In-hospital Acute Renal Failure Research Articles

Comparative Evaluation of Intermountain Risk Score With Mehran Risk Score for Risk Estimation of Contrast-Induced Nephropathy and Short-Term Mortality in ST-Segment Elevation Myocardial Infarction Patients.

Contrast-induced nephropathy (CIN) has become one of the most important causes of in-hospital acute renal failure with the increasing use of contrast-mediated imaging tools. This significantly increases the morbidity and mortality of the affected subjects and causes a financial burden on the health system. In this context, prediction of CIN is important and some risk scores have been developed to predict CIN. The most frequently used and popular among these is the Mehran Score (MS), which is based on a number of hemodynamic and metabolic parameters. The Intermountain Risk Score (IMRS) is a recently developed risk score that highly predicts short-term mortality based on common laboratory parameters, and many parameters of this risk score have been found to be closely associated with CIN. In this context, we aimed to compare MS and IMRS in terms of CIN and short-term mortality estimation. The study included 931 patients who underwent percutaneous coronary intervention. CIN developed in 21.5% of patients. Both MS and IMRS independently predicted CIN. In receiver operating characteristic analysis, IMRS was found to be non-inferior to MS in predicting CIN and IMRS was superior to MS in predicting short-term mortality. IMRS and MS were independently associated with short-term mortality.

Isolated surgical tricuspid repair versus replacement: meta-analysis of 15 069 patients

ObjectivesTricuspid valve disease is increasingly encountered, but surgery is rarely performed in isolation, in part because of a reported higher operative risk than other single-valve operations. Although guidelines recommend valve...

Acute myocardial infarction in older adult patients

OBJECTIVES: To assess clinical and coronary angiographic characteristics, previous medical history, and clinical course, by age group, in older adults after myocardial infarction who underwent primary percutaneous coronary intervention (pPCI). METHODS: Single-center, cohort study that enrolled all patients with ST-segment elevation myocardial infarction who underwent pPCI at a specialized cardiology reference center in the South of Brazil. Older adults were defined as age ≥ 60 years, as set out in Brazilian legislation. Patients in the following age groups were compared: 60 to 64 years, 65 to 69 years, 70 to 74 years, 75 to 79 years, and ≥ 80 years. Patients’ clinical course was assessed at initial hospital admissions and after 2 years of clinical follow-up. Data were analyzed using SPSS 19, and significance was established at p < 0.05. RESULTS: From December 2015 to December 2018, a total of 636 patients were enrolled consecutively. Angiographic success rates were around 90% in all age groups. There were no differences in medications used, except for glycoprotein IIb/IIIa inhibitors, which were more frequently used in patients of lower age groups. Older patients had more in-hospital acute renal failure and higher in-hospital mortality. Predictors of mortality were age over 75, chronic renal failure, need for ventilatory support, severe arrhythmia, and sepsis. CONCLUSIONS: pPCI in older adult patients is a safe procedure with a high success rate.

Outcome Predictors in Patients Presenting With Acute Aortic Dissection.

To investigate the role of thyroid hormones and other factors in acute aortic dissection and an association with in-hospital adverse events. A retrospective analysis. A university-affiliated cardiac center. A total of 151 patients with aortic dissection admitted to the authors' hospital between January 2011 and May 2015. None. The total in-hospital mortality rate was 12.6%. Triiodothyronine (T3) level was lower in nonsurviving than surviving patients (0.8±0.3 v 1.0±0.4 nmol/L, p<0.05). T3 independently predicted in-hospital mortality (hazard ratio [HR] 0.07, 95% CI 0.01-0.43, p<0.01) and in-hospital acute renal failure (HR 0.22, 0.05-0.89, p<0.05) for all patients. Other independent predictors of in-hospital mortality were pericardial effusion (HR 8.18, 2.11-31.67, p<0.01), conservative treatment (HR 82.12, 12.49-540.09, p<0.01) and Stanford type-A aortic dissection (HR 3.86, 1.06-14.09, p<0.05). Inpatient conservative treatment, T3 (HR 0.01, 0.00-0.18, p<0.01) as well as pericardial effusion (HR 11.80, 2.46-56.59, p<0.01), Stanford type-A dissection (HR 22.35, 3.15-158.40, p<0.01), and in-hospital acute renal failure (HR 16.95, 2.04-140.86, p<0.01) were predictors for in-hospital mortality. In nonconservatively treated patients, T3 (HR 0.02, 0.00-0.88, p<0.05) as well as cardiac care unit stay (HR 0.74, 0.59-0.94, p<0.01) and postoperative acute renal failure (HR 21.32, 3.07-147.88, p<0.01) were predictors for in-hospital mortality. T3 was downregulated in acute aortic dissection. Low T3 level was a risk factor for in-hospital death and acute renal failure in patients with acute aortic dissection.

Are we still wondering or wandering in the dark?

Acute renal failure (ARF) or acute kidney injury (AKI), especially superimposed in a chronic renal failure patient can detrimentally and terminally unbalanced a hardly maintained physiologic function, determining the dialysis for that patient. Otherwise, the acute phenomenon, possibly self limited, can acutely affect a relatively healthy patient, as well as compromising the renal function [1]. It is not uncommon as well that the patients with chronic renal failure would also be the one requiring radiology or cardiology studies involving contrast. Besides several measures have been taken, several strategies and protocols have been applied, the ‘‘evidences’’ are still uncertain. In the age of evidences and certainties, how could we possibly intervene with a clinical common sense? Contrast-induced nephropathy (CIN) is reported to occur in as many as 14.5% of unselected patients undergoing coronary angiography/intervention [2], and is the third most common cause of in-hospital acute renal failure after hypotension and surgery [3]. Important risk factors for CIN include pre-existing renal dysfunction, especially that due to diabetic nephropathy, reduced circulating volume, the volume and type of contrast agent employed, and concomitant administration of potentially nephrotoxic drugs [4, 5]. Several agents have been proposed to provide prophylaxis against CIN [6]. However, until recently, only saline hydration (1 ml/kg 0.45% saline for 12 h preand post-contrast exposure has been confirmed to be effective) [5]. The precise mechanisms leading to CIN remain a matter of debate, although the root of the problem appears to be an injury to the renal medulla resulting from a combination of reduced blood flow, an osmotic effect, and direct tubular toxicity [7, 8]. The last of these may be a direct result of toxic free radical release, which occurs after contrast administration. Acetylcysteine (NAC), an antioxidant, has been advocated for a while in addition to saline hydration in preventing CIN [9, 10], although this has not been a universal finding [11, 12]. Successful protocols tested to-date require the initiation of therapy on the day before contrast exposure, precluding the treatment of same-day and emergency patients. However, different protocols and administration routes have been used, but systematic reviews failed to find a definitive answer whether the practice is effective to be justified. While the recommendations of using NAC and ascorbic acid are based on the proposed lack of evidenced efficacy that may be limited to the high risk population only. The management is clinically simple and could still present a benefit without any evident safety concern for the patients. In the current study of Calabro et al. [13], investigators found a reduction in the incidence of CIN, confirming previous results of a high risk population [14] in the low risk patients (no diabetes, age \65 and no creatinine greater than 1.4 mg/dL). Raw numbers for their studies are, respectively, 6.7% in the initial retrospective study, an with incidence of CIN of 4.4% in the treatment high risk group versus 9.8% in the non-treated low risk group, and 7.1% in the prospective observational study using a historical control, with an D. Cattano (&) Department of Anesthesiology, The University of Texas Medical School at Houston, Houston, USA e-mail: davide.cattano@uth.tmc.edu

Risk for Contrast Nephropathy in Patients Undergoing Coronarography

Among the causes of in-hospital acute renal failure, contrast-induced nephropathy ranks third in prevalence. Although it represents a condition of renal impairment with spontaneous recovery, contrast nephropathy should always be considered, because it prolongs hospitalization and it may become a severe complication requiring dialysis. The purposes of this study are: (i) to determine if the application of the most effective contrast-induced nephropathy prevention strategies in the Cardiology Intensive Care Unit can prove to be successful in reducing nephropathy risk; and (ii) to identify which of the involved risk factors persist after the preventive treatment. We examined the patients who had a coronarography at the Bentivoglio hospital from April 2007 to April 2008 who required at least 3 days of permanence in hospital due to the presence of potential risk factors; 136 out of 784 patients were included. Among the selected patients, 21 (15.44%) developed a renal impairment compatible with contrast-induced nephropathy. The risk factors that seemed to display the best correlation with risk of contrast nephropathy were advanced age and an ventricular failure (ejection fraction <40%); however, the critical condition did not appear to be due to a single risk factor, but it resulted from the association of more contextual risk factors. Particularly, the concomitant presence of ventricular failure, anemia, diabetes, previous myocardial infarction and advanced age (>70 years) determined a threefold increased risk of contrast nephropathy. Our data suggest that the development of contrast nephropathy following coronarography is associated with worse renal function during hospitalization and at discharge.

Preditores e impacto clínico intra-hospitalar do sangramento associado à intervenção coronária percutânea

INTRODUÇÃO: O sangramento associado à intervenção coronária percutânea (ICP) é uma complicação frequente e muitas vezes negligenciada quanto a sua importância prognóstica. Diversos estudos têm demonstrado o impacto clínico adverso do sangramento, principalmente no aumento da mortalidade a curto e longo prazos. O objetivo deste estudo é avaliar os preditores e o impacto clínico do sangramento em uma grande coorte contemporânea de pacientes submetidos a ICP. MÉTODOS: Avaliamos 2.892 pacientes consecutivos submetidos a ICP eletiva ou de urgência, entre janeiro de 2008 e junho de 2009, em um centro de referência para a realização do procedimento. Foram comparados os grupos que apresentaram ou não sangramento em relação às variáveis clínicas, angiográficas e relacionadas à intervenção, bem como a evolução clínica intrahospitalar. Regressão logística múltipla foi realizada com a finalidade de determinar o grau de influência e independência dos fatores preditores de sangramento. RESULTADOS: A incidência de sangramento periprocedimento foi de 1,7%. Considerando-se apenas os pacientes com síndrome coronária aguda (SCA), a incidência elevou-se para 3,4%. A análise multivariada identificou, como fatores independentes de sangramento, SCA [odds ratio (OR) 3,96, intervalo de confiança de 95% (IC 95%) 1,45-11,42], utilização de inibidores de glicoproteína IIb/IIIa (OR 2,55, IC 95% 1,68-3,87), insuficiência renal crônica (OR 2,34, IC 95% 1,11-3,49), Killip IV (OR 2,32, IC 95% 1,54-3,5) e acesso vascular por via femoral (OR 1,72, IC 95% 1,19-3,14). O sangramento periprocedimento foi associado com insuficiência renal aguda (16,7% vs. 1,6%; P < 0,001) e mortalidade no período intra-hospitalar (10,4% vs. 0,7%; P < 0,001). CONCLUSÕES: O presente estudo demonstra que o sangramento periprocedimento, mais frequentemente observado em pacientes com SCA, é preditor de eventos clínicos adversos maiores no período intra-hospitalar, incluindo maior mortalidade.

Predictors of One-Year Disability and Death in Chinese Hospitalized Women after Ischemic Stroke

Background and Purpose: Women have a worse functional outcome after stroke, but the specific factors associated with a poor outcome in women are rarely reported. This study was designed to investigate the clinical predictors of 1-year disability and death in women after ischemic stroke. Methods: Patients with ischemic stroke consecutively registered from March 2002 to July 2007 were followed prospectively for 1 year. Multivariate regression models were employed to analyze predictors of disability (defined as modified Rankin scale score, mRS, 3–5 ) and death. Results: A total of 2,774 ischemic stroke patients were included with 1,119 (40.3%) females (mean age 65 ± 13.5 years). Among female patients, disability (mRS 3–5) is 1.68-fold higher and case fatality is 1.23-fold higher than in men at the 1-year follow-up. Diabetes is an independent predictor of 1-year disability among women (odds ratio, 1.56; 95% confidence interval, CI, 1.01–2.39). In-hospital acute renal failure (hazard ratio, HR, 7.26; 95% CI, 3.47–5.19), suboptimal antiplatelets (HR, 0.55; 95% CI, 0.37–0.83) and antihypertensive therapy (HR, 0.61; 95% CI, 0.42–0.90) are associated with death at 1 year after stroke among women. Conclusions: The present study indicates that diabetes, in-hospital acute renal failure, suboptimal antiplatelets and antihypertensive therapy are the possible explanations for the poor 1-year outcome of women hospitalized with ischemic stroke.

Sodium bicarbonate-based hydration prevents contrast-induced nephropathy: a meta-analysis

BackgroundContrast-induced nephropathy is the leading cause of in-hospital acute renal failure. This side effect of contrast agents leads to increased morbidity, mortality, and health costs. Ensuring adequate hydration prior to contrast exposure is highly effective at preventing this complication, although the optimal hydration strategy to prevent contrast-induced nephropathy still remains an unresolved issue. Former meta-analyses and several recent studies have shown conflicting results regarding the protective effect of sodium bicarbonate. The objective of this study was to assess the effectiveness of normal saline versus sodium bicarbonate for prevention of contrast-induced nephropathy.MethodsThe study searched MEDLINE, EMBASE, Cochrane databases, International Pharmaceutical s database, ISI Web of Science (until 15 December 2008), and conference proceedings for randomized controlled trials that compared normal saline with sodium bicarbonate-based hydration regimen regarding contrast-induced nephropathy. Random-effects models were used to calculate summary odds ratios.ResultsA total of 17 trials including 2,633 subjects were pooled. Pre-procedural hydration with sodium bicarbonate was associated with a significant decrease in the rate of contrast-induced nephropathy (odds ratios 0.52; 95% confidence interval 0.34–0.80, P = 0.003). Number needed to treat to prevent one case of contrast-induced nephropathy was 16 (95% confidence interval 10–34). No significant differences in the rates of post-procedure hemodialysis (P = 0.20) or death (P = 0.53) was observed.ConclusionSodium bicarbonate-based hydration was found to be superior to normal saline in prevention of contrast-induced nephropathy in this updated meta-analysis.

No Increased Risk for Contrast-Induced Nephropathy after Multiple CT Perfusion Studies of the Brain with a Nonionic, Dimeric, Iso-Osmolal Contrast Medium

Contrast-induced nephropathy (CIN) is one of the most common causes of in-hospital acute renal failure. The aim of this study was to assess the risk for CIN after repeated administration of the nonionic, dimeric, iso-osmolal contrast agent iodixanol regardless of pre-existing renal function. Changes in serum creatinine (SCr) levels were compared with those of control subjects who did not receive iodinated contrast media (CM). Between January 2005 and March 2007, a total of 100 consecutive patients were prospectively included. Patients underwent a CT perfusion (CTP) study of the brain from clinical signs of acute cerebral infarction. CTP was performed with an intravenous bolus of 60 mL of iodixanol-270. Precontrast and postcontrast SCr levels were obtained, and the CTP study was repeated within 32 hours and postcontrast SCR was assessed. The control group consisted of 100 patients scheduled for plain cranial CT examination, who were not exposed to iodinated CM. Mean baseline SCr level was 0.96 +/- 0.35 mg/dL in the contrast group and 1.14 +/- 0.74 mg/dL in the control group. After repeated administration of CM, a total of 7 patients had a relative increase of greater than or equal to 25% compared with baseline. In the control group, a relative increase of 25% or more was seen in 12 patients. The difference in the incidence of the rise in SCr of >25% was not significantly different (P = .094). Multiple contrast-enhanced studies with intravenously administered iodixanol are not associated with a higher risk for CIN compared with a control group receiving no CM.

Incidência, preditores e impacto clínico dos sangramentos maiores associados à intervenção coronária percutânea

INTRODUÇÃO: O sangramento associado ao periprocedimento é uma das complicações mais freqüentes da intervenção coronária percutânea (ICP). O objetivo deste estudo foi avaliar a incidência, os preditores de sangramento maior e o impacto deste nos eventos adversos após ICP. MÉTODO: Realizada análise retrospectiva de 8.739 pacientes consecutivos submetidos a ICP eletiva no período de junho de 1997 a fevereiro de 2008. Comparamos os pacientes que apresentaram ou não sangramento maior (grupos SM e NSM, respectivamente) em relação às características clínicas e angiográficas e do procedimento, e a evolução intra-hospitalar e tardia. RESULTADOS: Sangramento maior ocorreu em 1,6% dos pacientes. O modelo de regressão logística múltipla identificou como fatores preditores independentes de sangramento maior associado à ICP: sexo feminino, idade, cirurgia de revascularização miocárdica prévia e uso dos inibidores da glicoproteína IIb/IIIa. O sangramento maior periprocedimento foi preditor independente de insuficiência renal aguda, infarto agudo do miocárdio (IAM) e óbito na fase hospitalar e de IAM na fase tardia. CONCLUSÃO: Este estudo demonstra que o sangramento maior associado periprocedimento é preditor independente de eventos adversos nas fases precoce e tardia pós-ICP.

Similar low rate of contrast induced nephropathy compared to a control group using Iodixanol for repeated Cerebral Perfusion Computed tomography in case of suspected brain ischemia

Ziele: Contrast-induced nephropathy is one of the most common causes of in-hospital acute renal failure. In case of suspected brain ischemia, CT perfusion imaging allows to rapidly depict the salvageable tissue at risk. The aim of this study was to assess the risk of contrast-induced nephropathy (CIN) after repeated administration of the dimeric, iso-osmolal contrast agent iodixanol for cerebral perfusion CT regardless of preexisting renal function. Changes in serum creatinine (SCr) are compared to a control group that did not receive iodinated contrast media. Methode: Between January 2005 and March 2007, 100 consecutive patients were prospectively included. Patients underwent a CT perfusion (CTP) study of the brain due to clinical signs of acute cerebral infarction. CTP was performed with an IV bolus of 60ml iodixanol 270. Pre- and postcontrast SCr levels were obtained and the CTP study was repeated within 32 hours and postcontrast SCR was assessed. Ergebnis: All patients were included in the final analysis. Mean baseline SCr was 85µmol/l ±33.63µmol/l in the contrast group and 109µmol/l ±85µmol/l in the control group.