict diabetes.

Pseudomonas aeruginosaSusceptible Only to Colistin in Intensive Care Unit Patients

Gram-negative bacilli, including multi-drug-resistant (MDR) Pseudomonas aeruginosa, are responsible for severe intensive care unit (ICU)-acquired infections, mainly pneumonia and bacteremia. The aim of this study was to determine the incidence of MDR strains of Pseudomonas in patients undergoing cardiac surgery, to elucidate the effectiveness of treating these patients with colistin, and to assess the safety of the drug. A prospective study was conducted among 1,452 patients who underwent surgery for a variety of cardiac lesions over a one-year period, and who spent a portion of the recovery period in the surgical ICU. Their case histories were analyzed to identify infectious complications. Diagnosis of infection was based on clinical data, and the pathogen was tested with respect to its susceptibility to colistin (polymyxin E). The clinical response to the antibiotic was evaluated. Over the 12-month period, among 115 infected patients, 15 were affected by strains of P. aeruginosa. In 10 patients, this pathogen proved resistant to all potentially active antibiotics except colistin. All of the affected patients were being ventilated mechanically, and eight of them presented with ventilator-associated pneumonia (VAP), whereas one patient suffered a deep incisional surgical site infection and bacteremia and the remaining patient had a superficial infection of a lower-extremity vein graft donor site. The MDR pathogen was introduced to the hospital by three patients transferred from three institutions. All patients were treated with intravenous colistin. In cases of VAP, aerosolized colistin was added. Deterioration of renal function occurred in three patients (30%), all of whom had a history of renal insufficiency. Cure or clinical improvement was observed in seven patients (70%), whereas four patients, including one who improved initially, developed sepsis and died with multiple organ dysfunction syndrome (mortality rate 40%). The increasing prevalence of MDR P. aeruginosa in ICU patients has rekindled interest in polymyxins, which had been abandoned because of toxic side effects. Colistin retained significant in vitro activity against this virulent organism, had an acceptable safety profile, and should be considered as a treatment option in critically ill patients with infection caused by MDR gram-negative bacilli. Aerosolized colistin may merit further consideration as a therapeutic intervention for patients with refractory pulmonary infections.