Risk Factor For Adverse Outcomes Research Articles

Risk factors for adverse outcomes in children with diabetic ketoacidosis.

Develop a multivariable model to identify children with diabetic ketoacidosis (DKA) and/or hyperglycemic hyperosmolar state (HHS) at increased risk of adverse outcomes, and apply it to analyze adverse outcomes during and after the COVID-19 pandemic. Retrospective review of clinical data from 4565 admissions (4284 with DKA alone, 31 [0.7%] only HHS, 250 [5.4%] hyperosmolar DKA) to a large academic children's hospital from January 2010-June 2023. 2010-2019 data (N=3004) were used as a training dataset, and 2020-2021 (N=903) and 2022-2023 (N=658) data for validation. Death or intensive care unit stays >48 hours comprised a composite "Adverse Outcome" group. Risks for this composite outcome were assessed using generalized estimating equations. There were 47 admissions with Adverse Outcomes (1.5%) in 2010-2019, 46 (5.0%) in 2020-2021, and 16 (2.4%) in 2022-2023. Eight patients died (0.18%). Maximum serum glucose, initial pH and diagnosis of type 2 diabetes most strongly predicted Adverse Outcomes. The proportion of patients with type 2 diabetes was highest in 2020-2021. A multivariable model incorporating these factors had excellent discrimination (area under receiver operator characteristic curve [AUC] of 0.948) for the composite outcome in the training dataset, and similar predictive power (AUC 0.960 and 0.873) in the 2020-2021 and 2022-2023 validation datasets, respectively. In the full dataset, AUC for death was 0.984. Type 2 diabetes and severity of initial hyperglycemia and acidosis are independent risk factors for Adverse Outcomes, and explain the higher frequency of Adverse Outcomes during the COVID-19 pandemic. Risks decreased in January 2022-June 2023.

Frailty and its association with long-term mortality among community-dwelling older adults aged 75 years and over

BackgroundFrailty, a significant risk factor for adverse outcomes and mortality, poses an emerging challenge with profound implications for public health and clinical practice. The measurement of frailty offers potential enhancements in healthcare services for older adults. The prevalence of frailty and its association with long-term mortality in a nationwide, unselected population of community-dwelling older adults, particularly those aged 75 and over, has not been previously studied on a large scale in Israel.MethodsA retrospective cohort study was conducted at Meuhedet Health Maintenance Organization, Israel’s third largest healthcare service provider, serving 1,276,000 people (13.8% of Israelis). The prevalence of frailty and its association with all-cause mortality were studied among older adults aged 75 years and over who were followed for 2–8 years. Frailty, defined by the cumulative deficit method, utilized clinical data from the preceding 10-year period, comprising 28 chronic diseases and age-related health deficits.ResultsThe cohort included 43,737 older adults, with a median age of 77 years (IQR 75–82 years); among them, 19,300 (44.1%) were males. Overall, 19,396 (44.3%) older adults were frail: 12,260 (28.0%) mildly frail, 5,533 (12.7%) moderately frail and 1,603 (3.7%) severely frail. During the follow-up period 15,064 (34.4%) older adults died: 4,782 (39.0%) mildly frail, 3,016 (54.5%) moderately frail and 1,080 (67.4%) severely frail. Cox regression analysis demonstrated that mortality was associated with severe frailty (HR 2.63, 95%CI 2.45–2.80), moderate frailty (HR 2.05, 95%CI 1.96–2.14), and mild frailty (HR 1.45, 95%CI 1.39–1.51), independent of age, gender, and population sector. Among patients aged 90 years and over, no significant differences in cumulative survival were found between those with moderate and severe frailty (p = 0.408).ConclusionsFrailty is prevalent among community-dwelling Israeli older adults aged 75 years and over, and it is associated with long-term mortality. Considering its association with long-term mortality across frailty levels until the age of 90, early identification and intervention for frailty are recommended within this population. Policymakers should consider the use of the cumulative deficit method for evaluating frailty at both the population health and clinical levels.

Evaluation of oral herpes simplex virus shedding among solid organ transplant recipients: A pilot study.

Herpes simplex viruses (HSVs) frequently reactivate during immunosuppression and may be a risk factor for adverse outcomes after solid organ transplant (SOT). While suppressive antiviral therapy reduces the risk of symptomatic HSV reactivation, the kinetics of asymptomatic viral shedding with chronic immunosuppression after transplant are not well understood. We report the characteristics of oral HSV shedding among 15 HSV-1 seropositive SOT recipients (n = 8 liver, n = 7 kidney, median age 58.5 years, median 20 months post-transplant) who were not taking daily antiviral suppressive therapy. Participants self-collected oral swabs three times daily for 6 weeks for HSV quantification and recorded the presence of oral symptoms or lesions in a diary. Sample collection adherence was high (median 122 swabs/person, range: 85.7%-101.6% of expected swabs). Most participants (n = 12, 80%) experienced at least one shedding episode, with a median shedding rate of 8.9% (range: 0%-33.6%). There were 32 total shedding episodes, 24 (75%) of which occurred without symptoms or lesions. For episodes of known duration, the median length was 21.8 hrs (interquartile range: 10.8-46.1 hrs). Most shedding episodes (78.1%) lasted >12 hrs, suggesting that twice-daily sampling may be sufficient to detect most episodes. These data show that self-collection of oral swabs is feasible for patients who have undergone SOTs and can provide insight into the frequency of oral HSV reactivation, which can be used to design future studies in this population.

Association of Dementia with Adverse Outcomes in Older Patients with Acute Myocardial Infarction in the ICU.

Dementia limits timely revascularization in individuals with acute myocardial infarction (AMI). However, it remains unclear whether dementia affects prognosis negatively in older individuals with AMI in the intensive care unit (ICU). This research aimed to evaluate the dementia effect on the outcomes in individuals with AMI in ICU.Data from 3,582 patients aged ≥ 65 years with AMI in ICU from the Medical Information Mart for Intensive Care IV (MIMIC IV) database were evaluated. The independent variable was dementia at baseline, and the primary finding was death from any cause during follow-up. A 1:1 propensity score matching (PSM) showed 208 participants with and without dementia. The correlation between dementia and poor prognosis of AMI was verified using a double-robust estimation method.In the PSM cohort, the 30-day all-cause mortality was 37.50% and 33.17% in the dementia and non-dementia groups (P = 0.356), respectively, and the 1-year all-cause mortality was 61.06% and 51.44%, respectively (P = 0.048). Cox regression analysis showed no association between dementia and elevated 30-day (hazard ratio [HR] 1.15, 95% confidence interval [CI] 0.84, 1.60) and 1-year (HR 1.28, 95% CI 0.99, 1.66) all-cause mortality after AMI. Similarly, dementia was not connected with in-hospital mortality, bleeding, or stroke after AMI. Interaction analysis showed that 1-year all-cause mortality was 48.00% higher in individuals with dementia and diabetic complications than in those without diabetic complications.Dementia is not an independent risk factor for adverse outcomes in AMI. Thus, it may be inappropriate to include dementia as a contraindication for invasive AMI therapy.

1082 Maximising Surgical Outcomes in Midline Incisional Hernia Repairs: Are We Employing Every Possible Optimisation?

Abstract Introduction Large midline Incisional hernia repair can involve complex surgery which poses many challenges, with a high recurrence and complication rate. The recently published European Hernia Society Guidelines has identified several risk factors contributing to the increased complications after surgical repair. We aim to assess the effect of these modifiable risk factors for adverse outcomes within our patient population. Method All adult patients who underwent a repair of midline incisional hernias larger than 3cm in a DGH hospital between July 2021 and July 2022 were included. Data on patient demographics, modifiable risks factors and complications were collected. Analysis was performed using Microsoft Excel. Results 26 patients (age: 64 [33-84] years; M:F, 9:17) underwent a midline incisional hernia repair were included. The average hernia size was 8cm. The average body mass index (BMI) was 33.1, seven were smokers and three had diabetes mellitus. Of the three patients who developed a recurrence, average BMI was 36 and two were smokers. None of the patients were counselled for weight loss or smoking cessation. Conclusions In our cross-sectional study, patients with a large hernia, high BMI, diabetes, a smoking history are associated with adverse outcomes. We aim to highlight and raise the awareness to surgeons who perform these repairs to counsel their patients on their modifiable risk factors and its associated risk of hernia recurrence. Preoperative optimisation improves surgical outcome and subsequently reduces healthcare costs.

Commentator Discussion: Are There Etiology-Specific Risk Factors for Adverse Outcomes in Patients on Impella 5.5 Support?

Commentator Discussion: Are There Etiology-Specific Risk Factors for Adverse Outcomes in Patients on Impella 5.5 Support?

Pomalidomide use and kidney outcomes in patients with relapsed/refractory multiple myeloma and chronic kidney disease: A real-world, population-based cohort study.

Background: Pomalidomide-based regimens are the cornerstone of treatment for relapsed/refractory MM (RRMM). Despite the high incidence of chronic kidney disease (CKD) in RRMM, individuals with advanced CKD have been excluded from phase II/III RCTs, creating a gap in our understanding of the effects of pomalidomide use in patients with RRMM complicated with advanced CKD. We undertook a cohort to study to understand the efficacy safety of pomalidomide-based regimens among patients with CKD using real-world data. Methods: Population-based, cohort study of patients ≥ 18 years with RRMM treated with pomalidomide in Ontario, Canada. Primary outcome was all-cause mortality. Secondary outcomes were time-to-major adverse kidney events (MAKE), time-to-next treatment, kidney response and safety. Results: 748 patients with RRMM utilizing pomalidomide were included; 440 had preserved kidney function, 210 had moderate CKD (eGFR 30-59 ml/min/1.73m2), and 98 had advanced CKD (eGFR <30 ml/min/1.73m2). Mean age was 70.2 years, 43.3% were women. Patients with advanced CKD had a higher risk of all-cause mortality compared to the preserved kidney function group (aHR 1.37, 95% CI 1.06, 1.78). MAKE was higher in advanced CKD (aHR 1.70, 95% CI 1.03, 2.35). Kidney response was similar between moderate and severe CKD groups (aOR 1.04, 95%, CI 0.56-1.90). Safety outcomes were similar between groups. Conclusions: Patients with advanced CKD and RRMM on pomalidomide-based regimens exhibited reduced survival and a higher risk for MAKE. However, the probability of experiencing some degree of kidney recovery is 50% in both moderate and severe CKD, with comparable safety outcomes. Micro-abstractOur study aims to fill a gap created by excluding patients with multiple myeloma (MM) and advanced chronic kidney disease (CKD) from RCTs. We utilized administrative data available in Ontario, Canada and included patients with moderate/advanced CKD and RRMM, treated with pomalidomide-based regimens. Compared with patients with preserved renal function, pomalidomide is safe in patients with moderate/advanced CKD, and both groups demonstrated 50% likelihood of renal recovery. Mortality is increased in the advanced CKD group, mainly driven by patients on renal replacement therapy. Clinical Practice pointsPatients with relapsed/refractory MM (RRMM) are at increased risk of CKD and at the CKD is also a risk factor for adverse outcomes in MM including mortality. Despite the higher incidence and prevalence of CKD in MM, patients with advanced CKD have been excluded from randomized controlled trials evaluating novel MM therapies, including pomalidomideTo fill this gap in our knowledge, we undertook a population-based, retrospective, cohort study of individuals ≥ 18 years with RRMM treated with pomalidomide in Ontario, Canada. The primary outcome was all-cause mortality. Secondary outcomes were kidney response, time-to-major adverse kidney events (MAKE), time-to-next treatment, and safety events.We found that patients with advanced CKD had a higher risk of all-cause mortality compared to the preserved kidney function group, driven by patients on hemodialysis. Kidney response rates were similar in both moderate and severe CKD groups, around 50%. MAKE were more frequent in advanced CKD. Safety outcomes were similar in patients with normal renal function and those with CKD.Our findings confirm that pomalidomide is safe to use in patients with moderate to severe CKD. Moreover, patients with both moderate and advanced CKD may recover kidney function. Therefore, pomalidomide-base regimens can be used in patients with CKD and these patient should not be precluded from treatment.

Machine learning prediction of the case-fatality of COVID-19 and risk factors for adverse outcomes in patients with non-small cell lung cancer.

Since the emergence of coronavirus disease 2019 (COVID-19) across the globe, patients with cancer have been found to have an increased risk of infection with COVID-19 and are highly likely to experience a severe disease course. This study analyzed the clinical outcomes of COVID-19 in patients with non-small cell lung cancer (NSCLC) and identified the risk factors for adverse outcomes. The study included patients diagnosed with COVID-19 between January 2020 and April 2022 at the Samsung Medical Center in Seoul, Republic of Korea, who have a history of NSCLC. The case-fatality rate and risk factors for COVID-19 were analyzed using a machine-learning prediction method. Additionally, the study investigated the effect of COVID-19 on the systemic treatment of patients with advanced-stage NSCLC. Overall, 1,127 patients were included in this study, with 10.3% of the patients being older than 75 years; of these patients, 51.8% were ex- or current smokers. Among the 584 patients cured after surgery, 91 had stable disease after concurrent chemo-radiotherapy, and 452 had recurrent or metastatic NSCLC. Among 452 patients with recurrent or metastatic NSCLC, 387 received systemic treatment in a palliative setting during COVID-19. Of these, 188 received targeted therapy, 111 received cytotoxic chemotherapy, 63 received immunotherapy +/- chemotherapy, and 26 received other agents. Among them, 94.6% of patients continued systemic treatment after the COVID-19 infection. Only one patient discontinued treatment because of complications of the COVID-19 infection, and 18 patients changed their systemic treatment because of disease progression. The case fatality rates were 0.86% for patients with early-stage NSCLC, 4.4% for patients with locally advanced NSCLC, and 9.96% for patients with advanced NSCLC. The factors associated with fatalities included palliative chemotherapy, type of palliative chemotherapy, age (≥75 years), diabetes, smoking history, history of lung radiotherapy, hypertension, sex, and chronic obstructive pulmonary disease (COPD). The predictive model using logistic regression and eXtreme Gradient Boosting (XGB) performed well [area under the curve (AUC) for logistic regression =0.84 and AUC for XGB =0.84]. The case fatality rate in patients with NSCLC was 4.8%, while most patients with advanced NSCLC continued to receive systemic treatment. However, patients with risk factors require careful management of COVID-19 complications.

The role of preoperative D-dimer blood level in assessing the risk of open abdominal aortic surgery (statistical study)

Introduction. Changes in the hemostasis and fibrinolysis system in patients with aortoiliac segment lesion can cause the development of specific thromboembolic and hemorrhagic complications, accompanied by a high level of mortality. Preoperative laboratory analysis of the D-dimer blood level may help to objectify the risk assessment of open surgery in this category of patients. Objective. Assessment of the significance of preoperative blood D-dimer level in predicting the development of morbidity and mortality after open surgery on the aortoiliac segment. Materials and methods. The study included 108 patients who were determined the D-dimer blood level before planned reconstructive intervention on the aortoiliac segment at the Pavlov University from 2013 to 2021. The first group consisted of 56 patients with aneurysmal aortoiliac segment lesions, and the second group included 52 patients with occlusive-stenotic lesions of the aortoiliac segment. Results. 92 (85%) patients had an increase of D-dimer level above 500 μg/L, among them 18 patients developed early postoperative complications, and 4 cases were fatal. In 16 (15%) patients with normal D-dimer levels, the postoperative the period was uneventful. Both groups showed statistically significant differences in preoperative blood D-dimer levels depending on the presence or absence of early postoperative complications. In the first group, the median of D-dimer level in the smooth course of the postoperative period was 2035 μg/L, and in patients with complicated course – 3770 μg/L (p=0.04), in the second group these indicators were 635 μg/L and 1231.5 μg/L (p=0.02), respectively. The threshold value of D-dimer level in predicting the risk of death in the first group was 4150 μg/L (p=0.001). Conclusion. The blood D-dimer level may be an additional laboratory risk factor for adverse outcome of open surgery in patients with aortoiliac occlusive disease.

Clinical characteristics and risk factors for ZF2001 fully vaccinated inpatients with COVID-19: A retrospective cohort study

ABSTRACT The ZF2001 vaccine has demonstrated high efficacy in preventing coronavirus disease 2019 (COVID-19). However, the clinical characteristics of breakthrough infections in vaccinated individuals and the risk factors for adverse outcomes in COVID-19 patients remain unclear. We conducted a retrospective single-center cohort study at Xiangya Hospital of Central South University, including 210 fully vaccinated COVID-19 inpatients from December 5, 2022, to January 31, 2023. Data on clinical characteristics, laboratory findings, disease severity, treatment, and prognosis were collected and analyzed. Our findings revealed that COVID-19 inpatients still experienced common symptoms at the onset of illness, but most laboratory findings were within the normal range, except for white blood cell count (WBC), lymphocyte count, and lactate dehydrogenase (LDH) levels. Following standard treatment, 95.7% of patients were discharged from the hospital. We identified seven variables significantly associated with a higher risk of adverse outcomes, including age over 65, elevated WBC count, reduced lymphocyte count, higher levels of blood urea nitrogen (BUN), LDH, troponin, D-dimer, and procalcitonin. This study supports the substantial clinical benefits of the ZF2001 vaccine for COVID-19 patients. Additionally, age over 65, elevated WBC count, reduced lymphocyte count, and higher blood levels of BUN, LDH, D-dimer, and procalcitonin may be used as predictive factors for disease progression in fully vaccinated COVID-19 inpatients.

Is the sFlt-1/PlGF ratio efficient in predicting adverse neonatal outcomes in small-for-gestational-age newborns? A prospective observational multicenter cohort study.

Fetuses with growth abnormalities are at an increased risk of adverse neonatal outcomes. The aim of this study was to investigate if placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1), or the sFlt-1/PlGF ratio were efficient predictive factors of adverse neonatal outcomes in small-for-gestational-age (SGA) newborns. A prospective observational multicenter cohort study was performed between 2020 and 2023. At the time of the SGA fetus diagnosis, serum angiogenic biomarker measurements were performed. The primary outcome was an adverse neonatal outcome, diagnosed in the case of any of the following: <34 weeks of gestation: mechanical ventilation, sepsis, necrotizing enterocolitis, intraventricular hemorrhage grade III or IV, and neonatal death before discharge; ≥34 weeks of gestation: Neonatal Intensive Care Unit hospitalization, mechanical ventilation, continuous positive airway pressure, sepsis, necrotizing enterocolitis, intraventricular hemorrhage grade III or IV, and neonatal death before discharge. In total, 192 women who delivered SGA newborns were included in the study. The serum concentrations of PlGF were lower, leading to a higher sFlt-1/PlGF ratio in the adverse outcome group. No significant differences in sFlt-1 levels were observed between the groups. Both PlGF and sFlt-1 had a moderate correlation with adverse neonatal outcomes (PlGF: R - 0.5, p < 0.001; sFlt-1: 0.5, p < 0.001). The sFlt-1/PlGF ratio showed a correlation of 0.6 (p < 0.001) with adverse outcomes. The uterine artery pulsatility index (PI) and the sFlt-1/PlGF ratio were identified as the only independent risk factors for adverse outcomes. An sFlt-1/PlGF ratio of 19.1 exhibited high sensitivity (85.1%) but low specificity (35.9%) in predicting adverse outcomes and had the strongest correlation with them. This ratio allowed the risk of adverse outcomes to be assessed as low with approximately 80% certainty. The sFlt-1/PlGF ratio seems to be an efficient predictive tool in adverse outcome risk assessment. More studies on large cohorts of SGA-complicated pregnancies with and without preeclampsia are needed to develop an optimal and detailed formula for the risk assessment of adverse outcomes in SGA newborns.

Neurological function before and after an in-hospital cardiac arrest – A nationwide registry-based cohort study

BackgroundAccording to the Utstein Registry Template for in-hospital cardiac arrest (IHCA), a good neurological outcome is defined as either Cerebral Performance Category (CPC) 1–2 at discharge from hospital or unchanged CPC compared to baseline. However, the latter alternative has rarely been described in IHCA. This study aimed to examine CPC at admission to hospital, the occurrence of post-arrest neurological deterioration, and the factors associated with such deterioration. MethodsWe studied adult IHCA survivors registered in the Swedish Registry of Cardiopulmonary Resuscitation between 2007 and 2022. The CPC was assessed based on information from admission and discharge from hospital. The data were analyzed using descriptive statistics and significance tests. ResultsOne in ten IHCA had a CPC score > 1 at admission to hospital. Out of 7,677 IHCA who survived until hospital discharge and had full CPC data, 6,774 (88%) had preserved CPC, 150 (2%) had improved CPC, and 753 (10%) had deteriorated CPC. Among the factors significantly associated with deteriorated neurological function are IHCA in a general ward or intensive care unit, non-shockable rhythm, no ECG surveillance, and a higher proportion of intra-arrest and post-resuscitation treatments (all p-values < 0,05). ConclusionMost patients had preserved neurological function compared to admission. Factors associated with deteriorated neurological function are mainly concordant with established risk factors for adverse outcomes and are primarily intra-arrest and post-resuscitation, making deterioration hard to predict. Further, every tenth survivor was admitted with CPC more than 1, stressing the use of unchanged CPC as an outcome in IHCA.

Shock index to predict outcomes in patients with trauma following traffic collisions: a retrospective cohort study.

Taiwan, which has a rate of high vehicle ownership, faces significant challenges in managing trauma caused by traffic collisions. In Taiwan, traffic collisions contribute significantly to morbidity and mortality, with a high incidence of severe bleeding trauma. The shock index (SI) and the modified shock index (MSI) have been proposed as early indicators of hemodynamic instability. In this study, we aimed to assess the efficacy of SI and MSI in predicting adverse outcomes in patients with trauma following traffic collisions. This retrospective cohort study was conducted at Chi Mei Hospital from January 2015 to December 2020. The comprehensive analysis included 662 patients, with data collected on vital signs and outcomes such as mortality, blood transfusion, emergent surgical intervention (ESI), transarterial embolization (TAE), and intensive care unit (ICU) admission. Optimal cutoff points for SI and MSI were identified by calculating the Youden index. Logistic regression analysis was used to assess outcomes, adjusting for demographic and injury severity variables. An SI threshold of 1.11 was associated with an increased risk of mortality, while an SI of 0.84 predicted the need for blood transfusion in the context of traffic collisions. Both SI and MSI demonstrated high predictive power for mortality and blood transfusion, with acceptable accuracy for TAE, ESI, and ICU admission. Logistic regression analyses confirmed the independence of SI and MSI as risk factors for adverse outcomes, thus, providing valuable insights into their clinical utility. SI and MSI are valuable tools for predicting mortality and blood transfusion needs in patients with trauma due to traffic collisions. These findings advance the quality of care for patients with trauma during their transition from the emergency room to the ICU, facilitating prompt and reliable decision-making processes and improving the care of patients with trauma.

The impact of smoking on COVID-19-related mortality: a Brazilian national cohort study

IntroductionCurrent evidence suggests the potential heightened vulnerability of smokers to severe coronavirus disease (COVID-19) outcomes. AimsThis study aimed to analyze the clinical outcomes and mortality related to tobacco use in a cohort of hospitalized Brazilian COVID-19 patients. MethodsThis retrospective cohort study analyzed adults hospitalized for COVID-19 in Brazil using the SIVEP-Gripe database (official data reported by public and private healthcare facilities for monitoring severe acute respiratory syndrome cases in Brazil). The inclusion criteria were patients over 18 years of age with a positive RT-qPCR test for SARS-CoV-2. The analysis focused on in-hospital mortality, considering smoking as an exposure variable, and included covariates such as age, gender, and comorbidities. Smoking history was collected from the self-reported field in the database. Statistical analyses included descriptive statistics, crude Odds Ratios, and multivariable binary logistic regression. ResultsThis study included 2,124,285 COVID-19 patients, among whom 44,774 (2.1 %) were smokers. The average age of the smokers was higher than that of the never-smokers (65.3 years vs. 59.7 years). The clinical outcomes revealed that smokers had higher rates of intensive care unit admission (51.6 % vs. 37.2 % for never-smokers), invasive ventilatory support (31.5 % vs. 20.2 % for never-smokers), and higher mortality (42.7 % vs. 31.8 % for never smokers). In the multivariable analysis, smokers demonstrated a heightened risk of death (aOR 1.23; 95 % CI 1.19–1.25). ConclusionsThis large populational-based cohort study confirms the current evidence and underscore the critical importance of recognizing smoking as a substantial risk factor for adverse outcomes in COVID-19 patients.

Efficacy and safety of Ferrous iron on the prevention of Vascular cOgnitive impaiRment among patients with cerebral Infarction/TIA (FAVORITE): rationale and design of a multicentre randomised trial

BackgroundThe incidence of vascular cognitive impairment (VCI) is high in patients suffering from ischaemic stroke or transient ischaemic attack (TIA) or with vascular risk factors. Effective prevention strategies for VCI...

Clinicopathological characteristics of pediatric ANCA-associated glomerulonephritis.

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis and glomerulonephritis is uncommon in children. We sought to characterize the histological and clinical features of the disease and report on risk factors for adverse outcomes in a pediatric cohort. Retrospective single-center cohort of all pediatric (< 20years) patients diagnosed with ANCA-associated glomerulonephritis (AAGN) by kidney biopsy between 2002 and 2022 at Johns Hopkins University. Histological and clinical features were extracted from the medical record. Clinical, laboratory, and histological findings were analyzed to determine the association with kidney failure (KF) and/or death. A total of 17 patients were identified (GPA n = 7, MPA = 10) with a median age of 15years (IQR 12-17) at presentation, a slight female predominance (59%), with seven patients reaching the composite outcome of death (n = 1) or kidney failure (n = 6). There was no difference in presenting clinical symptoms or extra-renal manifestations between the two groups. Univariable Cox regression identified several factors associated with an increased hazard of endpoint including the degree of global or segmental sclerosis, interstitial fibrosis and tubular atrophy (IFTA), C3 and C1q staining, presence of subendothelial deposits, and proteinuria. Multivariable regression was not performed due to the small sample size. We saw a trend towards increased utilization of plasma exchange and a decrease in cyclophosphamide utilization in the more recent era. There was no association between treatment modality and outcome. Pediatric AAGN is a rare disease associated with significant morbidity. We identified glomerulosclerosis and IFTA on histology, and proteinuria on initial presentation as risk factors for KF/death.

#189 Aortic stenosis is an independent risk factor for mortality in end-stage kidney disease patients on the transplant waitlist

Abstract Background and Aims Valvular heart disease (VHD) is a risk factor for adverse outcomes in end-stage kidney disease (ESKD) patients. However, the impact of individual valvular heart lesions on outcomes in patients on the kidney transplant waitlist is unclear. This study aims to analyse the relationship between different VHD and all-cause mortality, and to determine the characteristics of patients on the transplant waitlist stratified by the different types of VHD. Method This was a single-center retrospective cohort study of ESKD patients who were referred for kidney transplant waitlist placement from May 2008 to February 2021 and had undergone baseline transthoracic echocardiogram (TTE). Significant VHD was defined as VHD of at least moderate severity based on TTE findings. Patients were followed up until death or kidney transplantation. Results Of the 512 patients included, 89 (17.4%) had significant VHD. Mean follow-up duration was 6.6 ± 3.3 years. Significant VHD included 46 (9.0%) tricuspid regurgitation (TR), 44 (8.6%) mitral regurgitation (MR), 11 (2.2%) aortic regurgitation (AR), 7 (1.4%) aortic stenosis (AS) and 2 (0.4%) mitral stenosis (MS). Of the different VHD (Table 1), only AS was associated with all-cause mortality (hazard ratio (HR) 2.41, 95% CI 1.53-3.78, p &amp;lt; 0.0001, Fig. 1) and remained significant after adjusting for age, diabetes mellitus (DM) and other cardiovascular diseases (CVD) (adjusted HR 1.71, 95% CI 1.07-2.73, p = 0.02). Risk factors associated with AS included older age (odds ratio (OR) 1.12, 95% CI 1.03-1.23, p = 0.01), history of CVD (OR 7.31, 95% CI 1.59-33.6, p = 0.01), longer dialysis vintage (OR 1.01, 95% CI 1.00-1.02, p = 0.02), previous parathyroidectomy (OR 15.1, 95% CI 2.68-85.4, p = 0.002) and higher corrected calcium (OR 43.9, 95% CI 1.56-1240, p = 0.03). Age (adjusted OR 1.12, 95% CI 1.02-1.24, p = 0.02), history of CVD (aOR 7.70, 95% CI 1.50-39.5, p = 0.02) and previous parathyroidectomy (aOR 11.8, 95% CI 1.83-76.7, p = 0.01) remained significant in the multivariable model. No specific risk factors were identified for the other valvular lesions. Conclusion AS appears to be an independent risk factor for all-cause mortality in ESKD patients on the transplant waitlist. Differences in mortality and risk factors associated with different types of VHD may suggest differing underlying pathophysiological mechanisms.

Acute Myocardial Infarction in COVID-19 Patients-A Review of Literature Data and Two-Case Report Series.

Background/Objectives: The newly emergent COVID-19 pandemic involved primarily the respiratory system and had also major cardiovascular system (CVS) implications, revealed by acute myocardial infarction (AMI), arrhythmias, myocardial injury, and thromboembolism. CVS involvement is done through main mechanisms-direct and indirect heart muscle injury, with high mortality rates, worse short-term outcomes, and severe complications. AMI is the echo of myocardial injury (revealed by increases in CK, CK-MB, and troponin serum markers-which are taken into consideration as possible COVID-19 risk stratification markers). When studying myocardial injury, physicians can make use of imaging studies, such as cardiac MRI, transthoracic (or transesophageal) echocardiography, coronary angiography, cardiac computed tomography, and nuclear imaging (which have been used in cases where angiography was not possible), or even endomyocardial biopsy (which is not always available or feasible). Two-case-series presentations: We present the cases of two COVID-19 positive male patients who were admitted into the Clinical Department of Cardiology in "Sfântul Apostol Andrei" Emergency Clinical Hospital of Galați (Romania), who presented with acute cardiac distress symptoms and have been diagnosed with ST elevation AMI. The patients were 82 and 57 years old, respectively, with moderate and severe forms of COVID-19, and were diagnosed with anteroseptal left ventricular AMI and extensive anterior transmural left ventricular AMI (with ventricular fibrillation at presentation), respectively. The first patient was a non-smoker and non-drinker with no associated comorbidities, and was later discharged, while the second one died due to AMI complications. Conclusions: From this two-case series, we extract the following: old age alone is not a significant risk factor for adverse outcomes in COVID-19-related CVS events, and that the cumulative effects of several patient-associated risk factors (be it either for severe forms of COVID-19 and/or acute cardiac injury) will most probably lead to poor patient prognosis (death). At the same time, serum cardiac enzymes, dynamic ECG changes, along with newly developed echocardiographic modifications are indicators for poor prognosis in acute cardiac injury in COVID-19 patients with acute myocardial injury, regardless of the presence of right ventricular dysfunction (due to pulmonary hypertension).

The hospital frailty risk score effectively predicts adverse outcomes in patients with atrial fibrillation in the intensive care unit.

Atrial fibrillation (AF) and frailty are significant global public health problems associated with advancing age. However, the relationship between frailty and older patients with AF in the intensive care unit (ICU) has not been thoroughly investigated. This study aimed to investigate whether the hospital frailty risk score (HFRS) is associated with adverse outcomes in older patients with AF in the ICU. This was the first retrospective analysis of older patients with AF admitted to the ICU between 2008 and 2019 at a tertiary academic medical center in Boston. The HFRS was used to measure frailty severity. The outcomes of interest were in-hospital and 30-day mortality and the incidence of sepsis and ischemic stroke. There were 7,792 participants aged approximately 80 years, almost half (44.9%) of whom were female. Among this group, 2,876 individuals were identified as non-frail, while 4,916 were classified as frail. The analysis revealed a significantly greater incidence of in-hospital (18.8% compared to 7.6%) and 30-day mortality (24.5% versus 12.3%) in the frail group. After accounting for potential confounding factors, a multivariate Cox proportional hazards regression analysis revealed that frail participants had a 1.56-fold greater risk of mortality within 30 days (95% CI = 1.38-1.76, p < 0.001). Frailty is an independent risk factor for adverse outcomes in older patients with AF admitted to the ICU. Therefore, prioritizing frailty assessment and implementing specific intervention strategies to improve prognostic outcomes are recommended.

Association of Preterm Birth with Adverse Glomerular Disease Outcomes in Children and Adults.

While some studies of children with nephrotic syndrome have demonstrated worse outcomes in those born preterm compared with term, little data exists on associations of preterm birth with outcomes in adult-onset glomerular disease. Cardiovascular outcomes in those born preterm with glomerular disease are unknown. We performed a cross-sectional and longitudinal analysis of participants in the Cure Glomerulonephropathy (CureGN) cohort. Preterm (<37 weeks' gestation) was compared to term (≥37 weeks' gestation). A survival analysis and adjusted Cox proportional hazards model were used to examine a composite outcome of 40% decline in estimated glomerular filtration rate (eGFR) or progression to kidney failure. An adjusted logistic regression model was used to examine remission of proteinuria. There were 2,205 term and 235 preterm participants. APOL1 risk alleles were more common in those born preterm. More pediatric than adult participants in CureGN were born preterm: 12.8% vs. 7.69% (P<0.001). Adults born preterm as compared to term had a higher prevalence of Focal Segmental Glomerulosclerosis (FSGS) (35% vs. 25%, P=0.01) and APOL1 high-risk genotype (9.4% vs 4.2%, P=0.01). Participants born preterm had a shorter time interval to a 40% eGFR decline/kidney failure after biopsy (P=0.001). In adjusted analysis, preterm participants were 28% more likely to develop 40% eGFR decline/kidney failure (Hazard Ratio: 1.28 [1.07, 1.54], P=0.008) and 38% less likely to attain complete remission of proteinuria (Odds Ratio: 0.62 [0.45, 0.87], P=0.006). There was no significant difference in cardiovascular events. Preterm birth was a risk factor for adverse outcomes in this heterogenous cohort of children and adults with glomerular disease. Adults born preterm were more likely to have an APOL1 high-risk genotype and FSGS. In analyses adjusted for FSGS and APOL1 risk status, there was less remission and faster progression of kidney disease in those born preterm.