Recurrent Pulmonary Edema Research Articles

P223 BENEFICIAL EFFECT OF ACEI/ARB, BETABLOCKER AND MINERALOCORTICOID RECEPTOR ANTAGONIST IN PATIENTS WITH RECURRENT FLASH PULMONARY EDEMA INITIATED ON HEMODIALYSIS FOR END STAGE RENAL FAILURE

Background and Objectives: Recurrent flash pulmonary edema is a rare manifestation of ESRF commencing hemodialysis, necessitating more frequent dialysis. Recurrent flash pulmonary edema is seen in renal artery stenosis and rarely in chronic kidney disease. Objective of the study is look for any possible contributory factors for recurrent flash pulmonary edema in patients with ESRF initiated on hemodialysis; and the potential role of ACEI/ARB, β blockers and MRA in controlling episodes of flash pulmonary edema. Methods: All patients initiated on hemodialysis from January 2020 to December 2023 were studied in detail; including ECHO cardiography and renal ultrasound doppler. Patient were divided in to 2 groups based on absence or presence of recurrent flash pulmonary edema (Group A and Group B).Group B further divided in to Group C and D. Group C were treated with ACEI/ARB, β blocker and MRA in addition to nitroglycerine infusion and hemodialysis. Group D were given usual anti hypertensives nitroglycerine infusion and hemodialysis as per requirement. Group C and D were followed up for 2 months and evaluated for the final out come. Results: 238 patients were initiated on hemodialysis during the period of 3 years. 18 patients (7.56%) presented with recurrent flash pulmonary edema (Group B) and 220 patients (92.44%) comprised Group A. Patients in Group B had more severe LVH, left ventricular diastolic dysfunction (LVDD) PAH and accelerated hypertension. None of the patients had renal artery stenosis. At the end of 2 months patients in Group C (9 patients) were free from recurrent flash pulmonary edema compared to Group D (9 patients) Conclusions: Recurrent flash pulmonary edema is a rare manifestation of ESRF. Renal artery stenosis was not seen in our patients. LVH, LVDD due to uremic cardiomyopathy and accelerated hypertension due to RAAS activation may be the contributory factors. Treatment with ACEI/ARB, β blockers and MRA may help in controlling episodes of flash pulmonary edema.

Evaluation and Management of the Individual with Recurrent High Altitude Pulmonary Edema.

Luks AM, Grissom CK. Evaluation and Management of the Individual with Recurrent HAPE. High Alt Med Biol. 25:238-246, 2024. Individuals with a history of acute altitude illness often seek recommendations from medical providers on how to prevent such problems on future ascents to high elevation. Although many of these cases can be managed with pharmacologic prophylaxis and counseling about the appropriate rate of ascent alone, there are some situations in which further diagnostic evaluation may also be warranted. One such situation is the individual with recurrent episodes of high altitude pulmonary edema (HAPE), as one of several predisposing factors may be present that warrants additional interventions beyond pharmacologic prophylaxis and slow ascent and may even preclude future travel to high altitude. This review considers this situation in greater detail. Structured around the case of an otherwise healthy 27-year-old individual with recurrent episodes of HAPE who would like to climb Denali (6,190 m), the review examines the known risk factors for disease and then provides guidance regarding when and how to evaluate such individuals and appropriate steps to prevent HAPE on further ascents to high elevation. Except in rare circumstances, a history of recurrent HAPE does not preclude further ascent to high elevation, as a multipronged approach including pharmacologic prophylaxis, careful planning about the rate of ascent, and the degree of physical effort and other strategies, such as preacclimatization, staged ascent, and use of hypoxic tents, can be employed to reduce the risk of recurrence with future travel.

Mitral transcatheter edge-to-edge repair vs. isolated mitral surgery for severe mitral regurgitation: a French nationwide study.

Mitral valve surgery and, more recently, mitral transcatheter edge-to-edge repair (TEER) are the two treatments of severe mitral regurgitation in eligible patients. Clinical comparison of both therapies remains limited by the number of patients analysed. The objective of this study was to analyse the outcomes of mitral TEER vs. isolated mitral valve surgery at a nationwide level in France. Based on the French administrative hospital discharge database, the study collected information for all consecutive patients treated for mitral regurgitation with isolated TEER or isolated mitral valve surgery between 2012 and 2022. Propensity score matching was used for the analysis of outcomes. A total of 57 030 patients were found in the database. After matching on baseline characteristics, 2160 patients were analysed in each arm. At 3-year follow-up, TEER was associated with significantly lower incidence of cardiovascular death (hazard ratio 0.685, 95% confidence interval 0.563-0.832; P = .0001), pacemaker implantation, and stroke. Non-cardiovascular death (hazard ratio 1.562, 95% confidence interval 1.238-1.971; P = .0002), recurrent pulmonary oedema, and cardiac arrest were more frequent after TEER. No significant differences between the two groups were observed regarding all-cause death (hazard ratio 0.967, 95% confidence interval 0.835-1.118; P = .65), endocarditis, major bleeding, atrial fibrillation, and myocardial infarction. Our results suggest that TEER for severe mitral regurgitation was associated with lower cardiovascular mortality than mitral surgery at long-term follow-up. Pacemaker implantation and stroke were less frequently observed after TEER.

The characteristic of acute coronary syndromes of patients with multivessel coronary artery disease in centers with and without cardiac surgery on-site.

Multivessel disease (MVD) is diagnosed in a fair number of patients with acute coronary syndrome (ACS). There are 36 cardiac-surgery (CS) centres and 157 catheterization laboratories dedicated to treat ACS in Poland. The aim of the study was to analyze MVD patient outcomes presented with ACS in centers with or without CS on-site. The present study is a retrospective analysis (2017-2020) of MVD ACS patients (n = 4618) outcomes between those treated in centers with CS on site (n = 595) and those without CS (n = 4023). Patients in CS centers had a higher prevalence of renal failure (13.3% vs. 8.8%, p ≤ 0.001) and a more frequent history of coronary angioplasty - percutaneous coronary intervention (18.9% vs. 14.4%, p = 0.005). During the coronary angiography a femoral artery access was more often used in CS center patients (47.1% vs. 15.2%, p < 0.001). Percutaneous coronary intervention of MVD was more often performed in CS centers (74.6% vs. 71.0%, p = 0.054). In-hospital death (7.6% vs. 4.6%, p = 0.002), reinfarction (1.1% vs. 0.1%, p < 0.001), hemorrhagic complications (6.4% vs. 1.6%, p < 0.001), recurrent target vessel revascularization (1.8% vs. 0.4%, p ≤ 0.001) and pulmonary edema (3.7% vs. 1.5%, p < 0.001) occurred more often in CS centers. The safety of ACS treatment in MVD patients in centers without CS on site is non-inferior to their treatment in centers with CS on site. Interestingly, there were more in-hospital adverse events observed in ACS MVD patients treated in centers with CS.

Resistant Hypertension with Recurrent Flash Pulmonary Edema in the Setting of Bilateral Renal Artery Occlusion

Resistant Hypertension with Recurrent Flash Pulmonary Edema in the Setting of Bilateral Renal Artery Occlusion

Valve In Valve Transaortic Valve Replacement (ViV-TAVR) in a Patient with Recurrent Pulmonary Edema: A Novel Procedure That Could Be Effective and Life-Saving in High-Risk Patients

Background: Bio-prosthesis is the method of choice in managing aortic valve stenosis due to THE lesser probability of coagulation, even though higher valve replacement rates are undeniable. Valve-in-Valve Surgical Valve Replacement (ViV-SAVR) is shown to have lower rates of mortality than reoperation. We have reported a patient undergoing a ViV-SAVR procedure with exceptionally better results than in the literature. Case presentation: A 73-year-old Caucasian female was admitted with dyspnea and pulmonary edema with a bioprosthetic Mitroflow valve stented 10 years before admission. The echocardiography showed ejection fraction = 30%, left ventricular end-diastolic volume = 135 mL, LVEDV index = 72.9 mi∕m2, degenerated aortic valve with severe transvalvular aortic regurgitation, and mild aortic stenosis (mean gradient = 19 mmHg, peak gradient = 36 mmHg). The prosthetic valve was positioned on the previous Mitroflow bioprosthetic valve strut, followed by aortography. The patient was followed up for one month using transesophageal echocardiography, with no paravalvular leakage. Aortic transvalvular mean gradient of 16 mmHg and EOA of 1.3 cm2. Conclusion: ViV-SAVR is a method of treating aortic valve stenosis, which, if performed correctly, can enhance the survival and quality of life of the patients.

Recurrent flash pulmonary edema in unilateral renal artery stenosis with contralateral kidney shrinkage: A case report.

Flash pulmonary edema is a critical medical condition characterized by sudden and severe fluid accumulation in the lungs, which poses an immediate and life-threatening emergency. This can arise from a variety of underlying causes. This manuscript presents a case of recurrent pulmonary edema that was successfully managed through the insertion of a renal artery stent. A 78-year-old woman visited the emergency room with recurrent acute dyspnea. Computed tomography renal angiography revealed renal artery stenosis of a single-functioning kidney. Flash pulmonary edema caused by renal artery stenosis of a functioning single kidney. Percutaneous transluminal angioplasty and stenting were performed for the renal artery stenosis. The patient's kidney function rapidly improved, and she has been free of flash pulmonary edema for 2 years. Flash pulmonary edema can have various causes and can immediately be a life-threatening emergency. However, it can be treated with percutaneous revascularization if it is caused by renal artery stenosis. This case report reinforces the importance of accurate and immediate diagnosis when dealing with flash pulmonary edema. This case emphasizes the potential therapeutic benefit of renal artery stenting in the management of flash pulmonary edema caused by renal artery stenosis in patients with a single-functioning kidney.

A Case report of Resistant Hypertension due to Renal Artery Stenosis: Long Term Sufferings of a Middle-Aged Gentleman

Atherosclerotic renal artery stenosis is the leading cause of reno-vascular hypertension and is prevalent in elderly patients (over 65 years) and those with resistant hypertension. This article presents a case report of a 60-year-old gentleman who presented with resistant hypertension resulting in heart failure and significant morbidity. The patient's medical history included frequent hospitalizations with uncontrolled hypertension, flash pulmonary edema and heart failure. Despite multiple hospitalizations, the underlying cause of his condition remained unrecognized until further investigation revealed left sided renal artery stenosis as the culprit lesion. Successful renal artery angioplasty resulted in the resolution of the patient's high blood pressure and improvement of general well-being. This case highlights the potential for resistant hypertension due to renal artery stenosis to be overlooked, particularly in patients with multiple comorbidity. It is important to consider the possibility of renal artery stenosis in patients with uncontrolled blood pressure with recurrent pulmonary oedema, not responding to multiple anti-hypertensive drugs in the highest possible dose. Bangladesh J Medicine 2023; 34(2): 163-167

Endovascular Versus Medical Management of Atherosclerotic Renovascular Disease: Update and Emerging Concepts.

Atherosclerotic renovascular disease is the most frequent cause of renovascular hypertension and its prevalence increases with age and in specific subset of patients, such as those with end-stage chronic kidney disease, heart failure, and coronary artery disease. Besides hypertension, atherosclerotic renovascular disease is responsible for several clinical manifestations, including life-threatening conditions, such as recurrent flash pulmonary edema, rapidly progressive chronic kidney disease, or acute kidney injury. Atherosclerotic renovascular disease is usually part of a more diffuse atherosclerotic process and requires a combination therapy including antihypertensive, antiplatelet and lipid-lowering agents, as well as optimization of antidiabetic treatment, if needed. Besides medical therapy, percutaneous renal angioplasty was supposed to be the most effective therapy for atherosclerotic renovascular disease, by leading to blood flow restoration. However, despite an apparently solid rationale, several randomized clinical trials failed to confirm the favorable effects of percutaneous renal angioplasty on blood pressure control, kidney function, cardiovascular and renal outcomes, previously reported in observational, retrospective and single-center cohorts, switching off the enthusiasm for this procedure. Several studies' limitations may partly account for this failure, including heterogeneity of diagnostic techniques, overestimation of the degree of renal artery stenosis, inappropriate timing of revascularization, multiple protocol revisions, frequent crossovers, and most importantly exclusion of patients at higher likelihood to respond to angioplasty. The purpose of this review is to summarize studies' potential weaknesses and provide guidance to the clinician for identification of patients who may benefit most from revascularization.

A Study on Fetomaternal Outcome of Preterm Eclampsia and its Relationship with Mode of Delivery

Introduction: Eclampsia (Greek, “shining forth”) is an acute and life-threatening complication of pregnancy, and is characterized by the appearance of tonic-clonic seizure, usually in a patient who had developed pre-eclampsia. Pre- eclampsia and eclampsia are collectively called hypertensive disorders of pregnancy and toxemia of pregnancy. This study aimed to analyze the feto-maternal outcome of preterm eclampsia and its relationship with the mode of delivery. Methods: This descriptive type of cross-sectional study was conducted at the eclampsia unit of the Department of Obstetrics and Gynecology, Dhaka Medical College Hospital, Dhaka, Bangladesh. The study was carried out from February 2012 to July 2012. A total of 92 subjects were enrolled in this study as per inclusion criteria. Result: In this study, the prevalence of eclampsia was 10.12%, and preterm eclampsia was 1.31%. The majority of the patients (48.91%) were within 20-25 years of age, and only 1.09% were &gt;30 years of age. Most of the patients were primi gravida (78.26%). The majority of the patients (54.35%) reported within 3-5 hours. Most of the patients came at 33-34 weeks gestation, but quite a significant percentage (30%) came at 28-32 weeks of gestation. A large number of patients delivered spontaneously, a fair number of patients were induced &amp; a few patients required LSCS. In both SVD &amp; induced groups, the majority of the patients (62% &amp; 66% respectively) were delivered within 7-12 hours. In the SVD group, 10% of patients were delivered within 6 hours whereas in the cesarean section group 85% of patients were delivered within 6 hours. Maximum patients (81%) had induction delivery intervals between 7-12 hours. 12 (60%) patients had LSCS done due to fetal distress, 2 (10%) due to previous H/O LSCS, 1 (5%) due to primi gravida with a twin pregnancy, and 5(25%) due to primi gravida with breech presentation. Of patients who presented at 28-32 weeks of gestation, among them 16 had SVD, 11 patients had induction of labor, and LSCS was done in only one case &amp; which was stillborn. The majority of the babies in the SVD &amp; induced group developed asphyxia (81% &amp; 90% respectively) and the majority needed admission to NICU (62% &amp; 73% respectively). PND was also high (&gt;50%) in both groups. Of patients who presented at 33-34 weeks of gestation, 19 had SVD, 15 patients had induction of labor, and only 4 patients required LSCS. A significant number of babies in all three groups (42%, 47% &amp; 100% respectively) were healthy. Although in SVD &amp; induced groups a large number of babies developed asphyxia (58% &amp; 47% respectively) and admission was required in NICU 26% in both groups. PND was few in both groups. For patients who presented at 35-36 weeks of gestation, the majority was delivered by LSCS (15) &amp; outcomes of babies were good in this group as well as in the SVD group. Only one baby developed birth asphyxia. The maternal outcome was good in all three groups (85%, 91%, &amp; 100% respectively). No maternal complication occurred in the cesarean section group. In SVD &amp; induced group few maternal complications occurred such as recurrent convulsion (12% &amp; 13% respectively), CVD (single case in both groups), pulmonary edema (1), HELLP syndrome (1), and septicemia (1). Three mothers die in SVD &amp; induced group. Conclusion: This study concluded that early-onset eclampsia has been associated with worse perinatal outcomes. Gestational age &lt;32 weeks who do not go into labor spontaneously may offer induction, as the cesarean section does not carry any good prognosis to the fetus but rather increases morbidity to the mother. When gestational age crosses &gt;33 weeks, a complete evaluation of the fetal condition, mental condition, and cervix is necessary to plan for the mode of delivery.

Role of Early Mitral Valve Surgery in Acute Infective Endocarditis: A Case Series and Review of Literature

Infective Endocarditis (IE) is a serious cardiac infection diagnosed with syndromic approach based on clinical, immunological, sonographic, and microbiological findings. It is highly suspected in patients with pre-existing heart disease who have bacteremia in absence of other obvious source. Due to its non-specific symptoms and delayed diagnosis causes severe septicemia, multiple organ failure, and high mortality. This case series describes three critically ill patients who were diagnosed with active IE upon admission to the Intensive Care Unit (ICU). All three patients were admitted in critical condition and were newly diagnosed with IE. They were initially stabilised with appropriate antibiotics. However, during their ICU stay, after two weeks, they experienced recurrent arrhythmias and severe Mitral Regurgitation (MR), complicating recurrent pulmonary oedema that hindered weaning from mechanical ventilation. Therefore, it was decided to perform Mitral Valve (MV) correction surgery during the acute phase of endocarditis (2 weeks after starting antibiotics). Unfortunately, all patients had in-hospital mortality. Intraoperative findings revealed extensive vegetation on the Anterior and Posterior Mitral Leaflet (AML and PML) with extension to the chordae. The high mortality was attributed to their critical pre-operative condition, septic shock, and cerebral embolism. Guidelines and task force management clearly state that early surgery plays a definitive role in acute endocarditis with complications. However, identifying the appropriate candidates for early surgery is challenging due to the associated high mortality. A database search on MV surgery in acute IE, comparing repair and replacement, has concluded that repair is safe and associated with better survival than replacement.

Challenge of Case 8: A 58-Year-Old Man Presented With Symptomatic Recurrent Pulmonary Edema

Challenge of Case 8: A 58-Year-Old Man Presented With Symptomatic Recurrent Pulmonary Edema

MANAGEMENT OF MAJOR AIRWAY HAEMORRHAGE WITH VENOVENOUS EXTRACORPOREAL MEMBRANE OXYGENATION IN A HEART TRANSPLANT RECIPIENT

<h3>Objective</h3> To report the successful use of venovenous extracorporeal membrane oxygenation in a heart transplant recipient with a catastrophic airway haemorrhage. <h3>Design and methods</h3> Review of hospital records and imaging. <h3>Results</h3> A 56 year-old man with a past medical history of asthma, bronchiectasis and immunoglobulin A deficiency presented with end-stage ischaemic cardiomyopathy and recurrent pulmonary oedema. He was assessed for and underwent a heart transplant. The donor graft was well matched, but a small soft left anterior descending coronary artery plaque was noted at retrieval. In the first 24 hours post-transplant, he had a falling cardiac index followed by dysrhythmias. He was placed on veno-arterial extracorporeal membrane oxygenation (VA ECMO) and underwent PCI to the LAD lesion and started on aspirin and prasugrel. 48 hours later, his oxygenation requirements increased, his chest x-ray showed infiltrates and differential hypoxia (Harlequin Syndrome) was diagnosed. VAV ECMO was established. Overnight following VAV ECMO, fresh blood and clots were suctioned from the endotracheal tube, with falling tidal volumes to the point he was effectively unventilated. A CT scan showed extensive bronchial casts. A rigid bronchoscopy removed the clot. No specific bleeding point was identified, but general ooze from both bronchi was observed. Antiplatelet agents and systemic heparin were stopped, whilst distal limb perfusion catheter heparin was continued. Serial bronchoscopies were performed daily, removing small quantities of clot and applying topical therapies to various bleeding points in the right upper lobe. Tidal volumes remained under 100ml. Disseminated intravascular coagulation was diagnosed and product replacement guided by laboratory results and thromboelastography was undertaken. With improving cardiac function, arterial decannulation was achieved, leaving the patient on VV ECMO. This was continued for a further week with repeated flexible bronchoscopy and clot retrieval. Bleeding resolved after several days with conservative therapy, avoiding surgical or interventional radiological procedures. Improvements in tidal volumes were observed and eventually VV ECMO was successfully weaned. Aspirin was restarted as single antiplatelet therapy. He subsequently made a good recovery. <h3>Discussion</h3> VV ECMO is well established as a treatment in respiratory failure and pulmonary haemorrhage. However, use of VAV and VV ECMO for a major airway bleed in a heart transplant patient has not, to our knowledge, been previously described. The risks of running circuits without anticoagulation in patients totally dependent on them are high and managing this risk, alongside the new stent in a crucial coronary artery, were challenging. This case highlights the importance of balancing thrombosis and bleeding risk, especially in the context of new coronary stents, and has prompted consideration whether short-acting agents such as tirofiban may have a role in these especially high-risk cases.

The characteristic of acute coronary syndromes of patients with multivessel coronary artery disease in centers with and without cardiac surgery on-site – data from PL-ACS registry

Abstract Background Every year more than 100,000 acute coronary syndromes are diagnosed in Poland. There are 36 cardio-surgical centers and more than 157 catheterization laboratories available in Poland dedicated to treat acute coronary syndromes. MVD patients have a considerable clinically relevant burden of adverse cardiovascular events following ACS. Purpose The aim of the study was to analyze the outcomes of acute coronary syndrome (ACS) treatment in Polish patients with the multivessel coronary disease (MVD) in the centers with and without cardiac surgery (CS) on site. Methods This was a retrospective analysis (1st January, 2017 to 31st December, 2020) of ACS patients outcomes using data from PL-ACS registry. PL-ACS registry is a polish archive of the ACS patients, which data are obtained from all cardiology and cardiac surgery departments in Poland. The registry is supervised by the Polish Ministry of Health. The following analysis considered only patients with MVD. MVD was defined as the presence of ≥70% diameter stenosis of three or more epicardial coronary arteries. For the purpose of this analysis the MVD patients (n=4618) were divided to two groups: those treated in the centers with the cardiac surgery department on site (CS group, n=595) and those without (non-CS group, n=4023). Results Patients in the CS group were elder (70.8 vs. 69.0, p=0.008) as compared to the non-CS group. There were no differences in sex (male 68.6% vs. 67.2%, p=0.49) and BMI (27.5% vs. 27.7%, p=0.12) were between both groups. There was no statistically significant difference between the types of acute coronary syndrome, between CS and non-CS group – [STEMI (34.6% vs 31.1%), NSTEMI (53.6% vs 55.3%), UA (11.8% vs 13.6%), p=0.16]. Patients in the CS group had higher prevalence of renal failure (13.3% vs. 8.8%, p≤0.001) and a more frequent had a history of a past coronary angioplasty (18.9% vs. 14.4%, p=0.005). During the coronary angiography a femoral artery access was more often used in CS group patients (47.1% vs. 15.2%, p&amp;lt;0.001). Percutaneous coronary intervention of MVD was more often performed in the CS group (74.6% vs. 71.0%, p=0.054). In-hospital death (7.6% vs. 4.6%, p=0.002), reinfarction (1.1% vs. 0.1%, p&amp;lt;0.001), hemorrhagic complications (6.4% vs. 1.6%, p&amp;lt;0.001), recurrent target vessel revascularization (1.8% vs. 0.4%, p≤0.001) and pulmonary oedema (3.7% vs. 1.5%, p&amp;lt;0.001) occurred more often in the CS group. Conclusions The safety of ACS treatment in MVD patients in centers without CS on site is non-inferior to treatment of such patients in center with CS on site. Interestingly, there were more in-hospital adverse cardiac events observed in ACS MVD patients treated in center with CS on-site. However, in centers with CS on site ACS MVD patients had a higher co-morbidity and were subjected to a higher number of PCIs. It suggests that in general, centers with CS-onsite treat more severe patients as compared to those without CS on-site. Funding Acknowledgement Type of funding sources: None.

Interventionelle Therapie einer atherosklerotischen Nierenarterienstenose

A hemodynamically acting atherosclerotic renal artery stenosis of one or both main renal arteries (in rare cases also stenosis of a larger segment artery) with a lumen narrowing of at least 70%, can lead to a variety of diseases. In the case of unilateral stenosis it can lead to renovascular hypertension, in bilateral stenosis (or in a functional or actual solitary kidney with stenosis) also frequently to progressive renal insufficiency (ischemic kidney disease) and/or to acute lung edema (pulmonary flash edema). Previously often attempted causal revascularization procedures (angioplasty with and without stent placing, more rarely surgical revascularization) achieve a patency rate of over 90%; however, according to the results of randomized studies, the desired functional effects of catheter-based interventions, such as improved blood pressure adjustment or improved renal function and reduced overall survival, fell short of the expectations, so that an optimized pharmaceutical treatment is mostly prioritized. Patients with a critical stenosis and strongly pronounced clinical complications, such as recurrent pulmonary edema and progressive kidney failure, can benefit from such measures. Therefore, in individual cases it can be justifiable and also medically necessary in the sense of a last resort, to instigate a revascularization procedure. The meticulous selection of patients suitable for this procedure is essential for clinical success.

Abstract #1183284: Recurrent pulmonary edema as a consequence of diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is a known sequela of high levels of circulating glucose with an insulin deficiency. Patients usually present with increased thirst, dyspnea, abdominal pain, and fatigue. Without immediate treatment, the patient may suffer detrimental outcomes from electrolyte abnormalities, acidosis, and other irregularities. We describe the case of a man who suffers from recurrent pulmonary edema as a consequence of DKA.

Exaggerated natriuresis after renal artery balloon angioplasty for flash pulmonary oedema: a potential complication in one-kidney renovascular hypertension.

Flash pulmonary oedema is a life-threatening complication of renal artery stenosis. We report a very rare complication in a patient with bilateral atherosclerotic renal artery stenosis who underwent unilateral renal artery angioplasty because of recurrent flash pulmonary oedema. Shortly after the procedure, she developed extreme polyuria (over 201 in the first 48 h) with massive natriuresis (>1000 mmol urinary sodium excretion in the first 24 h). Most likely, the occurrence of this phenomenon is related to the fact that her contralateral kidney was atrophic and no longer functioning due to total renal artery occlusion. We provide an overview of the literature and discuss several mechanisms that may contribute to the occurrence of this exaggerated natriuretic response in patients with one-kidney renovascular hypertension who undergo renovascular revascularization. We recommend close monitoring of natriuresis in such patients and - if needed - administration of intravenous isotonic saline (0.9% NaCl) to prevent hypovolemia.

Polymyxin B infusion related respiratory arrest: A case report

A 73 years old male, known hypertensive on medication, with the history of SARS-CoV-2 infection nine months ago, presented to us with mucormycosis, he was treated with Liposomal amphotericin B initially. He developed acute kidney injury with recurrent pulmonary oedema requiring ICU admission and Haemodialysis. He later developed catheter related blood stream infection that grew Carbapenem resistant Klebsiella pneumonia and was started on Polymyxin B. However from day 3 of antibiotics he started to develop recurrent respiratory arrest with no apparent cause. He required a brief period of mechanical ventilation and was successfully weaned. He had recurrent such episodes with no apparent cause. After extensive work up and literature search it was diagnosed as Polymyxin B induced respiratory failure. Polymyxins were stopped, patient was discharged in a stable condition after five days of further observation and is currently on follow up with no such episode of dyspnoea.

Renovascular Disease and Mesenteric Vascular Disease.

Renal artery stenosis is caused by atherosclerosis and fibromuscular dysplasia and is associated with ischemic nephropathy, renovascular hypertension, and accelerated cardiovascular disease. Routine screening for renal artery stenosis is not recommended but is reasonable in patients who have rapid onset of hypertension, resistant hypertension, progressive renal insufficiency, recurrent pulmonary edema, or repeat admissions for heart failure. Acute mesenteric ischemia is caused by arterial embolism or thrombosis, mesenteric venous thrombosis, or nonocclusive mesenteric ischemia, whereas chronic mesenteric ischemia is most often caused by arterial obstruction. This article reviews the epidemiology, pathophysiology, diagnosis, and management of these two conditions.

A Rare Occurrence of Premature Birth and Recurrent Acute Pulmonary Oedema in the Mother due to Cushing’s Syndrome: A Case Report

Presentation of Cushing’s syndrome during pregnancy is extremely rare. We report a 21-year-old female with Cushing’s syndrome diagnosed at 23 weeks of gestation and had recurrent acute pulmonary oedema during the antepartum and postpartum period. She delivered prematurely via emergency caesarean section at 28 weeks of gestation. This case highlights the rare occurrence of recurrent acute pulmonary oedema during pregnancy and consequential premature birth in a patient with adrenal Cushing’s. She was diagnosed with adrenal Cushing’s during the postpartum period based on unsuppressed serum cortisol after overnight and low-dose dexamethasone suppression test with a suppressed ACTH. CT scan of the adrenal glands revealed a right adrenal cortical adenoma. The risk of complications in infants and mothers who suffer from Cushing’s syndrome needs to be handled carefully. The diagnosis of Cushing’s syndrome in pregnant women often overlaps and is difficult to establish in early pregnancy.