Mild Renal Insufficiency Research Articles

Effects of chronic renal insufficiency and anemia upon long-term outcomes in patients undergoing percutaneous coronary intervention

To assess whether chronic renal insufficiency and anemia are significant independent and combined predictors of poor long-term outcomes after percutaneous coronary intervention (PCI). We examined the clinical and outcome data of 3770 PCI patients based on the pre-PCI values of glomerular filtration rate (GFR) and hemoglobin (Hb). Depending on their baseline GFR and Hb, the patients were classified into six groups: normal renal function with anemia or not; mild renal impairment with combined anemia or not; severe renal insufficiency with anemia or not. The clinical features and prognosis of patients were compared. Significant differences were found between the groups regarding female gender, age, body mass index, prior history of hypertension, diabetes mellitus, prior stroke, acute coronary syndrome, systolic blood pressure, left ventricular ejection fraction, total serum cholesterol, LDL-C and angiographic features (P < 0. 01). When evaluated as continuous variables, GFR and Hb were independent predictors of long-term mortality after adjusting for effects of each other (GFR: HR 0.979, 95% CI 0.960-0.999, P = 0.035; Hemoglobin: HR 0.952, 95% CI 0.921-0.984, P = 0.004). Mild renal insufficiency with anemia (HR 4.123, 95% CI 1.637-10.386, P = 0.003), severe renal insufficiency without anemia (HR 5.287, 95% CI 1.627-17.183, P = 0. 006) and severe renal insufficiency with anemia (HR 7.134, 95% CI 2.180-23.342, P = 0.001) having a statistically significant decrease in survival in patients undergoing PCI . Renal insufficiency and anemia are significant independent and combined predictors of long-term mortality in patients undergoing PCI.

Unexpected interaction between quetiapine and valproate in patients with bipolar disorder

Quetiapine, a second-generation antipsychotic originally used in the treatment of schizophrenia, was also found to be effective as monotherapy or as an adjunctive therapy for acute mania. Delirium in patients treated with quetiapine seems to be a rare phenomenon; however, we report two patients with bipolar disorder who developed delirium when prescribed quetiapine as an adjunct to valproate for acute mania. Both had previously developed mild renal insufficiency after an episode of lithium intoxication. The delirium resolved after quetiapine was discontinued. Unexpected interactions may occur when medications are combined without being subject to controlled clinical trials.

Livedo, dementia, thrombocytopenia, and endotheliitis without antiphospholipid antibodies: Seronegative antiphospholipid-like syndrome

We report a 51-year-old woman who presented with dementia, livedo racemosa, polyarthralgia, mild renal insufficiency, proteinuria, and thrombocytopenia. Cutaneous and renal biopsy specimens both showed an identical specific occlusive arteriolopathy consistent with Sneddon syndrome and antiphospholipid syndrome. However, no antiphospholipid antibodies were detected and we, therefore, diagnosed seronegative antiphospholipid-like syndrome. We discuss the nosology of this entity and its association with non-antiphospholipid antibody-related Sneddon syndrome. The common denominator of Sneddon syndrome and antiphospholipid syndrome with or without antiphospholipid antibodies seems to be the endothelial damage and occlusive arteriolopathy. Skin biopsy is useful to confirm the diagnosis of seronegative antiphospholipid-like syndrome.

Renal function evolution in cancer patients. Results of the IRMA-2 study

e20574 Background: In 2007, the IRMA-1 study reported the high prevalence of renal insufficiency (RI) in cancer patients. Because of this high frequency, the IRMA-2 study started to investigate the evolution of renal function in cancer patients. Methods: Data were collected for cancer patients presenting at one of the 19 IRMA-2 centers in March 2005. Data included: sex, age, weight, serum creatinine (SCR), haemoglobinemia, type of tumour, metastasis (bone and/or visceral) anticancer drugs. Dialysis, myeloma and lymphoma patients were not included. Glomerular filtration rate was estimated with the abbreviated RD (aRD) formula at the inclusion. Patients were retrospectively followed during 2 years after the inclusion, every 6 months, from March 2005 (T0) to March 2007 (T24). Results: 4945 cancer patients (breast 1816, colorectal 747, lung 463, ovarian 294, prostate 251) were included in 19 cancer centre in France. Median age 60.0, mean weight 66.2, 62.8% were women. Mean GFR decreased from 90.8 ml/min/1.73m2 to 83.7 over the two years (table). Meanwhile, the prevalence of RI increased, reaching 62.9% and 17.5% for a GFR&lt;90 and &lt;60, respectively at T24 (table). Among the 4945 patients, 193 (7.6% of the 2525 patients who were alive at the end of the study) had a SCR determination at each time point. Among the 641 patients with a SCR at T0 and at T24, 41.6% of those with a GFR&gt;=90 at T0 had a GFR&lt;90 at T24. Furthermore, 17.7% of patients with mild renal insufficiency (60 to 90) at T0 had a GFR&lt;60 at T24. Conclusions: IRMA-2 shows that renal function decreases rapidly in cancer patients with a loss in GFR of more than 3.5 mL/min/1.73m2 per year. This suggests that cancer patients are more exposed to a deterioration of renal function and that it should be closely monitored with at least a regular estimation of renal function, for instance every 6 months. So far, such a follow-up is not performed in clinical practice. Furthermore, drug therapy should be reevaluated, dosages adjusted when necessary, and some potentially nephrotoxic drugs changed for less or non-nephrotoxic drugs if possible. No significant financial relationships to disclose.

Les valves de l’urètre postérieur. État des lieux en Languedoc-Roussillon de 1998 à 2007 : données anténatales, néonatales et devenir à moyen terme

To evaluate the impact of prenatal diagnosis on the epidemiology and outcome of children with posterior urethral valves (PUV), considering that today termination of pregnancy may be proposed in the most severe cases. Forty-three cases of patients with PUV were diagnosed between 1998 and 2007 in the Languedoc-Roussillon region. In this study, we detailed the prenatal data and postnatal outcome of those patients with a mean follow-up period of 7.6 years. Medical interruption of pregnancy was performed in 15 severe cases. One death in utero was also observed. Twenty-seven patients were managed postnatally and one child died during the neonatal period because of lung hypoplasia. For the 26 remaining patients at the end of the follow-up period, 5 had mild renal insufficiency with a creatinine clearance calculated with the Schwartz formula of less than 80 ml/min/1.73 m2. One reached end-stage renal failure at the age of 7 years. Proteinuria and hypertension were rare. Today, because of the increase in medical termination of pregnancy in the most severe cases, most of the children born alive with PUV experienced a better renal prognosis when compared with previous data. Prenatal diagnosis and therapeutic progress significantly modified the epidemiology and outcome of this disease. Nevertheless, the best predictor of renal outcome remains renal function at 1 year of age.

This Month in Anesthesiology

In this observational study, investigators measured the prevalence of preoperative anemia in noncardiac surgery patients and assessed the relationship between preoperative anemia and postoperative mortality. Data were retrospectively collected on 7,759 consecutive noncardiac surgical patients between 2003 and 2006. The relationship between preoperative anemia and postoperative mortality was assessed using logistic regression and propensity analyses. Preoperative anemia was common and equal between genders. After adjustment for major confounders, anemia was associated with increased mortality (odds ratio = 2.36, 95% confidence interval = 1.57–3.41). The authors propose that treatment of preoperative anemia should be the focus of investigations for the reduction of perioperative risk.Investigators sought to identify the incidence, risk factors, and mortality impact of acute kidney injury (AKI) after general surgery using a national clinical dataset. The primary outcome was AKI within 30 days after surgery. The authors identified 11 independent preoperative predictors: age greater than or equal to 56 yr, male gender, emergency surgery, intraperitoneal surgery, diabetes mellitus requiring oral therapy, diabetes mellitus requiring insulin therapy, active congestive heart failure, ascites, hypertension, mild preoperative renal insufficiency, and moderate preoperative renal insufficiency. From these data, the authors developed a risk index that is predictive of AKI after general surgery so that trials attempting to reduce this risk can be conducted. See the accompanying Editorial View on page 449 Surgical site infections (SSIs) increase morbidity, mortality, length of hospital stay, and costs. The authors sought to identify modifiable risk factors associated with SSI after spinal surgery. Medical records from 104 patients with SSI were compared with 104 randomly selected control patients without SSI. Multivariate analysis identified independent risk factors for SSI including prolonged procedure duration, American Society of Anesthesiologists score of 3 or greater, lumbar-sacral operative level, posterior approach, instrumentation, obesity, razor shaving before surgery, and intraoperative inspired oxygen concentration of less than 50%. The authors propose that administration of at least 50% inspired oxygen should be tested prospectively as an intervention to prevent SSI after spinal surgery.The clinical safety and outcome of intensive insulin therapy compared with conventional insulin therapy was investigated in patients receiving postoperative intensive care after brain surgery. Four hundred and eighty three patients were prospectively and randomly assigned either to intensive insulin therapy or to conventional insulin therapy. Median hypoglycemic episodes were more frequent in patients receiving intensive insulin therapy (8 vs. 3). However, the length of stay in the intensive care unit (ICU) was shorter (6 vs. 8 days) and the infection rate was less (25.7% vs. 39.3%). Glasgow outcome scale score and overall survival at 6 months were similar. This study showed intensive insulin therapy in neurosurgical ICU patients after brain surgery is associated with iatrogenic hypoglycemia but appears to decrease infection rate and ICU stay. See the accompanying Editorial View on page 456 This Practice Advisory focuses on magnetic resonance imaging settings where anesthetic care is provided.The Functional Recovery Index questionnaire will be a good instrument for assessing recovery of ambulatory surgical patients.Challenges in informed consent influence anesthesiologists' views of current and future patients, their practice, their profession, and themselves. See the accompanying Editorial View on page 445 Current concepts on the pathogenesis of ventilator-associated pneumonia in relation to the endotracheal tube are reviewed.

Development and Validation of an Acute Kidney Injury Risk Index for Patients Undergoing General Surgery

The authors sought to identify the incidence, risk factors, and mortality impact of acute kidney injury (AKI) after general surgery using a large and representative national clinical data set. The 2005-2006 American College of Surgeons-National Surgical Quality Improvement Program participant use data file is a compilation of outcome data from general surgery procedures performed in 121 US medical centers. The primary outcome was AKI within 30 days, defined as an increase in serum creatinine of at least 2 mg/dl or acute renal failure necessitating dialysis. A variety of patient comorbidities and operative characteristics were evaluated as possible predictors of AKI. A logistic regression full model fit was used to create an AKI model and risk index. Thirty-day mortality among patients with and without AKI was compared. Of 152,244 operations reviewed, 75,952 met the inclusion criteria, and 762 (1.0%) were complicated by AKI. The authors identified 11 independent preoperative predictors: age 56 yr or older, male sex, emergency surgery, intraperitoneal surgery, diabetes mellitus necessitating oral therapy, diabetes mellitus necessitating insulin therapy, active congestive heart failure, ascites, hypertension, mild preoperative renal insufficiency, and moderate preoperative renal insufficiency. The c statistic for a simplified risk index was 0.80 in the derivation and validation cohorts. Class V patients (six or more risk factors) had a 9% incidence of AKI. Overall, patients experiencing AKI had an eightfold increase in 30-day mortality. Approximately 1% of general surgery cases are complicated by AKI. The authors have developed a robust risk index based on easily identified preoperative comorbidities and patient characteristics.

Lack of a Clinically Important Effect of Moderate Hepatic Insufficiency and Severe Renal Insufficiency on Raltegravir Pharmacokinetics

Raltegravir is a human immunodeficiency virus type 1 integrase strand transfer inhibitor with potent activity in vitro and in vivo. Raltegravir is primarily cleared by hepatic metabolism via glucuronidation (via UDP glucuronosyltransferase 1A1), with a minor component of elimination occurring via the renal pathway. Since the potential exists for raltegravir to be administered to patients with hepatic or renal insufficiency, two studies were conducted to evaluate the influence of moderate hepatic insufficiency (assessed by using the Child-Pugh criteria) and severe renal insufficiency (creatinine clearance, <30 ml/min/1.73 m(2)) on the pharmacokinetics of raltegravir. Study I evaluated the pharmacokinetics of 400 mg raltegravir in eight patients with moderate hepatic insufficiency and eight healthy, matched control subjects. Study II evaluated the pharmacokinetics of 400 mg raltegravir in 10 patients with severe renal insufficiency and 10 healthy, matched control subjects. All participants received a single 400-mg dose of raltegravir in the fasted state. In study I, the geometric mean ratios (GMR; mean value for the group with moderate hepatic insufficiency/mean value for the healthy controls) and 90% confidence intervals (CIs) for the area under the concentration-time curve from time zero to infinity (AUC(0-infinity)), the maximum concentration of drug in plasma (C(max)), and the concentration at 12 h (C(12)) were 0.86 (90% CI, 0.41, 1.77), 0.63 (90% CI, 0.23, 1.70), and 1.26 (90% CI, 0.65, 2.43), respectively. In study II, the GMRs (mean value for the group with renal insufficiency/mean value for the healthy controls) and 90% CIs for AUC(0-infinity), C(max), and C(12) were 0.85 (90% CI, 0.49, 1.49), 0.68 (90% CI, 0.35, 1.32), and 1.28 (90% CI, 0.79, 2.06), respectively. Raltegravir was generally well tolerated by patients with moderate hepatic or severe renal insufficiency, and there was no clinically important effect of moderate hepatic or severe renal insufficiency on the pharmacokinetics of raltegravir. No adjustment in the dose of raltegravir is required for patients with mild or moderate hepatic or renal insufficiency.

Evaluation of Renal Function of Angiomyolipoma Patients After Selective Transcatheter Arterial Embolization

BackgroundAngiomyolipoma patients may have renal insufficiency before selective transcatheter arterial embolization (TAE) or may undergo subsequent surgery after TAE. Therefore, this retrospective study examined our experience with TAE or TAE and subsequent surgery on renal function of angiomyolipoma patients with and without preexisting renal insufficiency. Methods25 patients who had undergone TAE for renal angiomyolipoma over a 7-year period were reviewed. The 25 patients were grouped according to whether or not they had undergone further surgery. Preexisting renal insufficiency was compared between the 2 groups. The TAE and surgery group was further subdivided into 2 subgroups according to total nephrectomy or not. The TAE-alone group was further subdivided into 2 subgroups by presence of preexisting renal insufficiency or not. In each group and subgroup, pre-TAE and post-TAE renal function, including serum creatinine and creatinine clearance were compared. ResultsTAE rather than TAE and surgery was more likely chosen in the presence of preexisting renal insufficiency (6/13 versus 1/12, P=0.035). In TAE-alone patients, no statistical differences were noted between serum creatinine and creatinine clearance before and after TAE. Conversely, TAE and surgery patients who had undergone total nephrectomy rather than nephron-sparing surgery differed significantly in preand post-TAE serum creatinine (0.77 versus 1.07, P=0.014) and creatinine clearance (98.1 versus 70.7, P=0.032). ConclusionsThis study demonstrated that TAE alone for treating renal angiomyolipomas was able to preserve renal function, despite the presence of mild preexisting renal insufficiency. Conversely, surgery after TAE, particularly total nephrectomy, should be avoided whenever possible.

Preventing contrast-induced nephropathy in patients with baseline renal dysfunction undergoing coronary angiography

Although contrast-induced nephropathy (CIN) is usually self-limited, it may cause permanent renal injury and even lead to long-term dialysis in patients with preexisting renal impairment. Cardiologists face a dilemma as to whether to alleviate coronary syndromes by coronary intervention or to risk CIN in these patients. Strategies to prevent CIN, including hydration, use of low-osmolal or iso-osmolal contrast media, administration of N-acetylcysteine, and blood purification procedures, were proposed to be effective; however, there are conflicting results. Recently, we found that prophylactic hemodialysis could significantly improve renal survival in patients with advanced renal insufficiency undergoing coronary angiography in a randomized controlled trial. In these patients, fluid supplementation is poorly tolerated and impractical, especially in those with poor heart function. However, the routine use of prophylactic hemodialysis in patients with mild renal insufficiency requires further investigation.

The profile of renal function over time in a cohort of pediatric heart transplant recipients

To assess the burden over time of renal dysfunction in pediatric heart transplant patients using an objective measure on an annual basis for serial comparison. GFR was measured at regular interval by nuclear medicine scintigraphy. Results were analyzed in relation to age, time post-transplantation, gender, and average calcineurin-inhibitor dose for the first two months post-transplantation. Results were compared with cGFR using the Schwartz equation. A total of 91 patients (56 males) transplanted between 1990 and 2004 underwent 373 GFR measurements. Median age at transplantation was 3.3 yr (birth - 17.8). Median first GFR at 0.7 yr (0.1-4.1) post-transplant was normal (94 mL/kg/1.73 m(2)). Freedom from at least mild renal insufficiency was 84% and 33% at one and five years post-transplant. Females had better renal function early post-transplant (GFR 105 mL/min/1.73 m(2)) but an increased probability of an abnormal GFR over time. Higher calcineurin inhibitor dose in the first two months post-transplantation was associated with an increasing probability of an abnormal GFR over time. The cGFR overestimated the measured GFR by 33 +/- 26 mL/kg/1.73 m(2). Renal insufficiency is an important morbidity after pediatric transplantation with the majority of patients experiencing at least mild renal dysfunction. Calculated GFR significantly underestimates the burden of renal insufficiency in this patient population.

A Phase II intra‐patient dose‐escalation trial of weight‐based darbepoetin alfa with or without granulocyte‐colony stimulating factor in myelodysplastic syndromes

This Phase II study evaluated darbepoetin alfa (DA) in 24 patients with predominantly low or intermediate-1 risk myelodysplastic syndrome (MDS). Intra-patient dose escalation of DA was undertaken in three 6-week dose cohorts until a major erythroid response was achieved: 4.5 mcg/kg/week, 9 mcg/kg/week, and 9 mcg/kg/week plus granulocyte-colony stimulating factor (G-CSF) 2.5 mcg/kg twice weekly. Patients with refractory anemia with ringed sideroblasts (RARS) commenced DA at 9 mcg/kg/week. The weight-based dosing regimen translated into a median starting DA dose of 390 mcg/week. Erythroid responses were observed in 16/24 patients (67%; 12 major and 4 minor), with a median response duration of 11 months in major responders. Addition of G-CSF generated a major erythroid response in 7/15 patients (47%) who suboptimally responded to DA alone. DA was well tolerated, except for worsening of baseline mild hypertension and renal insufficiency in one patient with diabetes. IPSS score <0.5 and RBC transfusions <2 units/month increased the probability of an erythroid response. A minority of subjects (12%) developed low-level non-neutralizing anti-DA antibodies. Our data indicate that weekly weight-based dosing of DA, with the addition of G-CSF in selected individuals, can be an effective erythropoietic option in a high proportion of lower-risk MDS patients.

Interventional therapy of coronary artery disease in China: retrospective and perspective

Interventional therapy of coronary artery disease in China: retrospective and perspective

Abstract 3116: Subclinical Coronary Atherosclerosis Detected by Coronary CT Angiography in Asymptomatic Population with and without Mild Renal Insufficiency

BACKGROUND The prevalence of coronary artery disease (CAD) increased in patients with moderate to severe renal insufficiency. The impact of renal insufficiency on the development of CAD may increase as renal function continues to deteriorate, however, there is no data available in mild renal insufficiency. The purpose of this study was to explore the association between mild renal insufficiency and coronary atherosclerosis, using coronary CT angiography (CCTA). METHODS We consecutively enrolled 4984 asymptomatic subjects (mean age 49 ± 10 years, 61% male), who underwent CCTA (64-slice MDCT) as part of a general health evaluation. We categorized subjects based on their estimate of renal function (estimated glomerular filtration rate (eGFR), using MDRD equation: ≥ 60 vs. 45 to 59 ml/min/1.73 m 2 ). Patients with eGFR less than 45 ml/min/1.73 m 2 were excluded. Coronary artery calcium score (CACS), presence of plaque, and significant stenosis (≥ 50% lumen diameter) were compared between 2 groups. Regression analysis was performed to assess the correlation between CAD and mild renal insufficiency. RESULTS Three hundreds forty-two subjects (7%) had mild renal insufficiency (eGFR: 45 to 59) and 4642 (93%) had normal renal function (eGFR: ≥ 60 ml/min/1.73 m 2 ). Subjects with mild renal insufficiency showed higher incidence of CAD (124 (36%) vs. 1039 (22%), p&lt;0.001) and significant stenosis (31 (9%) vs. 147 (3%), p&lt;0.001). However, after adjusting conventional risk factors, mild renal insufficiency was no longer an independent risk factor for the presence of CAD and significant stenosis. Furthermore, after age and sex-matching, there was no significant difference in incidence of moderate to severe (≥ 100) CACS (44 (13%) vs. 39 (12%), p=0.64), CAD (122 (36%) vs. 114 (34%), p = 0.57), and significant stenosis (11 (9%) vs. 9 (6%), p = 0.19) between 2 groups. CONCLUSIONS The higher incidence of CAD and significant stenosis in subjects with mild renal insufficiency was observed, however, which are primarily attributed to the effect of other conventional risk factors. Mild renal insufficiency may not act as an independent risk factor for coronary atherosclerosis.

Is preoperative serum creatinine a reliable indicator of outcome in patients undergoing coronary artery bypass surgery?

Evaluating renal function by calculating creatinine clearance as an alternative measure to serum creatinine may give a better estimation of postoperative renal function in patients undergoing coronary artery bypass grafting. Using our database, we conducted a retrospective review of the records of all 11,884 patients aged 21 years or older undergoing pure bypass grafting who required cardiopulmonary bypass. Preoperative renal function was categorized as normal renal function (serum creatinine </=1.1 mg/dL and creatinine clearance > 60 mL/min), occult renal insufficiency (serum creatinine </= 1.1 mg/dL and creatinine clearance </= 60 mL/min), mild renal insufficiency (1.1 mg/dL < serum creatinine </= 1.5 mg/dL and creatinine clearance </= 60 mL/min) or moderate renal insufficiency (serum creatinine > 1.5 mg/dL and creatinine clearance </= 60 mL/min). Out of 11,884 patients in the sample, 7856 (66.1%) had normal renal function, and 706 (5.9%) had occult renal insufficiency. The rate of postoperative mortality, renal failure, atrial fibrillation, prolonged ventilation, intra-aortic balloon pump usage, and prolonged hospital stay (>7 days) was higher in patients with occult renal insufficiency than in the normal group in univariable analysis. Multivariable logistic regression analysis demonstrated that patients with occult renal insufficiency compared with the group with normal renal function were at higher risk for mortality (odds ratio = 2.59, 95% confidence interval 1.15-5.86; P = .022) and prolonged hospital stay (>7 d) (odds ratio = 1.30, 95% confidence interval 1.08-1.57; P = .005). To identify higher-risk patients requiring special intensive care, and in whom new interventions can be performed to improve outcome, we recommend the preoperative calculation of creatinine clearance, especially in older women with a lower body mass index.

Are urodynamic studies really needed during bladder augmentation follow-up?

Objective We assessed clinical and urodynamic outcomes, over a minimum 10-year follow-up period, of neuropathic bladder patients treated with a bladder augmentation (BA) to determine if periodic urodynamic studies are needed. Material and methods Thirty-two patients with poorly compliant bladders underwent BA at a mean age of 11 years (2.5–18). Mean follow-up was 12 years (10–14.5) and mean patient age at the end of the study was 22 years (12.2–33). During follow-up all patients were controlled at regular intervals with urinary tract imaging, serum electrolyte and creatinine levels, cystoscopy and urodynamic studies. Preoperative, 1-year post-BA and latest urodynamic studies results were compared. Results Urodynamic studies at 1-year post-BA showed a significant increase in bladder capacity and a decrease in end-filling detrusor pressure compared with preoperative values (396 vs 106 ml; 10 vs 50 cm H 2O, P < 0.0001). The increase in bladder capacity was more significant at the end of the study than after 1 year (507.8 vs 396 ml, P < 0.002). Thirteen patients had phasic contractions after 1 year and 11 at the end (not significant, NS), and these contractions were more frequent with colon than with ileum (NS). At the end of follow-up, phasic contraction pressure had decreased while trigger volume had increased (35 vs 28 cm H 2O; 247 vs 353 ml, NS). All patients are dry and have normal renal function, except one who had mild renal insufficiency before BA. Conclusion BA improves bladder capacity and pressure, and these changes are maintained over time (although phasic contractions do not disappear). Repeated urodynamic studies are only necessary when upper urinary tract dilatation or incontinence does not improve.

Oxalate Nephropathy Complicating Roux-en-Y Gastric Bypass

The most common bariatric surgery is Roux-en-Y gastric bypass (RYGB), which has been associated with hyperoxaluria and nephrolithiasis. We report a novel association of RYGB with renal insufficiency as a result of oxalate nephropathy. Eleven cases of oxalate nephropathy after RYGB were identified from the Renal Pathology Laboratory of Columbia University. The clinical features, pathologic findings, and outcomes are described. Patients were predominantly white (72.7%) with a mean age of 61.3 yr. Indications for RYGB included morbid obesity (eight patients) and reconstruction after total gastrectomy for gastric cancer (three patients). All 11 patients had a history of hypertension, and 9 were diabetic. Patients presented with acute renal failure, often superimposed on mild chronic renal insufficiency (n = 7), at a median of 12 mo after RYGB. The mean creatinine at baseline, at discovery of acute renal failure, and at biopsy was 1.5, 5.0, and 6.5 mg/dl, respectively. Renal biopsies revealed diffuse tubular degenerative changes, abundant tubular calcium oxalate deposits, and varying degrees of tubulointerstitial scarring. In addition, seven biopsies had underlying diabetic glomerulosclerosis and two had glomerulosclerosis attributable to obesity and hypertension. Eight of 11 patients rapidly progressed to ESRD and required hemodialysis at a mean of 3.2 wk after renal biopsy. The remaining three patients were left with significant chronic kidney disease. Oxalate nephropathy is an underrecognized complication of RYGB and typically results in rapid progression to ESRD. Patients with pre-existing renal disease may be at higher risk for this complication.

Kidney-Heart Connection: Experimental Mild Renal Insufficiency Induces Early Cardiac Fibrosis and Myocardial Diastolic Dysfunction Followed by Late Systolic Failure

Kidney-Heart Connection: Experimental Mild Renal Insufficiency Induces Early Cardiac Fibrosis and Myocardial Diastolic Dysfunction Followed by Late Systolic Failure

Impact of Mild or Moderate Renal Insufficiency on the Intravascular Ultrasonic Analysis of Chronic Vascular Response to Paclitaxel-Eluting and Bare-Metal Stents (from the TAXUS IV, V, and VI Trials)

The presence of even mild renal insufficiency is usually associated with an increased rate of cardiovascular events after coronary stenting. The aim of this study was to evaluate the impact of mild to moderate renal insufficiency on the chronic vascular responses to the implantation of paclitaxel-eluting stents (PES; Taxus) and bare-metal stents (BMS). In the TAXUS IV, TAXUS V, and TAXUS VI trials, patients with serum creatinine levels >2.0 mg/dl were excluded. In the present analysis, 816 patients with serum creatinine levels <or=2.0 mg/dl had intravascular ultrasound images acquired after the procedures and/or at 9-month follow-up (406 with PES, 410 with BMS). Patients were stratified by level of creatinine clearance (Ccr; group 1: Ccr <40; group 2: 40 <or=Ccr <60; group 3: 60 or/=Ccr <80; group 4: Ccr >or=80 ml/min/1.73 m(2)). For all levels of Ccr, patients with PES compared with those with BMS had less intimal hyperplasia area (group 1: 0.97 +/- 0.98 vs 2.94 +/- 1.89; group 2: 0.94 +/- 0.86 vs 2.30 +/- 1.21; group 3: 0.99 +/- 1.02 vs 2.53 +/- 1.29; group 4: 0.87 +/- 0.95 vs 2.12 +/- 1.29 mm(2), all p values <0.0001) and greater increases in peristent plaque and media area (group 1: 0.90 +/- 0.98 vs -0.02 +/- 0.98 mm(2), p = 0.03; group 2: 0.57 +/- 1.43 vs 0.20 +/- 1.14 mm(2), p = 0.11; group 3: 1.20 +/- 1.95 vs 0.02 +/- 1.17, p <0.0001; group 4: 0.35 +/- 1.44 vs -0.19 +/- 1.08 mm(2), p = 0.08). Neointimal growth and vessel remodeling were not affected by variations in Ccr after either BMS or PES implantation over the range studied. The incidence of incomplete stent apposition at follow-up was lowest in patients with the greatest renal impairment after BMS and PES implantation. In conclusion, neointimal proliferation was less prominent and expansive vessel remodeling was more prominent after PES than BMS implantation, independent of the severity of renal dysfunction.

Impact of moderate or severe renal insufficiency on long-term outcomes in patients undergoing drug-eluting stent based coronary intervention

Aims We sought to examine the impact of moderate or severe renal insufficiency (RI) on long-term clinical outcomes after successful percutaneous coronary intervention (PCI) with drug-eluting stent implantation. Methods All-cause mortality and major adverse cardiac events were prospectively determined for 1174 patients after successful PCI with drug-eluting stent implantation. Based on estimated creatinine clearance (CrCl) levels, long-term outcomes were compared between patients with CrCl < 60 ml/min (RI group; n = 460) and those with CrCl ≥ 60 ml/min (control group; n = 714). Hazard ratio for mortality and myocardial infarction was further evaluated for patients with severe (CrCl < 30 ml/min), moderate (CrCl 30–59 ml/min), mild RI (CrCl 60–89 ml/min) and normal renal function (CrCl ≥ 90 ml/min). Results Patients in RI group were older, lower body weight and hemoglobin, more female gender, and less cigarette smokers than those in control group. During follow-up (averaged 19.2 months) after successful PCI, all-cause death (8.3% vs. 1.5%, P < 0.001), cardiac death (5.7% vs. 1.1%, P < 0.001) and occurrence of non-fatal myocardial infarction (2.2% vs. 0.4%, P = 0.005) were significantly higher, but rate of target vessel revascularization (TVR) was lower (5.7% vs. 9.6%, P = 0.017) in RI group than in control group. Multivariate analysis revealed that CrCl < 60 ml/min, diabetes, left ventricular ejection fraction < 0.50 and anemia were independent risk factors for mortality and non-fatal myocardial infarction. Compared with patients with normal renal function, hazard ratio for a composite of mortality and myocardial infarction was 1.079 ( P = 0.907), 5.067 ( P = 0.007) and 8.828 ( P = 0.002) in patents with mild, moderate and severe RI, respectively. Conclusions Irrespective of whether drug-eluting stent implantation reduces TVR, the presence of moderate or severe RI is still associated with unfavorable long-term outcomes.