Pre-existing End-stage Renal Disease Research Articles

Endovascular treatment of type B aortic dissection in patients with end-stage renal disease.

This study aimed to evaluate the postoperative and intermediate outcomes of thoracic endovascular aortic repair (TEVAR) in patients with end-stage renal disease (ESRD). We retrospectively reviewed patients with type B aortic dissection (TBAD) undergoing TEVAR at our single center from January 2010 to December 2020. Patients with pre-existing ESRD were enrolled as the study group. One hundred consecutive patients from September 2013 to March 2015 without ESRD were included as the control group. The primary and secondary outcomes were adverse events and survival, respectively. Kaplan-Meier curves of survival and freedom from adverse events were calculated and analyzed using the log-rank univariate test. Multivariable analysis was used to isolate the effects of ESRD. A total of 39 patients with ESRD and TBAD underwent TEVAR during the study period. The median follow-up time of patients with and without ESRD was 45 and 46months, respectively. There was significant difference between the survival at 4years of patients with and without ESRD (72.8% vs 94.9%; p = 0.011). Meanwhile, the incidence of adverse events was significantly higher in patients with ESRD (p = 0.026). Multivariable logistic regression analysis showed that ESRD (OR, 2.46; p = 0.049) and peripheral artery disease (OR, 4.11; p = 0.002) were the predictors of adverse events. The rates of adverse events and survival expectancy were poor in patients with ESRD and TBAD.

Peripheral extracorporeal membrane oxygenation support expands the application of robot-assisted coronary artery bypass.

Robot-assisted coronary artery bypass (RCAB) is typically not offered to higher risk patients with reduced cardiopulmonary function, critical coronary artery disease, and challenging chest wall anatomy. In this study, we report the novel use of nonemergency intraoperative peripheral extracorporeal membrane oxygenation as partial cardiopulmonary support during RCAB for patients who were considered high-risk candidates for conventional CAB and at the same time not eligible for RCAB without cardiopulmonary support. Forty-five high risk patients (mean age, 68years; Society of Thoracic Surgeons score, 6.27%; ejection fraction, 45%) underwent RCAB with nonemergency peripheral extracorporeal membrane oxygenation support for the following indications: inability to tolerate single-lung ventilation (n=17; 38%), low ejection fraction <35% (n=17; 38%), inadequate exposure of internal thoracic artery (n=24; 53%), critical coronary artery disease (n=16; 36%), and hemodynamic instability after anesthesia induction (n=3; 7%). Following robotic internal thoracic artery takedown, all patients had beating heart minimally invasive direct CAB through a 2-inch minithoracotomy. Up to 30days, there were no strokes (0%), myocardial infarctions (0%), or access vessel complications (0%). One noncardiac related mortality (2.2%) was related to hemodialysis access issues in a patient with preexisting end-stage renal disease. One redo-CAB (2.2%) patient required sternotomy to locate the target vessel. Thirty-four (75.6%) patients were extubated within 6hours of surgery. Our results examine the feasibility of using peripheral extracorporeal membrane oxygenation during RCAB for high-risk patients who otherwise had limited options. The use of peripheral extracorporeal membrane oxygenation in RCAB can potentially expand the surgical treatment options in high-risk coronary artery disease patients.

Acute Kidney Injury Affects Mid-Term Outcomes of Thoracoabdominal Aortic Aneurysms Repair

The effect of acute kidney injury (AKI) on mid-term outcomes following thoracoabdominal aortic aneurysm (TAAA) repair is not well known. We hypothesized that postoperative AKI would reduce mid-term survival and aimed to analyze the effect of AKI on mid-term outcomes after TAAA repair. This retrospective study identified 294 consecutive TAAA repairs at Kobe University Hospital from October 1999 to March 2019. Patients with preexisting end-stage renal disease that required hemodialysis (n=11) and patients who died intraoperatively (n=2) were excluded. Finally, 281 patients were analyzed. AKI was defined according to Kidney Disease: Improving Global Outcomes guidelines (KDIGO) classification. Of the 281 patients, 178 (63.3%) developed AKI, of which 98 (34.9%) had mild, 34 (12.1%) had moderate, and 46 (16.4%) had severe AKI. Twenty-six patients (12.8%) required renal replacement therapy after surgery. Twenty-three in-hospital deaths (8.2%) were recorded, including 2 (0.7%) without AKI, 0 (0%) with mild AKI, 1 (0.4%) with moderate AKI, and 20 (7.1%) with severe AKI (p < .001). The 4-year survival was 91.9±3.0% for no AKI, 91.3±3.2% for mild AKI, 72.4±8.5% for moderate AKI and 32.6±7.4% for severe AKI (p < .001). Multivariable Cox-hazard regression analysis demonstrated that moderate and severe AKI, older age and emergency surgery were significant risk factors for mid-term survival. In patients undergoing TAAA repair, severe AKI was associated with an increase in in-hospital mortality and both moderate and severe AKI were negatively associated with mid-term survival. Preventing moderate/severe AKI may improve mid-term survival after TAAA repair.

MO677RRT DURING COVID 19 EPIDEMIC. EXPIRIENCE OF ONE CENTER

Background and AimsThe incidence of Acute kidney injuri AKI during Covid 19 infection is 3 – 15%, up to 50% for patients (pts) with Acute respiratory distress syndrome ARDS.MethodFrom March till December 2020. Department for hemodialysis in Novi Sad did 184 renal replacement therapy (RRT) procedures (proc) on 65 Covid 19 positive pts.ResultsThere were 73,85% men and 26,15% women (p < 0,01), with average (avs.) age of 65,8 years (SD 9,20). Most of them were admitted directly to the Intensive care unit, 64,62% (p < 0,01). The length of stay in hospital ranged from 2 - 61 days (avs. 15,86; SD 11,19). The most common comorbidities were hypertension (86,1%), diabetes (33,8%), coronary disease (30,8%) and chronic obstructive pulmonary disease (21,5%). Most common indication for RRT was acutisation of chronic kidney disease (CKD) 43,08% (p < 0,01) followed by pre-existing end stage renal disease (ESRD) 29,23% and AKI 27,69%. RRT was started 1 - 31 days after the admittance (avs. 8,51; SD 7,33). 57 intermittent hemodialysis proc (30,98%) were done on 13 pts (14,06%) who were hemodynamicly and respiratory stable. The decision to initiate CRRT was made upon the renal indications, the presence of ARDS or significant volume load. A total of 127 CRRT proc (69,02%) were done on 57 pts (87,5%). The most of them were CVVHDF (74,02%) and the rest CVVHD (25,98%). Most commonly used membrane was oXiris 47,24% (p < 0,001) followed by EMIC2 25,98%, Kit 8 17,32% and ST-150 9,45%. Most CRRT proc (89,76%) were done with heparin as an anticoagulant and 10 proc (7,87%) in 5 pts using citrate. 3 proc (2,36%) in 2 pts were done without using anticoagulant. The procedurès duration had to depend on the number of devices, the number of pts requiring CRRT and the number of available trained medical workers. The average achieved length of proc was 712 min. (11 h and 52 min.) (SD 435,07). Most patients had 1 (49,12%; p< 0,001) or 2 (30,69%) CRRT proc, up to 9 (avs. 2,23; SD 1,95). The average achieved ultrafiltration was 2716,41 ml (SD 1016,82). In 23 pts (40,35%) 26 CRRT proc (20,47%) had to be stopped earlier, because of circuit clotting (9,45%; p < 0,001), deterioration of hemodynamic instability/respiratory insufficiency (7,09%), device malfunction (2.36%) and RRT need for another pts (1,58%). ARDS has developed 42 pts (64,61%). The need for vasoactive support had 41 pts (63,08%). 51 pts (78,46%) requiring RRT died.ConclusionComparing group of pts who survived with group of those who died, greater number of pts with ESRD was in the first group. In survivor group, RRT was started earlier with greater number and shorter duration of proc. In the group of pts who died, there were more ARDS and vasoactive support need. They had a higher levels of CRP, leukocyte count and the neutrophil to lymphocyte ratio.MO677 Table 1.Characteristic of groups of pts who survived and the group of pts who diedsurvived (No 14)died (No 51)pAge 64,14 (SD 11,77) 66,27 (SD 8,45)0,45sexM10 (71,43%)38 (74,51%)0,91fF4 (28,57%)13 (25,49%)No of comorbidities2,86 (SD 0,86)2,43 (SD 1,06)0,84IndicationAKI0 (0%)18 (35,29%)0,00CKD ac2 (14,29%)26 (50,98%)ESRD12 (85,71%)7 (13,73%)Los in hospital (days) 16,83 (SD 9,29) 15,63 (SD 11,66)0,37Los before RRT (days) 2,43 (SD 1,95) 10,18 (SD 7,39)0,00Los before RRT (only CRRT) (days) 3 (SD 2,27) 10,43 (SD 7,42)0,007No of proc 4,38 (SD 3,38) 1,88 (SD 1,36)0,008Duration of proc(min.) 464,17 (SD 27,36) 744,46 (SD 456,48)0,03membranesoXiris+EMIC215 (42,86%)78 (84,78%)0,00Kit8+ST-15020 (57,14%)14 (15,22%)UF/proc (ml) 2799,06 (SD 457,88) 2702,91 (SD 1111,24)0,14AnuriaY8 (57,14%)20 (39,22%)0,37N6 (42,56%)31 (60,78%)vasoactive supportY0 (0%)41 (80,39%)0,00N14 (100%)10 (19,71%)ARDSY1 (7,14%)44 (86,27%)0,00N13 (92,86%)7 (13,73%)WBC (* 10^9/l)6,91 (SD 2,63)11,82 (SD 8,63)0,02NLR 7,48 (SD 3,92) 17,78 (SD 14,25)0,017PLR 266,41 (SD 162,52) 334,60 (SD 322,35)0,48CRP (mg/l) 114,68 (SD 141,80) 192,34 (SD 107,23)0,039PCT (ng/ml) 3,81 (SD 4,98) 12,67 (SD 26,58)0,28

Abstract WMP100: Excessive Blood Pressure Reduction Increases the Risk of Acute Kidney Injury After Intracerebral Hemorrhage

Background: Elevated blood pressure (BP) in the first 24 hours of admission of acute intracerebral hemorrhage (ICH) has been the focus of intensive therapeutic investigation, although early intensive BP lowering addresses a concern about development of acute kidney injury (AKI). However, it is unclear as to the effect of BP measure including the absolute BP reduction and increased BP variability on AKI in patients with acute ICH. Methods: We retrieved data of consecutive patients with acute ICH from our prospective stroke registry between July 2015 and August 2017. We excluded patients with preexisting end-stage renal disease or in-hospital death within 24 hours. The primary outcome was AKI within 7days after admission defined using the AKI Network criteria. We recorded BP on emergency department arrival and for every 1 hour from 1 to 24 hours after admission (25 measurements). We measured mean systolic BP (SBP) and maximum minus minimum SBP within both 12 hours and 24 hours, and also quantified SBP variabilities (SBPV) including standard deviation, coefficient of variation, successive variation, and average real variability. Results: Among 361 patients with ICH (age 72.7±12.8, male 55%, non-lobar 76%), 31 (9%) developed AKI. For all SBP measure, the 12-hour SBP reduction was associated with the increased risk of AKI in multivariable analysis (odds ratio [per10 mmHg increase] 1.30; 95% CI 1.10-1.35). There was no significant association between the SBP variability and risk of AKI. The area under the receiver operating characteristic curve of the 12-hour SBP reduction for predicting AKI was 0.75. The association between the 12-hour SBP reduction and AKI was not modified by preexisting chronic kidney disease (interaction P=0.40). Conclusion: Early BP reduction in the first 12 hours of admission contributed to the risk of AKI in acute ICH. This may have clinical implication to avoid excess absolute BP reduction in patients with acute ICH.

Frequency of Advanced Cardiac Life Support Medication Use and Association With Survival During In-hospital Cardiac Arrest

PurposeCardiopulmonary resuscitation is common in the United States, with >200,000 people experiencing an in-hospital cardiac arrest (IHCA) annually. Recent medication shortages have raised the question of the frequency and type of medication used during cardiac arrest resuscitation. We sought to determine the frequency and quantity of medications used during IHCA. MethodsThis retrospective, single-center, medical record review was performed at a large, urban teaching hospital. Adults ≥18 years old who had an IHCA with confirmed loss of pulse between January 2017 and March 2018 were identified. A standardized data collection tool was used to extract data from the electronic medical record. The primary outcome was the frequency and quantity of medications used during the IHCA. Secondary outcomes included median time to defibrillation and frequency of sodium bicarbonate use, including among patients with end-stage renal disease (ESRD). FindingsCriteria were met for 181 IHCA events. Demographic characteristics were 71% black, 17% white, mean age of 65 years, and 46% women. Epinephrine was given in 86.7% of the arrests, with a mean cumulative dose of 4.2 mg. Sodium bicarbonate was given in 63.5% of the arrests, with a mean cumulative dose of 9.0 g (1.9 amps). Amiodarone was given in 30.9% of the arrests, with a mean cumulative dose of 311.8 mg. Median time to defibrillation was 2 min (interquartile range, 1–4 min). Preexisting ESRD was present in 24.8% of patients, of whom 71.1% received sodium bicarbonate. Sodium bicarbonate administration was associated with a lower likelihood of survival to discharge (odds ratio [OR] = 0.27; 95% CI, 0.11–0.66) as well as a lower rate of return to spontaneous circulation (ROSC) (OR = 0.35; 95% CI, 0.13–0.95). Magnesium administration was associated with a lower rate of ROSC (OR = 0.39; 95% CI, 0.15–0.98). Of note, in patients with preexisting ESRD, no medications were significantly associated with a change in likelihood of survival to discharge or rate of ROSC. In patients without preexisting ESRD, magnesium was associated with a lower rate of ROSC (OR = 0.23; 95% CI, 0.08–0.77). ImplicationsWe found that in a hospital with established rapid response and code blue teams, numerous medications that are not recommended for routine use in cardiac arrest are still administered at significant frequencies. Furthermore, substantial amounts of drugs with known recent shortage are used in IHCA. Inc.

Elective Splenectomy in Immune Thrombocytopenic Purpura: An Analysis of National Inpatient Sample (NIS) Database between Years 2006 and 2014

Background: Over the years, splenectomy has dropped out of favor as a treatment option for Immune Thrombocytopenic Purpura (ITP) and is now considered only for patients who have failed multiple lines of therapy. One of the major concerns is surgical morbidity. We aim to study in-hospital outcomes following elective splenectomy in this population Methods: This is a retrospective cohort analysis of NIS database (years 2006 to 2014). Patients ≥18 years of age, who had an elective admission associated with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9‐CM) procedure code for splenectomy were included in the study. Our cohort of interest was patients with ITP who underwent elective splenectomy (ITP ES). ICD-9-CM diagnosis codes were used to identify patients with ITP. All other patients who underwent elective splenectomy were labeled as non-ITP ES. Utilization of intensive care services was identified by procedure codes associated with vasopressor use, cardiopulmonary resuscitation, mechanical ventilation and initiation of dialysis in the absence of pre-existing end stage renal disease. Primary outcome was inpatient mortality and secondary outcome was length of stay (LOS). Associated factors were analyzed using multivariate logistic regression analysis. A p-value &lt;0.05 was considered significant. We used STATA for statistical analysis. Results: A total of 102,698 admissions for elective splenectomies (ES) in adults were identified between the years 2006 and 2014,of which 11.36% (n= 11,668) were ITP ES. Inpatient mortality and mean LOS for all patients undergoing ES was 2.53% and 8.51 days respectively. Inpatient mortality and mean LOS in the ITP ES cohort was 0.86% and 4.37 days respectively. In the entire cohort of ES, inpatient mortality was lower in those with ITP versus non-ITP (OR 0.36, p&lt;0.001). Also females had lower mortality when compared to men (OR 0.50, p&lt;0.001). Inpatient mortality was higher with increasing age (OR 1.03, p&lt;0.001) and Charlson Comorbidity Index (CCI) ≥3 vs 0 (OR 1.54, p &lt;0.001). Mean length of stay was lower in those with ITP vs non ITP by 3.3 days (p&lt;0.001). Within the ITP-ES cohort, mortality was higher with increasing age (OR 1.12, p &lt;0.001), CCI ≥3 vs 0 (OR 18.39, p&lt; 0.0001) and CCI 2 vs 0 (OR 8.61, p 0.008). Inpatient mortality was lower in teaching hospitals compared to non-teaching hospitals with a trend towards significance (OR 0.35, p 0.05). Gender, insurance status, income quartile, geographic region and hospital size did not affect odds of inpatient mortality in this cohort. Length of stay (LOS) in ITP ES cohort had positive correlation with age (coefficient 0.038, p&lt;0.001), income quartile 51-75th vs 0-25th percentile (coefficient 0.81, p 0.03), CCI ≥3 vs 0 (coefficient 3.29, p&lt;0.001), CCI 2 vs 0 (coefficient 2.11, p&lt;0.001), CCI 1 vs 0 (coefficient 0.86, p&lt;0.001). There was no association of gender, insurance status and geographic region with LOS within this cohort. Conclusion: Inpatient mortality and length of stay in admissions for elective splenectomy was significantly lower in ITP patients compared to non ITP patients. Also, in ITP patients undergoing elective splenectomy, older age and a charlson comorbidity index of 2 or above were associated with higher odds of dying in the same admission.These findings from real world data have practical implications for clinicians and patients, as they weigh the pros and cons of splenectomy as a treatment option for ITP. Table Disclosures Donthireddy: Viracta: Other: PI for Clinical Trial.

Impact of Acute Kidney Injury Following Diagnosis of Aggressive Lymphoma or Acute Leukemia on Long-Term Kidney Outcomes

Acute kidney injury (AKI) is common in those with newly diagnosed hematologic malignancies. Precipitants of AKI in this population may include tumor lysis syndrome, hypotension and other insults associated with acute illness. In a general population, AKI not only leads to short-term consequences like fluid, electrolyte and acid-base abnormalities, but each episode has been linked to worse long-term outcomes, including chronic kidney disease, cardiovascular events and death. In patients with malignancies, loss of kidney function may be additionally detrimental, as this can jeopardize eligibility for full dose or first line chemotherapy, transplantation or enrollment in clinical trials. The purpose of this study is to determine the impact of AKI on long-term loss of kidney function in patients newly diagnosed with aggressive lymphomas or acute leukemia. We performed a population-based cohort study using data from the Rochester Epidemiology Project (REP). The REP is a medical-record linkage system that integrates data for patients across multiple medical care providers in Olmsted County, MN and surrounding areas to facilitate long-term follow-up. Adults admitted to the hospital between 2005 and 2017 following a new diagnosis of acute leukemia or aggressive lymphoma were evaluated for the exposure of AKI. AKI was defined by the KDIGO serum creatinine (SCr) criterion (Stage 1: 1.5-fold increase from baseline or 0.3mg/dL increase in 48-hours; Stage 2: 2-fold increase from baseline; Stage 3: 3-fold increase from baseline, increase in SCr to &gt;4mg/dL, or initiation of renal replacement therapy). Only the first episode of hospitalization was included. Cox proportional hazards regression was used to compare the primary outcome of loss of kidney function within 12 months of hospitalization [defined as ≥30% decline from baseline estimated glomerular filtration rate (eGFR)] in those with and without AKI. A subgroup analysis was performed in patients with a baseline eGFR &lt;60 mL/min/1.73m2. eGFR calculations used the Chronic Kidney Disease Epidemiology Collaborative equation. Outcome evaluation began 90-days after hospitalization to establish chronicity and was defined only by outpatient SCr values. Within the REP cohort, 1,085 patients were hospitalized following a new diagnosis of acute leukemia or lymphoma who consented to the use of their medical records for research. Sixteen patients with pre-existing end-stage renal disease were excluded, leaving 1,069 included patients for analysis. The majority were white (n=1,002; 93.7%) males (n=624; 58.4%) with a mean (SD) age of 64 (18) years. Mean baseline SCr was 1.0 (0.4) mg/dL with a corresponding eGFR of 80 (27) ml/min/1.73m2. A total of 355 patients (33.2%) experienced AKI during the index hospitalization, most commonly a maximum stage of I (n=231; 21.6%). Stages II and III AKI occurred in 42 (3.9%) and 59 (5.5%) patients, respectively. Cumulative incidence of ≥30% loss of baseline eGFR in the 12 months following hospitalization was 67.9% (95% CI 56.8%-76.1%) for those with any AKI and 38.8% (95% CI 31.8%-45.1%) for those without AKI during the index hospitalization. Patients diagnosed with any stage AKI were more likely to experience this outcome compared to those without AKI (HR 2.6, 95% CI 2.2-3.5, p&lt;0.001) in unadjusted analysis. Amongst those with a baseline eGFR ≤60 ml/min, no significant difference in the outcome was noted (HR 1.7, 95% CI 0.83-3.35, p=0.15). Patients with AKI during initial hospitalization following a new diagnosis of acute leukemia or aggressive lymphoma were significantly more likely to experience ≥30% loss of baseline eGFR in the 12 months following diagnosis. This highlights a critical need to identify interventions which prevent AKI and optimize renal recovery so as to decrease overall morbidity and preserve eligibility for desirable treatment options. Disclosures Barreto: FAST Biomedical, Inc: Consultancy. Leung:Prothena: Membership on an entity's Board of Directors or advisory committees; Takeda: Research Funding; Omeros: Research Funding; Aduro: Membership on an entity's Board of Directors or advisory committees.

Warfarin-induced spontaneous retroperitoneal hemorrhage from the renal vein: A rare case with an uncommon etiology.

The overall rate of major bleeding in patients with atrial fibrillation receiving warfarin therapy is approximately 4%. Among these 4% patients, spontaneous retroperitoneal hemorrhage (SRH) is a rare but potentially lethal complication with a nonspecific presentation that can lead to missed or delayed diagnosis. The current literature provides little direction for diagnosis and management of such cases. Anticoagulation-related SRH is associated with a high mortality rate (approximately 20%). Despite the vague presentation, prompt diagnosis is crucial to reverse the anticoagulation and prevent further bleeding. Contrast-enhanced computed tomography (CT) of the abdomen is the imaging modality of choice in suspected cases. Patients with SRH require aggressive treatment with blood transfusions, interventional radiological procedures, percutaneous drainage or surgical evacuation of the hematoma. We report a case of warfarin-induced SRH from the renal vein in a patient who presented to our emergency department with acute, nonspecific abdominal pain and shock. We diagnosed the patient with warfarin-induced SRH on the basis of clinical suspicion and characteristic CT findings. We initially treated the patient conservatively, followed by embolization of the right renal artery during the late course of hospital stay, and he was discharged with good recovery. SRH should be considered in the differential diagnosis of abdominal pain, hypotension, and/or decreased hemoglobin levels in patients receiving anticoagulation therapy, especially in those with preexisting end-stage renal disease.

Lower short-term mortality in ICU patients on chronic dialysis than in those requiring acute dialysis.

In ICU patients, we aimed to describe the outcomes of those with end-stage renal disease (ESRD) as compared to those requiring acute renal replacement therapy (RRT). Retrospective analysis of all adult patients admitted to a general, university hospital ICU from 2005 to 2012. ESRD was defined as use of chronic RRT >90days prior to admission. We included 5927 patients of whom 1004 (17%) received acute RRT and 161 (3%) had pre-existing ESRD requiring RRT. Thirty-day mortality was 42% vs 28% for acute RRT vs ESRD patients (adjusted hazard ratio (aHR) 0.90 (0.61-1.34)), and 16% for those not requiring RRT (aHR 0.91 (0.60-1.38) compared to ESRD patients). Ninety-day mortality was 55% vs 45% for acute RRT vs ESRD patients (aHR 0.96 (0.70-1.31)), and 22% for those not requiring RRT (aHR 1.19 (0.84-1.67) compared to ESRD patients). Ninety-day ESRD survivors were younger, less severely ill and needed less vasopressor treatment than 90-day ESRD non-survivors. Five-year mortality was 68% vs 69% for acute RRT vs ESRD patients (aHR 1.06 (0.81-1.39)), and 38% for those not requiring RRT (aHR 1.31 (0.99-1.74) compared to ESRD patients). The crude mortality for patients with pre-existing ESRD was high. Short-term mortality was within range of those not receiving RRT when adjusted for confounders. The severity of acute illness and the burden of comorbidities may be more important than the lack of kidney function per se for the short-term prognosis of RRT patients in the ICU.

Abstract 239: Frequency of Advanced Cardiac Life Support Medication Use and Association With Survival During In-Hospital Cardiac Arrest

Introduction: Resuscitation medication shortages are widespread across the US. We sought to determine the frequency and quantity of meds used during IHCA. Methods: Retrospective, single center, chart review at a large, urban teaching hospital. Adults over 18 who suffered IHCA between Jan 2017 and Mar 2018 were identified. Trained and supervised research assistants used a standardized data tool to extract data from the EMR. Primary outcome was the frequency and quantity of ACLS meds used during IHCA. Secondary outcomes included evaluating the association of med administration with ROSC and survival as well as the use of sodium bicarb with survival in patients with pre-existing end stage renal disease. Results: Criteria were met for 181 IHCA events. Demographics: 71% (128 of 181) black; mean age 65; and 46% (83 of 181) women. Epi was given in 86.7% (157 of 181) cases, with average cumulative dose of 4.2 mg, sodium bicarb given in 63.5% (115 of 181), average dose of 1.9 amps, calcium chloride given in 39.2% (71 of 181), average dose of 1.9 amps, amiodarone was given in 30.9% (56 of 181), average dose of 311.8 mg, and atropine was given in 13.8% (25 of 181), average dose of 1.3 amps. Administration of sodium bicarb was associated with lower rates of ROSC (OR 0.31, 95% CI 0.18 to 0.83) and lower survival (OR 0.31, 95% CI 0.13 to 0.73). Administration of mag sulfate was associated with lower rates of ROSC (OR 0.33, 95% CI 0.13 to 0.83), but no difference in survival (OR 0.34, 95% CI 0.10 to 1.14). Administration of epi, amiodarone, calcium, dextrose, or atropine was not associated with a change in rates of ROSC or survival. In patients with pre-existing ESRD (45 of 181), 73.3% (33 of 45) received sodium bicarb, with 51.5% (17 of 33) achieving ROSC, and 12.1% (4 of 33) surviving to discharge. In patients without ESRD (136 of 181), 60.3% (82 of 136) received sodium bicarb, with 65.9% (54/82) achieving ROSC, and 22.0% (18 of 82) surviving to discharge. (12.1% vs 22.0% p = 0.224). Conclusions: Substantial amounts of drugs with known recent shortage are used in IHCA with no significant increase in ROSC or survival to discharge. Administration of sodium bicarb during IHCA is associated with lower rates of ROSC and survival. These results may be due to confounders such as code duration.

In-Hospital Mortality After Spinal Surgery in Hemodialysis Patients: An 11-Year Population-Based Study

Patients with end-stage renal disease (ESRD) are at an increased risk of surgical mortality. We aimed to investigate the factors associated with in-hospital mortality in patients with ESRD who underwent spinal surgery, which remains to be determined. An age- and sex-matched cohort study was conducted using the Taiwan Longitudinal Health Insurance Database between January 2000 and December 2012. Kaplan-Meier curves were plotted with log-rank test to compare the differences between these 2 groups. The Cox proportional hazard model was used to estimate the hazard ratio of in-hospital mortality adjusted with potential confounding. In total, 4109 participants with pre-existing ESRD and 8218 patients without ESRD were included. The in-hospital mortality in ESRD (10.17%) was greater than without ESRD (1.39%). Spinal surgery patients with pre-existing ESRD had a 6.78-fold increase in-hospital mortality risk compared with those without ESRD. Spinal surgery patients with ESRD of any age, male or female, and comorbidities experienced a greater incidence of hospital mortality. In patients with ESRD, operations on spinal cords and spinal canal structures had the greatest hospital mortality (14.87%) compared with spinal fusion (3.46%) or excision or destruction of intervertebral disc (3.01%). Kaplan-Meier survival curves showed that patients with ESRD experienced greater hospital mortality than patients without ESRD in all 3 spinal surgery methods (log rank P < 0.0001). Spinal surgery patients with ESRD have greater in-hospital mortality than patients without ESRD. Age, sex, history of comorbidities, and types of surgical methods were associated with greater in-hospital mortality among patients with ESRD.

Cure of Insulin-Dependent Diabetes Mellitus by an Autologous Hematopoietic Stem Cell Transplantation Performed to Control Multiple Myeloma in a Patient with Chronic Renal Failure on Regular Hemodialysis

Management of patients with multiple myeloma having several coexisting comorbid medical conditions is a real challenge as complications related to the primary disease, its treatment and other comorbidities are prone to occur. In such complicated cases, an individualized therapy has to be adopted. A 45 year old male, with pre-existing end-stage renal disease, diabetes mellitus and hypertension, was diagnosed to have multiple myeloma in October 2012 at King Fahad Specialist Hospital in Dammam, Saudi Arabia. The diagnosis of diabetes was made one year prior to the diagnosis of his myeloma and he was receiving 40 to 50 units of insulin per day to control his diabetes. After receiving 4 cycles of bortezomib, lenalidomide and dexamethasone, his myeloma was controlled then in March 2013, an autologous hematopoietic stem cell transplantation was performed. One month following his autograft, his insulin requirements started to decrease gradually and 4 months post-transplantation his diabetes became insulin independent. For more than 4 years after his stem cell transplantation, both his diabetes and multiple myeloma are still under control. To our knowledge, this is the first world report of diabetes mellitus cured by stem cell therapy performed to control a hematologic malignancy.

Acute and Chronic Kidney Disease and Cardiovascular Mortality After Major Surgery.

The aim of the study was to determine the long-term cardiovascular-specific mortality in patients with acute kidney injury (AKI) or chronic kidney disease (CKD) after major surgery. In surgical patients, pre-existing CKD and postoperative AKI are associated with increases in all-cause mortality. In a single-center cohort of 51,457 adult surgical patients undergoing major inpatient surgery, long-term cardiovascular-specific mortality was modeled using a multivariable subdistributional hazards model while treating any other cause of death as a competing risk and accounting for the progression to end-stage renal disease (ESRD) after discharge. Pre-existing CKD and ESRD, and postoperative AKI were the main independent predictors. Before the admission, 4% and 8% of the cohort had pre-existing ESRD and CKD not requiring renal replacement therapy, respectively. During hospitalization, 39% developed AKI. At 10-year follow-up, adjusted cardiovascular-specific mortality estimates were 6%, 11%, 12%, 19%, and 27% for patients with no kidney disease, AKI with no CKD, CKD with no AKI, AKI with CKD, and ESRD, respectively (P < 0.001). This association remained after excluding 916 patients who progressed to ESRD after discharge, although it was significantly amplified among them. Compared with patients having no kidney disease, adjusted hazard ratios for cardiovascular mortality were significantly higher among patients with kidney disease, ranging from 1.95 (95% confidence interval, 1.80-2.11) for patients with de novo AKI to 5.70 (95% confidence interval, 5.00-6.49) for patients with pre-existing ESRD. Both AKI and CKD were associated with higher long-term cardiovascular-specific mortality compared with patients having no kidney disease.

Renal dysfunction and the associated decrease in survival after elective endovascular aneurysm repair

The reported frequency of renal dysfunction after elective endovascular aneurysm repair (EVAR) varies widely in current surgical literature. Published research establishes pre-existing end-stage renal disease as a poor prognostic indicator. We intend to quantify the mortality effect associated with renal morbidity developed postoperatively and to identify modifiable risk factors. All elective EVAR patients with preoperative and postoperative renal function data captured by the Vascular Quality Initiative between January 2003 and December 2014 were examined. The primary study end point was long-term mortality. Preoperative, intraoperative, and postoperative parameters were analyzed to estimate mortality stratified by renal outcome and to describe independent risk factors associated with post-EVAR renal dysfunction. This study included 14,475 elective EVAR patients, of whom 96.8% developed no post-EVAR renal dysfunction, 2.9% developed acute kidney injury, and 0.4% developed a new hemodialysis requirement. Estimated 5-year survival was significantly different between groups, 77.5% vs 53.5%, respectively, for the no dysfunction and acute kidney injury groups, whereas the new hemodialysis group demonstrated 22.8% 3-year estimated survival (P< .05). New-onset postoperative congestive heart failure (odds ratio [OR], 3.50; 95% confidence interval [CI], 1.18-10.38), return to the operating room (OR, 3.26; 95% CI, 1.49-7.13), and postoperative vasopressor requirement (OR, 2.68; 95% CI, 1.40-5.12) predicted post-EVAR renal dysfunction, whereas a preoperative estimated glomerular filtration rate (eGFR)≥60mL/min/1.73m2 was protective (OR, 0.33; 95% CI, 0.21-0.53). Volume of contrast material administered during elective EVAR varies 10-fold among surgeons in the Vascular Quality Initiative database, but the average volume administered to patients is statistically similar, regardless of preoperative eGFR. Multivariable logistic regression demonstrated nonsignificant correlation between contrast material volume and postoperative renal dysfunction. Any renal dysfunction developing after elective EVAR is associated with decreased estimated long-term survival. Protecting renal function with a rational dosing metric for contrast material linked to preoperative eGFR may better guide treatment.

ShockOmics: multiscale approach to the identification of molecular biomarkers in acute heart failure induced by shock.

BackgroundThe ShockOmics study (ClinicalTrials.gov identifier NCT02141607) is a multicenter prospective observational trial aimed at identifying new biomarkers of acute heart failure in circulatory shock, by means of a multiscale analysis of blood samples and hemodynamic data from subjects with circulatory shock.Methods and DesignNinety septic shock and cardiogenic shock patients will be recruited in three intensive care units (ICU) (Hôpital Erasme, Université Libre de Bruxelles, Belgium; Hospital Universitari Mutua Terrassa, Spain; Hôpitaux Universitaires de Genève, Switzerland). Hemodynamic signals will be recorded every day for up to seven days from shock diagnosis (time T0). Clinical data and blood samples will be collected for analysis at: i) T1 < 16 h from T0; ii) T2 = 48 h after T0; iii) T3 = day 7 or before discharge or before discontinuation of therapy in case of fatal outcome; iv) T4 = day 100.The inclusion criteria are: shock, Sequential Organ Failure Assessment (SOFA) score > 5 and lactate levels ≥ 2 mmol/L. The exclusion criteria are: expected death within 24 h since ICU admission; > 4 units of red blood cells or >1 fresh frozen plasma transfused; active hematological malignancy; metastatic cancer; chronic immunodepression; pre-existing end stage renal disease requiring renal replacement therapy; recent cardiac surgery; Child-Pugh C cirrhosis; terminal illness. Enrollment will be preceded by the signature of the Informed Consent by the patient or his/her relatives and by the physician in charge.Three non-shock control groups will be included in the study: a) healthy blood donors (n = 5); b) septic patients (n = 10); c) acute myocardial infarction or patients with prolonged acute arrhythmia (n = 10).The hemodynamic data will be downloaded from the ICU monitors by means of dedicated software. The blood samples will be utilized for transcriptomics, proteomics and metabolomics (“-omics”) analyses.DiscussionShockOmics will provide new insights into the pathophysiological mechanisms underlying shock as well as new biomarkers for the timely diagnosis of cardiac dysfunction in shock and quantitative indices for assisting the therapeutic management of shock patients.

Prehospitalization Risk Factors for Acute Kidney Injury during Hospitalization for Serious Infections in the REGARDS Cohort

Background/Aims: Acute kidney injury (AKI) frequently occurs in hospitalized patients. In this study, we determined prehospitalization characteristics associated with AKI in community-dwelling adults hospitalized for a serious infection. Methods: We used prospective data from 30,239 participants of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a national cohort of community-dwelling adults ≥45 years old. We identified serious infection hospitalizations between 2003 and 2012. Using the Kidney Disease Improving Global Outcomes (KDIGO) criteria, we defined AKI as an increase in serum creatinine (sCr) ≥0.3 mg/dl from the first inpatient sCr measurement during the first 7 hospitalization days. We excluded individuals with a history of renal transplant or preexisting end-stage renal disease as well as individuals with <2 sCr measurements. We identified baseline characteristics (sociodemographics, health behaviors, chronic medical conditions, biomarkers, and nonsteroidal anti-inflammatory, statin, or antihypertensive medication use) independently associated with AKI events using multivariable generalized estimating equations. Results: Over a median follow-up of 4.5 years (interquartile range 2.4-6.3), we included 2,074 serious infection hospitalizations among 1,543 individuals. AKI occurred in 296 of 2,074 hospitalizations (16.5%). On multivariable analysis, prehospitalization characteristics independently associated with AKI among individuals hospitalized for a serious infection included a history of diabetes [odds ratio (OR) 1.38; 95% CI 1.02-1.89], increased cystatin C (OR 1.73 per SD; 95% CI 1.20-2.50), and increased albumin-to-creatinine ratio (OR 1.19 per SD; 95% CI 1.007-1.40). Sex, race, hypertension, myocardial infarction, estimated glomerular filtration rate, high-sensitivity C-reactive protein, and the use of nonsteroidal anti-inflammatory, statin, or antihypertensive medications were not associated with AKI. Conclusions: Community-dwelling adults with a history of diabetes or increased cystatin C or albumin-to-creatinine ratio are at increased risk for AKI after hospitalization for a serious infection. These findings may be used to identify individuals at high risk for AKI.

Long-term renal and neurologic outcomes among survivors of diethylene glycol poisoning.

At least 13 medication-associated diethylene glycol (DEG) mass poisonings have occurred since 1937. To our knowledge, this is the first longitudinal study characterizing long-term health outcomes among survivors beyond the acute poisoning period. To characterize renal and neurologic outcomes among survivors of a 2006 DEG mass-poisoning event in Panama for 2 years after exposure. This prospective longitudinal study used descriptive statistics and mixed-effects repeated-measures analysis to evaluate DEG-poisoned survivors at 4 consecutive 6-month intervals (0, 6, 12, and 18 months). Case patients included outbreak survivors with a history of (1) ingestion of DEG-contaminated medication, (2) hospitalization for DEG poisoning, and (3) an unexplained serum creatinine level of 1.5 mg/dL or higher (to convert to micromoles per liter, multiply by 88.4) during acute illness or unexplained exacerbation of preexisting end-stage renal disease. Demographics, mortality, dialysis dependence, renal function, neurologic signs and symptoms, and nerve conduction studies. Of the 32 patients enrolled, 5 (15.6%) died and 1 was lost to follow-up, leaving 26 patients at 18 months. Three (9.4%) missed 1 or more evaluations. The median age was 62 years (range, 15-88 years), and 59.4% were female. Three (9.4%) patients had preexisting renal failure. Enrollment evaluations occurred at a median of 108 days (range, 65-154 days) after acute illness. The median serum creatinine level for the 22 patients who were not dialysis dependent at time 0 was 5.9 mg/dL (range, 1.8-17.1 mg/dL) during acute illness and 1.8 mg/dL (range, 0.9-5.9 mg/dL) at time 0. Among non-dialysis-dependent patients, there were no significant differences in the log of serum creatinine or estimated glomerular filtration rate over time. The number of patients with subjective generalized weakness declined significantly over time (P < .001). A similar finding was observed for any sensory loss (P = .05). The most common deficits at enrollment were bilateral lower extremity numbness in 13 patients (40.6%) and peripheral facial nerve motor deficits in 7 (21.9%). All patients with neurologic deficits at enrollment demonstrated improvement in motor function over time. Among 28 patients (90.3%) with abnormal nerve conduction study findings at enrollment, 10 (35.7%) had motor axonal involvement, the most common primary abnormality. Neurologic findings of survivors tended to improve over time. Renal function generally improved among non-dialysis-dependent patients between acute illness and the first evaluation with little variability thereafter. No evidence of delayed-onset neurologic or renal disease was observed.

Derivation and Validation of a Renal Risk Score for People With Type 2 Diabetes

OBJECTIVEDiabetes has become the leading cause of end-stage renal disease (ESRD). Renal risk stratification could assist in earlier identification and targeted prevention. This study aimed to derive risk models to predict ESRD events in type 2 diabetes in primary care.RESEARCH DESIGN AND METHODSThe nationwide derivation cohort included adults with type 2 diabetes from the New Zealand Diabetes Cohort Study initially assessed during 2000–2006 and followed until December 2010, excluding those with pre-existing ESRD. The outcome was fatal or nonfatal ESRD event (peritoneal dialysis or hemodialysis for ESRD, renal transplantation, or death from ESRD). Risk models were developed using Cox proportional hazards models, and their performance was assessed in a separate validation cohort.RESULTSThe derivation cohort included 25,736 individuals followed for up to 11 years (180,497 person-years; 86% followed for ≥5 years). At baseline, mean age was 62 years, median diabetes duration 5 years, and median HbA1c 7.2% (55 mmol/mol); 37% had albuminuria; and median estimated glomerular filtration rate (eGFR) was 77 mL/min/1.73 m2. There were 637 ESRD events (2.5%) during follow-up. Models that included sex, ethnicity, age, diabetes duration, albuminuria, serum creatinine, systolic blood pressure, HbA1c, smoking status, and previous cardiovascular disease status performed well with good discrimination and calibration in the derivation cohort and the validation cohort (n = 5,877) (C-statistics 0.89–0.92), improving predictive performance compared with previous models.CONCLUSIONSThese 5-year renal risk models performed very well in two large primary care populations with type 2 diabetes. More accurate risk stratification could facilitate earlier intervention than using eGFR and/or albuminuria alone.

Risk Factors for ESRD in HIV-Infected Individuals: Traditional and HIV-Related Factors

Despite improvements in survival with human immunodeficiency virus (HIV) infection, kidney disease remains an important complication. Few studies have evaluated risk factors associated with the development of end-stage renal disease (ESRD) in HIV-infected individuals. We sought to identify traditional and HIV-related risk factors for ESRD in HIV-infected individuals and compare ESRD risk by estimated glomerular filtration rate (eGFR) and proteinuria levels. Retrospective cohort study. 22,156 HIV-infected veterans without pre-existing ESRD receiving health care in the Veterans' Affairs medical system between 1996 and 2004. Hypertension, diabetes, cardiovascular disease, hypoalbuminemia (serum albumin <3.5 mg/dL), CD4 lymphocyte count, HIV viral load, hepatitis C virus coinfection, proteinuria, and eGFR were identified using the Veterans' Affairs electronic record system. ESRD was ascertained by the US Renal Data System. 366 cases of ESRD occurred, corresponding to 3 cases/1,000 person-years. Hypertension (HR, 1.9; 95% CI, 1.5-2.4), diabetes (HR, 1.7; 95% CI, 1.3-2.2), and cardiovascular disease (HR, 2.2; 95% CI, 1.7-2.7) were associated independently with ESRD risk in multivariate-adjusted models, as were CD4 lymphocyte count <200 cells/μL (HR, 1.5; 95% CI, 1.2-2.0), HIV viral load ≥30,000 copies/mL (HR, 2.0; 95% CI, 1.5-2.8), hepatitis C virus coinfection (HR, 1.9; 95% CI, 1.5-2.4), and hypoalbuminemia (HR, 2.1; 95% CI, 1.8-2.5). Compared with persons without chronic kidney disease, defined as eGFR >60 mL/min/1.73 m(2) and no proteinuria, lower eGFR and higher proteinuria categories were associated jointly with exponentially higher ESRD rates, ranging from 6.6 events/1,000 person-years for persons with urine protein excretion of 30-100 mg/dL and eGFR >60 mL/min/1.73 m(2) to 193 events/1,000 person-years for persons with urine protein excretion ≥300 mg/dL and eGFR <30 mL/min/1.73 m(2). Results may not be generalizable to female and nonveteran populations. In HIV-infected persons, ESRD risk appears attributable to a combination of traditional and HIV-related risk factors for kidney disease. Combining eGFR and proteinuria for chronic kidney disease staging is most effective for stratifying the risk of ESRD.