Presence Of Renal Insufficiency Research Articles

Effect of renal insufficiency on the short- and long-term outcomes of endoscopic submucosal dissection for early gastric cancer: Propensity score-matched analysis.

It is unclear whether renal insufficiency (RI) itself is a risk factor for adverse outcomes after gastric endoscopic submucosal dissection (ESD). We aimed to evaluate the safety and efficacy of gastric ESD in patients with and without RI using propensity score-matching analysis. In all, 4775 patients with 4775 early gastric cancer lesions undergoing ESD were analyzed. 1:1 propensity score-matching was performed between patients with and without RI using 12 variables. After matching, logistic regression and survival analyses were performed for short- and long-term outcomes of ESD, respectively. The matching yielded 188 pairs of patients with and without RI. In both univariable and multivariable analyses, the presence of RI was not significantly associated with postprocedural bleeding (unadjusted odds ratio 1.81, 95% confidence interval 0.74-4.42; adjusted odds ratio 1.86, 95% confidence interval 0.74-4.65, respectively). When RI patients were subclassified into patients with estimated glomerular filtration rate (eGFR) 30-59 mL/min/1.73 m2 and eGFR <30 mL/min/1.73 m2 , no significant differences in bleeding rates were found compared to their matched controls in both groups. Perforation, en bloc resection, en bloc and R0 resection, and curative resection rates of RI patients were 2.1%, 98.4%, 91.0%, and 78.2%, respectively, which were comparable to those of non-RI patients. During a median follow-up of 119 months, there was no difference in gastric cancer-specific survival between patients with and without RI (P = 0.143). The outcomes of ESD were comparable in patients with and without RI. Decreased renal function itself may not be a reason to keep patients with RI from receiving gastric ESD.

Nephrological management and drug dosing in patients with rheumatic diseases and renal insufficiency

In patients with inflammatory rheumatic diseases and renal insufficiency there are two challenges for physicians: to adapt the antirheumatic medication to the renal function and to carry out anephroprotective treatment that prevents long-term deterioration of renal function and reduces the elevated cardiovascular risk. Aliterature search (in PubMed) was carried out and the current state of knowledge on nephroprotective treatment strategies and the treatment of rheumatic diseases in the presence of renal insufficiency was collated, evaluated and summarized. Lifestyle interventions, especially the cessation of smoking and drug treatment strategies form the basis of nephroprotection including the control of diabetes mellitus with metformin, sodium glucose transporter 2 (SGLT2) inhibitors, glucagon-like peptide 1 (GLP1) analogues and control of hypertension with blockade of the renin-angiotensin-aldosterone system (RAAS), hyperlipidemia, hyperphosphatemia and metabolic acidosis. The SGLT2 inhibitors are also effective for nondiabetic nephropathy. The elevated cardiovascular risk is further reduced by effective control of inflammatory rheumatic activity. Numerous conventional disease modifying antirheumatic drugs, especially methotrexate and the Janus kinase (JAK) inhibitors baricitinib and filgotinib, must mostly be adapted to the renal function. In contrast, biologics can be given in standard doses with the exception of anakinra. The increased cardiovascular risk currently limits the use of tofacitinib in patients with renal insufficiency. The antirheumatic medication should be modified and acomplex nephroprotective treatment concept is mandatory in the management of patients with rheumatic disease and renal insufficiency, that in the best-case scenario can be guaranteed by a close interdisciplinary cooperation of rheumatologists and nephrologists.

Renal Function After Transcatheter Piccolo Patent Ductus Arteriosus Closure With Contrast Angiography in Extremely Premature Infants

Transcatheter patent ductus arteriosus (PDA) device closure is increasingly performed in extremely premature infants. Contrast angiography improves the procedural safety and effectiveness by precise anatomic delineation. Contrast nephropathy is a concern in clinically ill premature infants, especially with the presence of renal insufficiency. We hypothesized that the benefit of transcatheter PDA closure outweighs the harm of contrast nephropathy in extremely premature infants. A total of 160 infants underwent successful transcatheter (n=59) and surgical (n=101) PDA closure at a median age of 26 (7 to 78) days. The surgical group had a lower procedural weight (870 vs 960 g, p=0.014). In the transcatheter group, serum creatinine decreased from 0.48 to 0.45 mg/100 ml at 24 hours (p=0.003, n=59) and decreased further to 0.37 mg/100 ml at 5 to 7 days after closure (p &lt;0.001). Median contrast amount was 1.9 ml/kg (0.6 to 6.1). In 8 infants with pre-existing renal insufficiency who underwent transcatheter closure, serum creatine significantly improved from 1.44 to 1.36 mg/100 ml at 24 hours and 0.79 mg/100 ml at 5 to 7 days after closure (p &lt;0.001). There was no difference in improvement of serum creatinine between transcatheter and surgical closure groups. In conclusion, despite the use of contrast, serum creatinine significantly improved with transcatheter PDA closure even in infants with pre-existing renal insufficiency. Contrast angiography should not be discouraged for transcatheter PDA closure because of the concern for contrast nephropathy in extremely premature infants.

Effect of renal function on high-density lipoprotein particles in patients with coronary heart disease

BackgroundAlthough renal insufficiency and dyslipidemia are known to be closely associated, the effect of kidney function on the size and clinical value of high-density lipoprotein (HDL) particles remains largely unknown, especially in patients with coronary heart disease.MethodsA total of 419 coronary heart disease patients and 105 non-coronary heart disease patients were included. HDL particle size, represented by HDL-C/apoA-I, was compared between groups stratified by estimated glomerular filtration rate (eGFR) and Gensini scores using standard Student’s t test and one-way ANOVA. Pearson’s correlation test was performed to analyze the association between eGFR and HDL-C/apoA-I in patients with coronary heart disease. The relationship between HDL particle size and the occurrence of coronary heart disease was explored using Univariate logistic regression analysis.ResultsIn patients with coronary heart disease, between-group analysis revealed that HDL-C/apoA-I increased as eGFR declined, and significance appeared as eGFR declined to under 60 ml/min·1.73 m2 (P < 0.001), and Pearson's correlation test also confirmed an inverse correlation between eGFR and HDL-C/apoA-I levels in coronary heart disease patients. When stratified by Gensini scores, in coronary heart disease patients with eGFR ≥ 90 mL/(min·1.73 m2), those with higher Gensini scores had smaller HDL-C/apoA-I. However, with or without kidney insufficiency, smaller HDL-C/apoA-I was associated with a higher occurrence of coronary heart disease (P < 0.05).ConclusionWith the presence of renal insufficiency, HDL-C/apoA1 was higher in patients with coronary heart disease. Lower HDL-C/apoA1 was still associated with a higher occurrence of coronary heart disease, but the original association between lower HDL-C/apoA1 and more severe coronary artery stenosis was lost in patients with renal insufficiency.

MP17-06 PREDICTORS AND COST COMPARISON OF SUBSEQUENT URINARY STONE CARE AT INDEX VERSUS NON-INDEX HOSPITALS

You have accessJournal of UrologyHealth Services Research: Value of Care: Cost and Outcomes Measures I (MP17)1 Sep 2021MP17-06 PREDICTORS AND COST COMPARISON OF SUBSEQUENT URINARY STONE CARE AT INDEX VERSUS NON-INDEX HOSPITALS William French, Davis Viprakasit, Charles Scales, Roger Sur, and David Friedlander William FrenchWilliam French More articles by this author , Davis ViprakasitDavis Viprakasit More articles by this author , Charles ScalesCharles Scales More articles by this author , Roger SurRoger Sur More articles by this author , and David FriedlanderDavid Friedlander More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002002.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Care fragmentation, or the engagement of different health care systems along the continuum of care, has been shown to negatively affect patient outcomes. There is a lack of literature on care fragmentation’s effect on urinary stone disease. METHODS: All-payer data from the 2016 Healthcare Cost and Utilization Project (HCUP) State Databases from Florida (FL) and New York (NY) were used to identify a cohort of adult patients with an emergency department visit for a diagnosis of urolithiasis, who subsequently re-presented to an index or non-index hospital for renal colic and/or urological intervention. Patient demographics, regional data, and procedural information were collected and 30-day episode-based costs were calculated. Multivariable logistic and gamma generalized linear regression were utilized to identify predictors of surgery at an index hospital and 30-day costs, respectively. RESULTS: Of the 33,863 patients who experienced a subsequent encounter, 9,593 (28.3%) received care at a non-index hospital. Receiving care at an index hospital was associated with a decreased number of healthcare encounters prior to surgery (OR 0.89, 95% CI 0.86-0.91; p <0.001) and fewer days to surgery (OR 0.998, 95% CI 0.997 – 0.998; p < 0.001). Predictors of receiving care at an index hospital included increasing Elixhauser Comorbidity score (≥3 vs. 0: OR 1.34, 95% CI 1.20-1.48; p < 0.001) and the presence of renal insufficiency (OR 1.21, 95% CI 1.10-1.32; p < 0.001). Undergoing any type of urologic intervention (Percutaneous nephrolithotomy: OR 0.61, 95% CI 0.48-0.77, p < 0.001; Ureteroscopy: OR 0.85, 95% CI 0.74-0.98, p=0.027; Shockwave lithotripsy: OR 0.64, 95% CI 0.52-0.80, p < 0.001; Stent: OR 0.82, 95% CI 0.74-0.92, p < 0.001; Nephrostomy tube: OR 0.76, 95% CI 0.59-0.96, p=0.021), living in a rural area (OR 0.55, 95% CI 0.42-0.73; p < 0.001) and being covered by Medicare (OR 0.85, 95% CI 0.78-0.93; p=0.001) significantly lowered the likelihood of an index presentation. 30-day episode-based costs were higher in the non-index setting, with a mean difference of $698.81 (Non-index: $13,672.21, 95% CI $13,291.71 - $14,052.72; Index: $12,889.15, 95% CI $12,676.53 - $13,101.77; p < 0.001). CONCLUSIONS: Non-index pathways of care following an initial diagnosis of urolithiasis are associated with more health encounters, longer times to definitive surgery, and increased costs. Strategies to improve care coordination following a diagnosis of urolithiasis are likely to improve patient experience and episode-based spending. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e310-e310 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information William French More articles by this author Davis Viprakasit More articles by this author Charles Scales More articles by this author Roger Sur More articles by this author David Friedlander More articles by this author Expand All Advertisement Loading ...

Prednisone-Responsive Hypercalcemia in a Patient With IgG4 Disease and Elevated Serum PTHrP Levels

Background: Ninety percent of hypercalcemia cases are related to either primary hyperparathyroidism or malignancy (1). This case presents one of the atypical etiologies of hypercalcemia. Clinical Case: A 53-year-old man with past medical history of nephrectomy was admitted for acute respiratory distress syndrome secondary to SARS-CoV-2. Hospital stay was complicated by septic shock and acute kidney injury requiring hemodialysis. Three months post hospital admission, the patient developed non-parathyroid (PTH) mediated hypercalcemia. Lab work results showed elevated serum calcium of 12.7 mg/dl (8.6–10.6), ionized calcium 6.8 mg/dl (4.2–5.4), albumin 2.6 g/dl (3.4–5.4), serum creatinine of 3.5 mg/dl (0.5–1.5), eGFR of 18.4 ml/min, and a PTH of 4 pg/ml (12–88). Liver profile - total bilirubin of 10.5 mg/dl (0–1.2), direct bilirubin of 5.9 mg/dl (0–0.2), GGTP 2055 U/L (6–60), alkaline phosphatase of 936 u/L (40–125), bone fractionated alkaline phosphatase 216 u/L (0–55), 25-OH Vitamin D of 11 ng/nl (20–80), 1,25 OH vitamin D of <5 pg/ml (19–79), TSH of 3.56 mciu/mL (0.35–4.0), CPK of 20 u/L (21–232) and a normal SPEP and immune-electrophoresisTreatment for hypercalcemia was initiated with calcitonin and oral steroids (prednisone 40mg/day for 4 days, 20mg/day for 1 day, and 10mg/day for 2 days), resulting in normalization of serum calcium. Patient received tube feedings that contained 2192 mcg retinol activity equivalents of vitamin A daily, which is associated with vitamin A intoxication in the presence of renal insufficiency. Vitamin A returned 0.78 mg/L (0.3–1.2). Serum Parathyroid hormone-related peptide (PTHrP) was elevated at 12.4 pmol/L (0.0–2.0). There was no obvious malignancy on various imaging studies. A magnetic resonance cholangiopancreatography (MRCP) showed biliary stricturing suggestive of primary sclerosing cholangitis (PSC), however, liver biopsy was not consistent with PSC. Serum IgG4 level was found to be elevated to 142 mg/dl (range: 1–123) which raised suspicion for autoimmune cholangiopathy. Discussion: Patient presented with non-PTH mediated hypercalcemia with low serum 1,25 OHD levels and elevated serum PTHrP level. Although most cases of elevated PTHrP associated with hypercalcemia are due to solid tumors, increased PTHrP levels have been seen in hypercalcemic patients with hematological malignancies and rare benign causes such as pneumonia (5). Association of elevated hypercalcemia with elevated IgG4 levels and PTHrP levels has not been previously reported. MRCP findings and abnormal morphology detailed in liver biopsy are suggestive of IgG4-related disease (IgG4RD) (3). The responsiveness in hypercalcemia to prednisone also supports this diagnosis. IgG4RD is associated with multi-organ autoimmune involvement. This case report highlights another complication of IgG4RD (i.e. hypercalcemia) associated with elevated PTHrP levels.

Haemorrhagic complications in patients with renal insufficiency during treatment or prophylaxis with dalteparin

ObjectivesLow-molecular-weight heparins are widely used in clinical practice for the treatment or prophylaxis of venous thromboembolism (VTE). As these drugs are eliminated mainly by renal means, any renal function impairment...

Treatment of rheumatic disease with renal insufficiency

Reduced renal function is not rare in patients with inflammatory rheumatic diseases and is associated with an increased risk of treatment-induced and perioperative adverse events. Aliterature search was carried out for the medical treatment and perioperative management of rheumatic disease in the presence of renal insufficiency. Patients with rheumatic disease and renal insufficiency have ahigher risk of cardiovascular disease, bone loss and immunodeficiency than those without kidney disease. The perioperative rate of cardiovascular and infectious complications and the risk of acute kidney failure are elevated in these patients. The pharmacokinetics of many drugs used in rheumatology is influenced by the kidney function. Especially methotrexate is contraindicated in patients with an estimated glomerular filtration rate (eGFR) <45 ml/min. Nonsteroidal anti-inflammatory drugs (NSAIDS) and cyclooxygenase (COX)-2 inhibitors should not be used with renal insufficiency or only for ashort term with the lowest effective dose. The treatment of osteoporosis with antiresorptive drugs may lead to adynamic bone disease in advanced kidney disease, and, therefore, the use of these drugs is controversial. Medication should be modified in patients with rheumatic disease and kidney involvement according the grade of renal insufficiency. There is also aneed for special perioperative management in these patients, with interdisciplinary cooperation of rheumatologists, nephrologists and orthopedic doctors.

Acute mesenteric ischemia (AMI): absence of renal insufficiency and performance of early bowel resection may indicate improved outcomes.

Acute mesenteric ischemia (AMI) is still associated with very high morbidity and mortality while the rareness and heterogeneity hamper the establishment of evidence-based guidelines. We sought to help standardize contemporary treatment by a cohort study at our tertiary center in the rising endovascular age. A retrospective cohort study was conducted from 2005 to 2015. Patients with occlusive (OMI), non-occlusive (NOMI), and venous mesenteric ischemia (VMI) were compared with respect to clinical and treatment parameters as well as outcome. The study cohort consisted of 48 patients composed of 27 males and 21 females with an average age of 63years and an average BMI of 25.1kg/m2. In 48% of patients (N=23), an acute arterial OMI had occurred while NOMI was present in 31% (N=15) and VMI in 21% (N=10). Interventional and intraoperative recanalizations were significantly more often required in OMI patients compared with other entities (p=0.003). Patients with venous mesenteric ischemia had a significant better overall survival than patients with OMI or NOMI in the univariate analysis (p=0.027). Patients with renal failure had a 14.7-fold higher relative risk (Cox p=0.013) and patients without bowel resection during primary surgery had a 17.8-fold higher relative risk (Cox p=0.047) to die of AMI in the postoperative course. AMI remains a rare but oftentimes fatal disease. Our study provides evidence that outcome may depend on the AMI subtype, presence of renal insufficiency, and early bowel resection. Further research should help individualize treatment for optimized outcomes.

Determinants and Risks Factors of Renal Failure in Patients with Heart Failure in Cardiology Department of CHU Sylvanus Olympio of Lom&amp;#233; (Togo)

Introduction: The morbidity and mortality of patients with heart failure are known to increase rapidly in the presence of renal insufficiency, which is usually the cause but may be a consequence. To organize better prevention of renal failure, we undertook this study to identify the determinants of renal failure in the population of patients with heart failure. Methodology: This was a retrospective descriptive and analytical study of heart failure (HF) cases hospitalized from January 1st to December 31st, 2016, over a period for twelve (12) months at CHU Sylvanus Olympio. Patients who performed cardiac Doppler ultrasound were included in our study. Renal failure was defined as eGFR (estimated glomerular filtration rate) less than 60 ml/min/1.73m2. Multivariate logistic regression was performed to investigate associated factors. The dependent variable was DFG status: coded 1 if the GFR is less than 60 ml/min and 0 if not. Results: A total of 216 patients were included. The majority were female (54.17%). The median age of patients was 53 years [IQI = 32 - 61 years] with extremes of 15 and 96 years. 16.49% of patients had a GFR of less than 60 ml/min. In multivariate analysis the average standard of living (OR = 2.40, p = 0.0456), diabetes (OR = 2.67, p = 0.0300), hypertension (OR = 5.66, p = 0.0399), alcoholism (OR = 4.00, p = 0.0063) were the main factors in the development of an RF/HF. Conclusion: The average standard of living, diabetes, hypertension, and chronic alcoholism are the determinants of renal failure in HF.

Significance of histological crescent formation in patients with IgA vasculitis (Henoch-Sch\xf6nlein purpura)-related nephritis: a cohort in the adult Chinese population

BackgroundIgA vasculitis (IgAV, formerly Henoch-Schönlein purpura) is a type of systemic vasculitis. This study aimed to explore the clinicopathological features, treatment and renal outcomes of adult IgAV-related nephritis (Henoch-Schönlein purpura nephritis) patients with different degrees of crescent formation.MethodsAdult patients with biopsy-proven IgAV-related nephritis in Nanjing Jinling Hospital were enrolled and divided into three groups as follows: control (no crescents, n = 257), group 1 (crescents < 25%, n = 381), and group 2 (crescents ≥25%, n = 60). The clinicopathological features, treatment and renal outcomes were compared among the three groups.ResultsThere were no significant differences in gender and age at biopsy among the three groups. Groups with more crescents had shorter renal durations and higher prevalence of macroscopic hematuria, proteinuria and nephrotic syndrome than the control group. The presence of renal insufficiency at biopsy was similar, whereas laboratory findings indicated that patients with ≥25% crescents had higher levels of serum creatinine and blood urea nitrogen than the control and group 1. Histologically, the incidence of glomeruli-Bowman’s capsule adhesion and capillary necrosis were proportional to the degree of crescent formation. Patients with more crescents received more positive immunosuppressive therapies. During follow-up, the levels of proteinuria and hematuria were in remission after treatment, and patients without crescents had lower levels of proteinuria. At the last follow-up, the renal function had deteriorated in the control and group 1, whereas the levels of serum creatinine at biopsy and last follow-up were similar in group 2. There was a significant difference in renal survival from end-stage renal disease (ESRD) or 50% decline in renal function among the three groups (log-rank, P = 0.030). However, no association between crescent formation and renal outcomes was found after adjusting potential confounders.ConclusionsAdult IgAV-related nephritis patients with more crescents had more-severe renal manifestations and worse treatment responses, whereas the proportions of crescents were not associated with higher risks for ESRD or 50% decline in renal function. A more suitable pathological classification standard is needed to predict renal prognosis.

Annals for Educators - 6 June 2017

Annals for Educators - 6 June 2017

Hypocalcemia After Bariatric Surgery: Prevalence and Associated Risk Factors.

The reported prevalence of hypocalcemia after bariatric surgery ranges from 1% after Roux-en-Y gastric bypass (RYGB) to 25% after bilio-pancreatic diversion-duodenal switch (BPD-DS). We aimed to define the prevalence of post-operative hypocalcemia and identify clinical predisposing factors. The study was conducted in an Academic Medical Center, USA. Retrospective analysis of all patients undergoing bariatric surgery from May 2008 to December 2014 at Mayo Clinic Rochester, Minnesota was performed. Patients with revision surgeries were excluded. Hypocalcemia was defined as the lowest recorded serum calcium occurring at least 2weeks post-operatively. Nine hundred ninety-nine patients fulfilled the criteria above. After correction for serum albumin concentration, 36 patients had serum calcium ≤8.9mg/dl. Mean serum calcium was 8.1±0.6mg/dl. The prevalence was 1.9% in the RYGB group, 9.3% in the sleeve gastrectomy (SG) group, and 10% in the BPD-DS group. In all three surgical types, patients with hypocalcemia had significantly lower serum albumin and serum 25 (OH) vitamin D concentrations when compared to their normocalcemic counterparts (P<0.01). The presence of renal insufficiency and vitamin D deficiency was associated with the highest risk of developing hypocalcemia after surgery [OR 16.8 (6.45-47.7) and 7.1(2.9-17.3), respectively]. Pre-operative renal insufficiency increased the odds of developing hypocalcemia by 20-fold. In our series, hypocalcemia was identified in 3.6% of patients undergoing all bariatric surgery. Patients who are predisposed to developing post-operative hypocalcemia, such as those with pre-operative renal impairment, or post-operative vitamin D deficiency and renal insufficiency, may benefit from increased surveillance and prevention strategies.

Characterization of Mineralocorticoid Receptor Antagonist Therapy Initiation in High-Risk Patients With Heart Failure.

Heart failure guidelines recommend routine monitoring of serum potassium, and renal function in patients treated with a mineralocorticoid receptor antagonist (MRA). How these recommendations are implemented in high-risk patients or according to setting of drug initiation is poorly characterized. We conducted a retrospective cohort study of Medicare beneficiaries linked to laboratory data in 10 states with prevalent heart failure as of July 1, 2011, and incident MRA use between May 1 and September 30, 2011. Outcomes included laboratory testing before MRA initiation and in the early (days 1-10) and extended (days 11-90) post-initiation periods, based on setting of drug initiation and the presence of renal insufficiency. Additional outcomes included abnormal laboratory results and adverse events proximate to MRA initiation. Of 10 443 Medicare beneficiaries with heart failure started on an MRA, 19.7% were initiated during a hospitalization. Appropriate follow-up laboratory testing across all time periods occurred in 25.2% of patients with inpatient initiation compared with 2.8% of patients begun as an outpatient. Patients with chronic kidney disease had higher rates of both hyperkalemia and acute kidney failure in the early (1.3% and 2.7%, respectively) and extended (5.6% and 9.8%, respectively) post-initiation periods compared with those without chronic kidney disease. Patients initiated on MRA therapy as an outpatient had extremely poor rates of guideline indicated follow-up laboratory monitoring after drug initiation. In particular, patients with chronic kidney disease are at high risk for adverse events after MRA initiation. Quality improvement initiatives focused on systems to improve appropriate laboratory monitoring are needed.

Tiempo de estancia prolongado en los pacientes ingresados por insuficiencia cardiaca aguda

ObjectiveTo identify the factors associated with prolonged length of hospital stay in patients admitted for acute heart failure. MethodsMultipurpose observational cohort study including patients from the EAHFE registry admitted for acute heart failure in 25 Spanish hospitals. Data were collected on demographic and clinical variables and on the day and place of admission. The primary outcome was length of hospital stay longer than the median. ResultsWe included 2,400 patients with a mean age of 79.5 (9.9) years; of these, 1,334 (55.6%) were women. Five hundred and ninety (24.6%) were admitted to the short stay unit (SSU), 606 (25.2%) to cardiology, and 1,204 (50.2%) to internal medicine or gerontology. The mean length of hospital stay was 7.0 (RIC 4-11) days. Fifty-eight (2.4%) patients died and 562 (23.9%) were readmitted within 30 days after discharge. The factors associated with prolonged length of hospital stay were chronic pulmonary disease; being a device carrier; having an unknown or uncommon triggering factor; the presence of renal insufficiency, hyponatremia and anaemia in the emergency department; not being admitted to an SSU or the lack of this facility in the hospital; and being admitted on Monday, Tuesday or Wednesday. The factors associated with length of hospital stay≤7days were hypertension, having a hypertensive episode, or a lack of treatment adherence. The area under the curve of the mixed model adjusted to the center was 0.78 (95% CI: 0.76-0.80; p<0.001). ConclusionsA series of factors is associated with prolonged length of hospital stay and should be taken into account in the management of acute heart failure.

Predictors of ertapenem therapeutic efficacy in the treatment of urinary tract infections (UTIs) in hospitalized adults: the importance of renal insufficiency and urinary pH.

In hospitalized adults acute uncomplicated cystitis (AUC) and catheter associated bacteriuria (CAB) may be treated with oral antibiotics. With AUC or CAB due to extended spectrum ß-lactamase (ESBL) + Gram negative bacilli (GNB) physicians often use intravenous therapy, e.g., ertapenem. We reviewed our recent experience in hospitalized adults with AUC and CAB treated with ertapenem. Therapeutic efficacy of ertapenem was assessed by decreased pyuria/bacteriuria, and elimination of the uropathogen. The effectiveness of ertapenem in the presence of renal insufficiency (CrCl < 50ml/min) and acid and alkaline urinary pH were evaluated. In addition, rapidity of eradication of bacteriuria was assessed by time to negative urine cultures (TTNC). In those with an acid urinary pH ertapenem was highly effective in eliminating bacteriuria (TTNC < 3days). TTNC was prolonged ( >3days) in patients with decreased renal function and alkaline urinary pH. We reviewed 45 hospitalized adults with AUC or CAB to determine if renal insufficiency and or alkaline urinary pH affected ertapenem efficacy. In the 33 adult hospitalized patients with AUC and 12 with CAB, we found that ertapenem was consistently effective in eliminating the GNB bacteriuria. In hospitalized adults, the presence of renal insufficiency and acid urine, bacteriuria was eliminated in < 3days. However, in those with renal insufficiency and an alkaline urine pH, the rapidity of cure, i.e., time to negative cultures (TTNC) was prolonged, i.e., > 3days which has not been previously reported.

The Study of Factors Associated with Severity of In-Stent Restenosis in Patients Treated with PCI for Acute Coronary Syndromes

Abstract Introduction: The management of in stent restenosis represents a topic of great actuality and interest, especially since the interventional treatment with stent implantation became largely accepted as the metod of choice in patients with acute coronary syndromes. Identification of certain risk factors that could predict the development of an in stent restenosis and its severity could be extremely useful for the clinical management of these patients. Methods: We retrospectively analyzed a total of 60 stent restenoses encountered in 57 patients admitted and treated in the Cardiology Clinic of Tirgu Mures. The interval of occurrence of restenosis ranged between 2 months and 37 months postintervention. We monitored the demographic characteristics (age, gender, colesterol, presence of renal insufficiency) and we realized a descriptive qualitative analysis of the angiographic procedural aspects. The in stent restenosis occurred most frequently on left anterior descending artery (63%), followed by the circumflex artery (22.15%) and right coronary artery (14.8%), regardless of the degree of stenosis prior to revascularization. Results: Statistical analysis using Chi square test revealed no statistically significant differences in terms of the correlation between the incidence of restenosis and gender (p=0.14), treatment with ACE inhibitors (p=0.16), implanted stent diameter (p=0.22) or the type of procedure (ram crossing over a secondary branch being considered as a procedure involved in the genesis of severe restenosis) (p=0.2). We used the t-student test for comparative analysis of the correlation between the continuous variables related to initial native lesion diameter and the degree of restenosis, without finding any a statistically significant correlation between them (p=0.226). However, a statistically significant correlation was found between cholesterol levels and the degree of stenosis (p=0.039). Descriptive analysis of restenosis lesions did not find any statistically significant correlation with the type or degree of stenosis in the native vessel, but showed statistically significant differences when evaluating the geometric assumption of restenosis by intraluminal diameter or intraluminal area (p=0.0018), suggesting that assessment of the degree of restenosis should be performed only by planimetric area. Conclusions: We can conclude that in stent restenosis represents a plurifactorial phenomenon, that is not conditioned by the severity of the native lesion or by the administration of ACE inhibitors or Spironolactone, however it depends directly on the control of cholesterol values afther the coronary revascularization.

A Patient with Chronic Lymphocytic Leukemia and Bone Localization: A Case Report

Metastatic disease of the bone is a rare complication of chronic lymphocytic leukemia (CLL), it may be result from richter's transformation or metastatic from non lymphoid malignancies. CLL is the most common form of adult leukemia, with the median age of 70 years at diagnosis [Siegel et al. 2013]. The diagnosis is established by blood counts, blood smears, and immunophenotyping of circulating B-lymphocytes.The result is the increased number of lymphocytes in the peripheral blood, leukocytosis with absolute lymphocytosis, the increase of the lymphnodes, the increase in size of the spleen. The diagnosis of chronic lymphocytic leukemia B requires the presence of Clonal B cells in the peripheral blood at or above 5,000 / ul for at least 3 months. Typing immunophenotypical pathological lymphocytes are positive for surface antigens CD5, CD19, CD23, weakly positive for CD20 and CD22, generally negative FMC7 and CD79b; also expressing surface immunoglobulins. The Rai and Binet staging systems, which are established by physical examination and blood counts, have been recognized as standards for deciding whether to begin treatment. Patients with active or symptomatic disease or with advanced Binet or Rai stages require therapy. For fit patients, chemoimmunotherapy with fludarabine, cyclophosphamide, and rituximab represents the current standard therapy. For unfit patients, treatment with an anti-CD20 antibody (obinutuzumab, rituximab, ofatumumab) plus a milder chemotherapy (Chlorambucil) may be applied. At relapse, if the treatment-free interval exceeds two to three years, the initial treatment may be repeated, if the disease relapses earlier, drugs such as bendamustine (plus rituximab), alemtuzumab, lenalidomide, ofatumumab, ibrutinib, or idelalisib, must be choosen. Patients with a del(17p) or TP53 mutation can be treated with ibrutinib or a combination of idelalisib and rituximab. in relapsing patients with TP53 mutations or del(17p) or patients that are refractory to repeated chemoimmunotherapies, an allogeneic SCT may be considered [Hallek M 2015].In this article we show a case of a 66-year-old man with CLL and a bone localization. In 2011 diagnosis of CLL, Rai Stage 0, Binet Stage A. Principal characteristics at diagnosis: HB 13.2 g /dl, White Blood Cells 15.800 / mm3, lymphocytes 61%, neutrophils 32%, monocytes 4%, platelets 141.000/mm3; normal hepatic end renal function; flowcytometric immunophenotyping of the peripheral blood revealed B-cell CLL; prognostic factors: CD38 negative, ZAP70 positive, rearrangement of the immunoglobulins mutated; FISH: negative; CT chest / abdomen / pelvis: presence of multiple aorto-pulmonary and axillary adenopathies (max diameter of 2 centimeters); bone marrow biopsy: infiltration of CLL equal to 60% of global cellularity. The patient was only observed until January 2015, when he was hospitalized due to acute anemia, requiring supportive therapy, and right foot pain . So it was decided to re-evaluate the whole disease in order to decide whether to start chemotherapy. The disease was staged again with instrumental and laboratory tests: presence of renal insufficiency, egd and colonoscopy negative, Coombs' test negative, bone marrow biopsy confirmed the diagnosis of chronic lymphocytic with bone marrow infiltration of 90%, abdomen ultrasound showed only moderate splenomegaly.On February, persistence of right foot pain and appearance of swelling, assessed by the orthopedic as a suspected algic and dystrophic syndrome. So he suggested to perform scintigraphy which revealed: pronounced inflammatory osteometabolic reaction of the right tibia/fibula/ankle third distal which could be referred, in the first evaluation, to algic and dystrophic syndrome. However, a local biopsy was performed: localization of chronic lymphocytic leukemia. On March 2015 a total body TC showed 2 nodular calcifications in the right lung lobe, multiple right paratracheal, barety space, aortopulmonary and axillary adenopathies. Prostate size increased. In order to study carefully the liver and prostate lesions, an ultrasound abdomen was performed that documented only enlarged spleen, normal size liver, free of focal disease, increased prostate due to symmetric bilobate hypertrophy . After the second cycle of chemotherapy, prolonged thrombocytopenia, so he continues only with a radiotherapy program. DisclosuresNo relevant conflicts of interest to declare.

Smoldering Multiple Myeloma: Impact of the Evolving Pattern on Early Progression

Introduction: Smoldering multiple myeloma (SMM) is a plasma cell dyscrasia defined by the presence of a monoclonal protein (MP) (≥ 30 g/L in serum or >1g/24-hours in urine) and/or plasma cell bone marrow involvement (BMPC) ≥ 10%, in the absence of symptoms due to the gammopathy. The risk of progression to symptomatic disease in patients with SMM is highly variable. Several biomarkers and prognostic index associated with risk of early progression based on tumoral load (M-protein size and percentage of BMPC), M-protein behaviour (evolving vs. non-evolving) and/or immunological status (heavy chain isotype, isotype suppression of uninvolved immunoglobulins and serum free light-chain (FLC) κ/λ ratio) have been recently identified. The identification of patients at risk for early progression is crucial when considering the current possibility of prompt therapeutic intervention. The aim of this study was to analyze the factors associated with early progression to multiple myeloma (MM) in patients diagnosed with SMM and long follow-up in a single institution. Methods: Medical records of the 207 patients (76M/131M; median age 65 years, range 33 to 92) diagnosed with SMM (International Myeloma Working Group criteria, 2003) at our institution between January 1973 and December 2012 were systematically reviewed. Progressive increase in the value of MP was defined as when at least 10% increase was observed within the first 6 months from diagnosis when MP was ≥ 30 g/L (Rosinol et al, Br J Haematol. 2003) or progressive increase in MP in each of the annual consecutive measurements during a period of 3 years in patients with an initial MP Results: Sixty-seven patients (33%) accomplished both SMM criteria (MC and BMPCs), while the remaining 140 patients only had one of them. With a follow up of 1,692 years-person, 105 patients had progressed (50.7%) to MM and one case to AL amyloidosis (0.5%). The estimated probability of progression at 2 and 5 years was 19.9% and 44.9% respectively, with a median time to progression (TTP) of 7.3 years (95% CI 3.9 to 10.6). At the time of progression, clinical manifestations were mainly anemia (52%) and skeletal lytic lesions (40%). The presence of renal insufficiency, extramedullary plasmacytomas or hypercalcemia was only identified in 12 patients (5.8%). The median survival after progression was 5 years (95% CI 3.8 to 6.2). Evolving type was recognized in 25% of the patients, and was associated with a probability of progression of 45% and 78.1% at 2 and 5 years and was higher than those with stable MP (HR 4.5; 95% CI 3 to 6.9; p At the univariate analysis the MP size ( Conclusion: In this series of patients with SMM with long follow up, evolving pattern, proportion of BMPCs and the presence of immunoparesis can accurately predict accurately the risk of early progression to symptomatic disease. Evolving type should be routinely monitored during the follow up of patients with SMM, since it is the most significant predictor for early progression. Disclosures No relevant conflicts of interest to declare.

Smoldering Multiple Myeloma: Impact of the Evolving Pattern on Early Progression

Introduction: Smoldering multiple myeloma (SMM) is a plasma cell dyscrasia defined by the presence of a monoclonal protein (MP) (≥ 30 g/L in serum or >1g/24-hours in urine) and/or plasma cell bone marrow involvement (BMPC) ≥ 10%, in the absence of symptoms due to the gammopathy. The risk of progression to symptomatic disease in patients with SMM is highly variable. Several biomarkers and prognostic index associated with risk of early progression based on tumoral load (M-protein size and percentage of BMPC), M-protein behaviour (evolving vs. non-evolving) and/or immunological status (heavy chain isotype, isotype suppression of uninvolved immunoglobulins and serum free light-chain (FLC) κ/λ ratio) have been recently identified. The identification of patients at risk for early progression is crucial when considering the current possibility of prompt therapeutic intervention. The aim of this study was to analyze the factors associated with early progression to multiple myeloma (MM) in patients diagnosed with SMM and long follow-up in a single institution.Methods: Medical records of the 207 patients (76M/131M; median age 65 years, range 33 to 92) diagnosed with SMM (International Myeloma Working Group criteria, 2003) at our institution between January 1973 and December 2012 were systematically reviewed. Progressive increase in the value of MP was defined as "evolving" when at least 10% increase was observed within the first 6 months from diagnosis when MP was ≥ 30 g/L (Rosiñol et al, Br J Haematol. 2003) or progressive increase in MP in each of the annual consecutive measurements during a period of 3 years in patients with an initial MP < 30 g/L (Rosiñol et al, Mayo Clin Proc. 2007). Immunoparesis was defined as any value below normal in not involved immunoglobulins. Bone marrow aspirates obtained at diagnosis were reviewed independently by 2 observers. Plasma cell percentages were estimated from a 500-cell count by each examiner and the mean values were considered.Results: Sixty-seven patients (33%) accomplished both SMM criteria (MC and BMPCs), while the remaining 140 patients only had one of them. With a follow up of 1,692 years-person, 105 patients had progressed (50.7%) to MM and one case to AL amyloidosis (0.5%). The estimated probability of progression at 2 and 5 years was 19.9% and 44.9% respectively, with a median time to progression (TTP) of 7.3 years (95% CI 3.9 to 10.6).At the time of progression, clinical manifestations were mainly anemia (52%) and skeletal lytic lesions (40%). The presence of renal insufficiency, extramedullary plasmacytomas or hypercalcemia was only identified in 12 patients (5.8%). The median survival after progression was 5 years (95% CI 3.8 to 6.2).Evolving type was recognized in 25% of the patients, and was associated with a probability of progression of 45% and 78.1% at 2 and 5 years and was higher than those with stable MP (HR 4.5; 95% CI 3 to 6.9; p<0.001) (Figure 1). Evolving pattern was more frequently associated with IgA isotype (41.2% vs. 23.8%; p=0.02). Negative impact in median TTP of evolving type was significant in patients either with both diagnostic criteria (MP and BMPCs; 1.3 vs. 6.3 years, p<0.001) and in those with only one of them (3.7 vs. not reached; p<0.001).At the univariate analysis the MP size (< vs. ≥ 30 g/L, median 13.4 vs. 3.1 years, p<0.001), the proportion of BMPCs (< vs. ≥ 20%, 17.2 vs. 2.9 years, p<0.001), the presence or absence of immunoparesis (3.9 vs. 16.9 years, p=0.001) and the evolving pattern (19.4 vs. 3 years, p<0.001) were significantly associated with a higher risk of progression. At the multivariate analysis only the evolving type (HR 4.9, 95% CI 2.8 to 8.7, p<0.001), the proportion of BMPCs (HR 2.5, 95% CI 1.3 to 4.6, p=0.004) and the presence of immunoparesis (HR 1.9, 95% CI 1.03-3.6, p=0.042) retained their statistical significance. Considering these last three variables, a model of risk stratification (Figure 2) was built, ranging from a probability of progression at 2 years of 81.8% for patients with the 3 factors present to only 4% for patients in group 4 (no risk factors).Conclusion: In this series of patients with SMM with long follow up, evolving pattern, proportion of BMPCs and the presence of immunoparesis can accurately predict accurately the risk of early progression to symptomatic disease. Evolving type should be routinely monitored during the follow up of patients with SMM, since it is the most significant predictor for early progression. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.