All-cause mortality and estimated renal function in type 2 diabetes mellitus outpatients: Is there a relationship with the equation used?

BACKGROUND

We investigated the relationship between serum creatinine (SCr) and estimated glomerular filtration rate (eGFR), evaluated by different formulae, and all-cause mortality (ACM) in type 2 diabetes mellitus (T2DM) outpatients.

METHODS

This observational cohort study considered 1365 T2DM outpatients, who had been followed up for a period of up to 11 years. eGFR was estimated using several equations.

RESULTS

Seventy subjects (5.1%) died after a follow-up of 9.8 ± 3 years. Univariate analysis showed that diagnosis of nephropathy (odds ratio (OR): 2.554, 95% confidence interval (CI): 1.616-4.038, p < 0.001) and microvascular complications (OR: 2.281, 95% CI: 1.449-3.593, p < 0.001) were associated with ACM. Receiving operating characteristic (ROC) curves showed that the areas under the curve for ACM were similar using the different eGFR equations. eGFR values were predictors of ACM, and the hazard ratios (HRs) of the different equations for eGFR estimation were similar.

CONCLUSION

In our cohort of T2DM outpatients, different eGFR equations perform similarly in predicting ACM, whereas SCr did not.

Pulmonary hypertension: epidemiology in different CKD stages and its association with cardiovascular morbidity

Background

Pulmonary hypertension (PH) was recently recognized as a common complication of end-stage renal disease (ESRD) that causes an increased risk of mortality. Epidemiological data for this disorder in earlier stages of chronic kidney disease (CKD) and its association with cardiovascular (CV) morbidity are scarce.

Methods

We retrospectively analyzed 2,351 Chinese CKD patients with complete clinical records and echocardiography data between Jan 2008 and May 2012. The patients were divided into the following 6 groups: CKD Stages 1–4; Stage 5 for those not on or initiated on hemodialysis for <3 months; and Stage 5D for the patients undergoing hemodialysis for ≥3 months. The prevalence of PH and CV morbidity was investigated, and their association was evaluated with a logistic regression model.

Results

PH was detected in 426 patients (18.1%). Mild, moderate and severe PH was diagnosed in 12.1%, 4.9% and 1.1% of the patients, respectively. Severe PH was detected in CKD Stages 5 and 5D. CV morbidity was found in 645 patients (27.4%). Compared with the non-PH group, the PH group had a higher risk for cardiac disease but not for cerebrovascular disease risk. PH severity was associated with cardiac morbidity risk [odds ratio (95% CI) for mild PH: 1.79 (1.30–2.47); moderate PH: 2.75 (1.73–4.37); severe PH: 3.90 (1.46–10.42)].

Conclusions

Our study showed for the first time the epidemiology profile of PH across the spectrum of CKD. Mild-to-moderate PH occurs with more frequency in advanced CKD, and severe PH is scarce in non-ESRD CKD. PH in CKD is associated with cardiac but not cerebrovascular disease, with increasing cardiac morbidity seen with increasing PH severity. Evidence from prospective studies addressing PH in this population is needed to predict cardiac events.

Renal complications in anorexia nervosa

PURPOSE

Anorexia nervosa is a malady with possible long-lasting physiological consequences. Among these, little is known about the renal effects, which remain rarely investigated.

METHODS

A literature review was conducted using electronic databases and manual search of relevant articles, discussing the renal impacts of anorexia nervosa.

RESULTS

Renal failure has been described in malnourished patients, but the optimal non-invasive tool to assess the glomerular function rate in this population needs to be further evaluated. Significant disruptions in osmolar regulation, even in the absence of potomania, arise from multiple factors: hypothalamic dysfunction, intrinsic renal insufficiency, and use of psychotropic medications. Urinary urgency and nocturnal enuresis are frequent symptoms, rarely reported by patients. Among hydroelectrolytic disorders, hypokalemia is the most frequent, especially in settings of vomiting or medication misuse. Hyponatremia, hypomagnesemia, and hypophosphatemia may also be encountered. Urinary lithiases are relatively frequent as a consequence of dehydration, laxative use, or both.

CONCLUSION

Investigation and follow-up of the renal function are essential in patients with an eating disorder, especially when the illness has been present for a long time.

Prevalence of renal insufficiency in hospitalised patients with venous thromboembolic events: a retrospective analysis based on 6,725 VTE patients

Renal impairment (RI) is an important factor in the selection of anticoagulant therapy in venous thromboembolic event (VTE) patients. In particular, the risk of bleeding events is higher for VTE patients with a glomerular filtration rate (GFR) below 30 mL/min. The aim of this study was to collect data on the prevalence of RI in hospitalised VTE patients in Germany. Furthermore, we investigated how renal function changed during inpatient treatment. We conducted a retrospective chart review in six German hospitals. All patients with a VTE diagnosis who were treated as inpatients from 2007-2011 were included. Patients were categorised according to their renal function. RI was estimated from serum creatinine values. Persistent RI was defined as an estimated glomerular filtration rate (eGFR) of <30 mL/min over at least 72 hours. Renal function could be determined for 5,710 VTE patients. Of these 21.4% had an eGFR>90 mL/min, 38.1% had an eGFR of 60-89 mL/min, 17.3% had an eGFR of 45-59 mL/min, 12.5% had an eGFR of 30-44 mL/min, 7.2% had an eGFR of 15-29 mL/min and 3.6% of the VTE patients had end-stage renal disease. Persistent severe RI was observed in 74.8% of patients with an eGFR <30 mL/min. Overall, 40.6% of the VTE patients investigated had an eGFR <60 mL/min; 10.8% had an eGFR <30 mL/min. Almost three quarters of RI-VTE patients suffered from persistent severe RI. These results suggest that more than one in ten VTE patients is exposed to a high risk of accumulating anticoagulants; most of these RI patients also face an increased risk of mortality.

Managing venous thromboembolism with novel oral anticoagulants in the elderly and other high-risk patient groups

The novel oral anticoagulants represent a new era of anticoagulation for patients with deep vein thrombosis and pulmonary embolism. These agents may offer advantages to patients in whom the use of traditional anticoagulants is typically challenging, such as elderly patients, patients with renal impairment and those with low body weight. Currently, rivaroxaban and dabigatran are the only approved novel oral anticoagulants for the treatment and secondary prevention of venous thromboembolism. It is likely that additional agents will become available in the near future. This review summarises recent phase III data for these agents, focusing, where possible, on results obtained in frail patients.

Epidemiology and clinical profile of Takotsubo cardiomyopathy

First described in Japan over 2 decades ago, takotsubo cardiomyopathy (TTC) has emerged as a unique cardiomyopathy with world-wide recognition, mimicking acute coronary syndrome. In early TTC experience, typical patients were older women, with a triggering emotional event, ST-segment elevation, and apical ballooning left ventricular (LV) contraction pattern. However, TTC is now more heterogeneous, occurring in males and younger individuals, without ST-segment elevation, as a spontaneous event in the absence of a trigger, and with diverse LV contraction patterns. Furthermore, TTC is more common than initially thought, now constituting 10% of women with suspected acute coronary syndrome. TTC is also associated with a broader range of psychological or physical triggers, including presentation during outpatient medical evaluations or hospitalization for acute illness. Although TTC has been considered a benign condition, it now carries a small but important risk for adverse outcomes, including cardiac arrest in 5%. Hemodynamic instability requiring intervention with vasopressor drugs or intra-aortic balloon pump is necessary in 15% and in-hospital mortality is approximately 5%, largely because of refractory cardiogenic shock or irreversible major comorbid conditions. Although complete cardiac recovery usually occurs rapidly, post-hospital survival may be less than the general population of similar age, largely because of concomitant illnesses. TTC may reoccur in up to 10% of patients, but β-blocking drugs are not absolutely preventive for initial or subsequent events.

Predictors and prognostic implications of major adverse cardiovascular events after renal transplant: 10 years outcomes in 321 patients

Renal transplantation is the treatment of choice in patients with end-stage renal disease. Major adverse cardiac events (MACE) are common after renal transplant, especially in the perioperative period, leading to excess morbidity and mortality. The predictors and long-term prognostic implications of MACE are poorly understood. We analyzed predictors and implications of MACE in a cohort of 321 consecutive adult patients, who received renal allograft transplantation between 1995 and 2003 at our institution. The characteristics of 321 patients were: age at transplant 44 ± 13 years, 60% male, 36% diabetes mellitus (DM), left ventricular ejection fraction (LVEF) 60 ± 16%. MACE occurred in 21 patients with cumulative rate of 6.5% over 3 years after renal transplant, 57% occurring within 30 days, 67% within 90 days, and 86% within 180 days. MACE was not predicted by any clinical or pharmacological variables including age, gender, hypertension, DM, prior myocardial infarction, smoking, duration of dialysis, LVEF, or therapy with β-blockers (BB), angiotensin converting enzyme inhibitors, or calcium channel blockers. However, a clinical decision to perform a stress test or a coronary angiogram was predictive of higher MACE rate. MACE, irrespective of type, was independently associated with higher mortality over a period up to 15 years and this seemed to be blunted by BB therapy. MACE rate after renal transplantation decreases over time, most occurring in the first 90 days and is not predicted by any of the traditional risk factors or drug therapies. It is associated with higher long-term mortality.

Diurnal and twenty-four hour patterning of human diseases: cardiac, vascular, and respiratory diseases, conditions, and syndromes

Various medical conditions, disorders, and syndromes exhibit predictable-in-time diurnal and 24 h patterning in the signs, symptoms, and grave nonfatal and fatal events, e.g., respiratory ones of viral and allergic rhinorrhea, reversible (asthma) and non-reversible (bronchitis and emphysema) chronic obstructive pulmonary disease, cystic fibrosis, high altitude pulmonary edema, and decompression sickness; cardiac ones of atrial premature beats and tachycardia, paroxysmal atrial fibrillation, 3rd degree atrial-ventricular block, paroxysmal supraventricular tachycardia, ventricular premature beats, ventricular tachyarrhythmia, symptomatic and non-symptomatic angina pectoris, Prinzmetal vasospastic variant angina, acute (non-fatal and fatal) incidents of myocardial infarction, sudden cardiac arrest, in-bed sudden death syndrome of type-1 diabetes, acute cardiogenic pulmonary edema, and heart failure; vascular and circulatory system ones of hypertension, acute orthostatic postprandial, micturition, and defecation hypotension/syncope, intermittent claudication, venous insufficiency, standing occupation leg edema, arterial and venous branch occlusion of the eye, menopausal hot flash, sickle cell syndrome, abdominal, aortic, and thoracic dissections, pulmonary thromboembolism, and deep venous thrombosis, and cerebrovascular transient ischemic attack and hemorrhagic and ischemic stroke. Knowledge of these temporal patterns not only helps guide patient care but research of their underlying endogenous mechanisms, i.e., circadian and others, and external triggers plus informs the development and application of effective chronopreventive and chronotherapeutic strategies.

Multiple biomarker strategy for improved diagnosis of acute heart failure in older patients presenting to the emergency department

AIM

Biomarkers can help to identity acute heart failure (AHF) as the cause of symptoms in patients presenting to the emergency department (ED). Older patients may prove a diagnostic challenge due to co-morbidities. Therefore we prospectively investigated the diagnostic performance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) alone or in combination with other biomarkers for AHF upon admission at the ED.

METHODS

302 non-surgical patients aged ≥ 70 years were consecutively enrolled upon admission to the ED. In addition to NT-proBNP, mid-regional pro-adrenomedullin (MR-proADM), mid-regional pro-atrial natriuretic peptide (MR-proANP), C-terminal pro-endothelin-1 (CT-proET-1) and ultra-sensitive C-terminal pro-vasopressin (Copeptin-us) were measured at admission. Two cardiologists independently adjudicated the final diagnosis of AHF after reviewing all available baseline data excluding the biomarkers. We assessed changes in C-index, integrated discrimination improvement (IDI), and net reclassification improvement (NRI) for the multimarker approach.

RESULTS

AHF was diagnosed in 120 (40%) patients (age 81±6 years, 64 men, 56 women). Adding MR-ADM to NT-proBNP levels improved C-index (0.84 versus 0.81; p=0.045), and yielded IDI (3.3%; p=0.002), NRI (17%, p<0.001) and continuous NRI (33.3%; p=0.002). Adding CT-proET-1 to NT-proBNP levels improved C index (0.86 versus 0.81, p=0.031), and yielded robust IDI (12.4%; p<0.001), NRI (31.3%, p<0.001) and continuous NRI (69.9%; p<0.001). No other dual or triple biomarker combination showed a significant improvement of both C-index and IDI.

CONCLUSION

In older patients presenting to the ED, the addition of CT-proET-1 or MR-proADM to NT-proBNP improves diagnostic accuracy of AHF. Both dual biomarker approaches offer significant risk reclassification improvement over NT-proBNP.

Trends in hospital admissions for pulmonary embolism in Spain from 2002 to 2011

The aim of our study was to analyse changes in the incidence, diagnostic procedures, comorbidity, length of hospital stay, costs and in-hospital mortality of patients hospitalised for pulmonary embolism in Spain over a 10-year period.

We included all patients who were hospitalised for pulmonary embolism (ICD-9-CM codes 415.11 and 415.19) as the primary diagnosis between 2002 and 2011. Data were collected from the National Hospital Discharge Database, covering the entire Spanish population.

115 671 patients were admitted. The overall crude incidence increased from 20.44 per 100 000 inhabitants in 2002 to 32.69 in 2011 (p<0.05). In 2002, 13.3% of patients had a Charlson comorbidity index >2, and in 2011 the prevalence increased to 20.8% (p<0.05). Mean length of hospital stay was 12.7 days in 2002 and decreased to 9.99 in 2011 (p<0.05). During the study period, mean cost per patient increased from €3915 to €4372 (p<0.05). In-hospital mortality decreased from 12.9% in 2002 to 8.32% in 2011 (p<0.05). The increase in the use of computed tomographic pulmonary angiography over time was associated with increased incidence and lower mortality.

Our results revealed an increase in the incidence of hospitalised pulmonary embolism patients from 2002 to 2011 with concomitant increase in comorbidities and cost. However, length of hospital stay and in-hospital mortality decreased.

Pulmonary hypertension in end-stage renal disease and post renal transplantation patients

BACKGROUND

Information regarding lung function parameters and functional capacity in renal failure and post renal transplantation patients with pulmonary hypertension (PH) is limited. The purpose of this study was to examine the clinical characteristics of patients with PH who were receiving hemodialysis (HD) or peritoneal dialysis (PD) or who had undergone renal transplantation.

METHODS

A prospective study was performed on 116 patients (HD =55, PD =17, and post renal transplantation =44) who underwent Doppler echocardiography. PH was defined as systolic pulmonary artery pressure (SPAP) ≥40 mmHg. Demographic information, clinical characteristics, pulmonary function tests (PFTs) and the six-minute walk test (6MWT) were collected and compared between the patients with and without PH.

RESULTS

Twelve (21.8%) patients receiving HD, four (23.5%) patients receiving PD, and eight (18.2%) post renal transplantation patients had PH. In the HD group, the physiological indicators (including pulmonary function test parameters, the final Borg score, and walking distance during the 6MWT) were all significantly lower in the patients with PH compared with those without PH (all P<0.0001). However, in the PD and post renal transplantation groups, no significant differences were noted in the demographic characteristics or in the physiological parameters when the PH patients were compared with those without PH (all P>0.05).

CONCLUSIONS

Among HD patients, marked aberrations in PFT results or walking distance may identify a subset of patients suffering from PH.

Predictive value of admission N-terminal pro-B-type natriuretic peptide and renal function in older people hospitalized for dyspnoea

BACKGROUND

We investigated the relationship between NT-pro-BNP, glomerular filtration rate (GFR), and all-cause mortality rates in a cohort of older people discharged from an internal medicine unit after admission for dyspnoea.

PATIENTS AND METHODS

NT-pro-BNP was evaluated in serum samples of 134 patients aged 80 ± 6 years who presented to a single academic centre with worsening dyspnoea. History data and anthropometric, clinical, and biochemical parameters including GFR were collected at the time of admission. 119 out of 134 were discharged alive from hospital and were included in the follow-up of 779 ± 370 days.

RESULTS

35 out of 119 subjects died after a follow-up of 266 ± 251 days. Cox proportional hazards model showed that GFR and Ln (NT-pro-BNP) were predictors for all-cause mortality with estimated hazard ratios of 0.969 (95% confidence interval: 0.950-0.988; P = 0.001) and 2.360 (95% confidence interval: 1.208-4.610; P = 0.012), respectively. Patients characterized by high NT-pro-BNP levels and GFR ≥ 60 mL/min/1.73 m(2) showed a dramatic reduction in survival duration compared with the groups with different combinations of the two variables (P = 0.008).

CONCLUSIONS

In the elderly, NT-pro-BNP and GFR are predictors of all-cause mortality after admission because of dyspnoea. Since the fact that subjects with high NT-pro-BNP and GFR ≥ 60 mL/min/1.73 m(2) exhibited a reduced survival, high admission NT-pro-BNP suggests future negative outcome.

In-hospital mortality for pulmonary embolism: relationship with chronic kidney disease and end-stage renal disease. The hospital admission and discharge database of the Emilia Romagna region of Italy

The impact of chronic kidney disease (CKD) on the outcome of acute pulmonary embolism (PE) is uncertain. We aimed to evaluate the effect of renal dysfunction (defined by ICD-9-CM codification) on in-hospital mortality for PE. We considered all cases of PE (first event) recorded in the database of hospital admissions for the Emilia-Romagna region, Italy, from 1999 to 2009. The inclusion criterion was the presence, as a main discharge diagnosis, of acute PE codes according to ICD-9-CM. Diagnoses of immobilization, dementia, sepsis, skeletal fractures, hypertension, heart failure, myocardial infarction, diabetes mellitus, peripheral vascular disease, cerebrovascular disease, chronic pulmonary disease, pneumonia, malignancy, CKD and end-stage renal disease (ESRD) were also considered to evaluate comorbidity. The outcome was in-hospital mortality for PE, and multivariate logistic regression analyses was performed. We considered 24,690 cases of first episode of PE. In-hospital mortality for PE was not different in patients without renal dysfunction, with CKD, or ESRD (23.6 vs. 24 vs. 18 % p = ns). In-hospital mortality for PE was independently associated with age (OR 1.045, 95 % CI 1.042-1.048, p < 0.001), female sex (OR 1.322, 95 % CI 1.242-1.406, p < 0.001), hypertension (OR 1.096, 95 % CI 1.019-1.178, p = 0.013), diabetes mellitus (OR 1.120, 95 % CI 1.001-1.253, p = 0.049), dementia (OR 1.171, 95 % CI 1.020-1.346, p = 0.025), peripheral vascular disease (OR 1.349, 95 % CI 1.057-1.720, p = 0.016) and malignancy (OR 1.065, 95 % CI 1.016-1.116, p = 0.008). Age and comorbidity are associated with in-hospital mortality for PE, whereas CKD does not appear to be an independent predictor of adverse outcomes in patients hospitalized for PE.

Association between in-hospital mortality and renal dysfunction in 186,219 patients hospitalized for acute stroke in the Emilia-Romagna region of Italy

Using a regional Italian database, we evaluated the relationship between renal dysfunction and in-hospital mortality (IHM) in patients with acute stroke (ischemic/hemorrhagic). Patients were classified on the basis of renal damage: without renal dysfunction, with chronic kidney disease (CKD), and with end-stage renal disease (ESRD). Of a total of 186,219 patients with a first episode of stroke, 1626 (0.9%) had CKD and 819 (0.4%) had ESRD. Stroke-related IHM (total cases) was independently associated with CKD, ESRD, atrial fibrillation (AF), age, and Charlson comorbidity index (CCI). In patients with ischemic stroke (n=154,026), IHM remained independently associated with CKD, ESRD, AF, and CCI. In patients with hemorrhagic stroke (n=32,189), variables that were independently associated with IHM were CKD, ESRD, and AF. Renal dysfunction is associated with IHM related to stroke, both ischemic and hemorrhagic, with even higher odds ratios than those of other established risk factors, such as age, comorbidities, and AF.

World Health Organization group 5 pulmonary hypertension

World Health Organization (WHO) group 5 pulmonary hypertension (PH) entails a heterogeneous group of disorders that may cause PH by unclear and/or multiple mechanisms. In particular, group 5 includes PH caused by hematologic disorders, systemic diseases, metabolic disorders, chronic renal failure, and disorders leading to pulmonary vascular occlusion or compression. This article discusses common pathogenic mechanisms leading to group 5 PH, followed by a detailed overview of epidemiology, pathogenesis, and disease-specific management of the individual group 5 conditions. Off-label use of vasomodulatory therapies, typically indicated for pulmonary arterial hypertension (WHO group 1 PH), in group 5 conditions is also discussed.

Pulmonary hypertension in patients with chronic and end-stage kidney disease

Pulmonary hypertension is defined as a mean pulmonary artery pressure ≥25 mm Hg and is a recently recognized complication of chronic kidney disease and end-stage renal disease. There is significant epidemiological overlap with kidney disease and the underlying causes of World Health Organization group 1-4 pulmonary hypertension (pulmonary arteriopathy, left heart disease, chronic pulmonary disease, and chronic thromboembolic disease, respectively). In addition, an entity of 'unexplained pulmonary hypertension,' group 5, in patients with chronic kidney disease and end-stage renal disease has emerged, with prevalence estimates of 30-50%. The pathogenesis of pulmonary hypertension in this population is due to alterations in endothelial function, increased cardiac output, and myocardial dysfunction leading to elevated left heart filling pressure, with recent data suggesting that left heart dysfunction may account for the vast majority of pulmonary hypertension in patients with kidney disease. Pulmonary hypertension is an independent predictor of increased mortality in patients on dialysis and those undergoing kidney transplantation. This review summarizes what is known about the epidemiology, pathogenesis, transplantation outcomes, mortality, and treatment of pulmonary hypertension in patients with chronic kidney disease and end-stage renal disease.

Prevalence and predictors of renal artery stenosis in patients undergoing peripheral and coronary angiography

BACKGROUND

Renal artery stenosis is a potential cause of secondary hypertension, ischemic nephropathy and end-stage renal disease. Atherosclerosis is by far the most common etiology of renal artery stenosis in elderly. We investigated whether the presence of significant atherosclerotic renal artery stenosis (ARAS) with luminal diameter narrowing ≥50 % could be predicted in patients undergoing peripheral and coronary angiography.

METHODS

The records of 3,500 consecutive patients undergoing simultaneous renal angiography along with peripheral and coronary angiography were reviewed. The patients with known renal artery disease were excluded.

RESULTS

Prevalence of ARAS was 5.7 %. Significant ARAS (luminal diameter narrowing ≥50 %) was present in 139 patients (3.9 %). Hypertension with altered serum creatinine and triple-vessel CAD were associated with significant renal artery stenosis in multivariate analysis. No significant relationship between the involved coronary arteries like left anterior descending, left circumflex, right coronary artery and ARAS was found. Only hypertension and altered serum creatinine were associated with bilateral ARAS. Extent of CAD or risk factors like diabetes, hyperlipidemia or smoking did not predict the unilateral or bilateral ARAS.

CONCLUSION

Prevalence of ARAS among the patients in routine cardiac catheterization was 5.7 %. Hypertension is closely associated with significant ARAS. Significant CAD in the form of triple-vessel disease and altered renal function tests are closely associated with ARAS. They predict the presence of significant renal artery stenosis in patients undergoing routine peripheral and coronary angiography. Moreover, hypertension and altered renal functions predict bilateral ARAS.

Effect of magnesium supplementation on carotid intima-media thickness and flow-mediated dilatation among hemodialysis patients: a double-blind, randomized, placebo-controlled trial

OBJECTIVES

The aim of the present study was to determine the efficacy of oral magnesium (Mg) supplementation on endothelial function through evaluation of carotid intima-media thickness (cIMT), brachial artery flow-mediated dilatation (FMD), and C-reactive protein (CRP) among hemodialysis (HD) patients.

METHODS

This randomized, controlled, double-blind clinical trial consisted of 54 patients on HD. One group was treated orally with 440 mg of Mg oxide 3 times per week for 6 months (n = 29). The control group (n = 25) was given placebo using the same administration protocol. cIMT, FMD, serum calcium levels, phosphorus, lipid, CRP, and bicarbonate were measured at baseline and at 6 months in both groups.

RESULTS

At 6 months, cIMT was significantly decreased in the Mg group (0.84 ± 0.13 mm at baseline and 0.76 ± 0.13 mm at 6 months, p = 0.001). However, in the placebo group, cIMT was significantly increased (0.73 ± 0.13 and 0.79 ± 0.12 mm, respectively, p = 0.003). When hypertension, diabetes mellitus, smoking, hyperlipidemia, and systemic lupus erythematosus were controlled for in the analysis, the effect of Mg remained significant in both groups (p = 0.000).

CONCLUSION

Our results indicate that Mg might not improve endothelial function (CRP level and FMD) and that a decreased cIMT as a marker of atherosclerosis may be due to the inhibition of calcification through the regulation parathormone, calcium, and phosphorus.

Stroke and renal dysfunction: are we always conscious of this relationship?

Cerebrovascular disease may represent an important clinical presentation of atherosclerosis in chronic kidney disease (CKD), and atherosclerosis is frequently encountered in CKD. In fact, kidney disease is now considered a risk factor for development of cardiovascular disease. Although guidelines for primary prevention of stroke have been recently published, CKD is hardly mentioned. Based on a series of available studies, we analyzed the relationship between reduced renal function, end-stage renal disease (ESRD), and stroke. Reduced renal function and risk of stroke appear to be related to the highest risk of patients on dialysis treatment. Primary and secondary prevention of stroke should be encouraged in participants with renal dysfunction.

In-hospital mortality in patients with renal dysfunction admitted for myocardial infarction: the Emilia-Romagna region of Italy database of hospital admissions

BACKGROUND

In-hospital mortality of patients with myocardial infarction (MI) in different European populations and renal dysfunction is variable. We aimed to evaluate in-hospital mortality for MI in chronic kidney disease (CKD), in end-stage renal disease (ESRD), and in subjects admitted for MI without renal dysfunction living in the Emilia-Romagna region of Italy.

METHODS

We considered all cases of MI (first event) recorded in the database of hospital admissions of the region Emilia-Romagna of Italy, from January 1999 to December 2009. The criterion for inclusion was the presence, as a first discharge diagnosis, of acute MI (International Classification of Diseases, 9th Revision, Clinical Modification). The Charlson comorbidity index (CCI), with the exclusion of CKD, was calculated. The outcome variable was in-hospital mortality for MI, and its association with comorbidities, CKD and ESRD, was analyzed.

RESULTS

During the considered period, 88,014 cases of first MI were recorded. The percentage of patients admitted with MI and died during hospitalization were higher in patients with ESRD (38.3 %) and CKD (16.5 %) than in those without renal dysfunction (14 %) (p < 0.01). In CKD and ESRD patients, data of in-hospital mortality for MI exhibited a twofold increase in the analyzed period. In-hospital mortality for MI was independently associated with age (OR 1.077, 95 % CI 1.075-1.080, p < 0.001), CCI excluding CKD (OR 1.101, 95 % CI 1.069-1.134, p < 0.001), cerebrovascular disease (OR 1.450, 95 % CI 1.349-1.557, p < 0.001), malignancy (OR 1.234, 95 % CI 1.153-1.320, p < 0.001), and ESRD (OR 4.137, 95 % CI 3.511-4.875, p < 0.001).

CONCLUSIONS

As for the Emilia-Romagna region of Italy, in-hospital mortality for MI is increasing over the last years, and mortality seems to be related with patients' comorbidities and presence of advanced stages of CKD.

Posterior Reversible Encephalopathy Syndrome during Recovery from Acute Kidney Injury after Hepatitis A Infection

The patient was a 25-year-old healthy male who experienced fever, chills, and abdominal pain for 5 days prior to the hospital visit. He was diagnosed with acute hepatitis A, and at admission he presented with anuric acute kidney injury and hepatic encephalopathy. He received continuous renal replacement therapy followed by intermittent regular hemodialysis. His urine output increased to 1,610 ml/day after 31 days. On day 32, he suddenly developed a headache and visual disturbance and experienced three short convulsions, which were followed by postictal confusion and high fever. T2 and FLAIR MRI images of the brain revealed hyperintense signal alterations in bilateral subcortical regions of the temporoparietal and occipital lobes, consistent with posterior reversible encephalopathy syndrome. His mental status was fully recovered after 7 h of conservative treatment, including antihypertensive therapy. On hospital day 56, the renal function of the patient had recovered, and he was discharged without neurologic sequelae.

Anorexia nervosa and the kidney

Anorexia nervosa is a common psychiatric disorder that disproportionately affects adolescents and young adults and is associated with high rates of morbidity and mortality. Anorexia nervosa can affect the kidney in numerous ways, including increased rates of acute kidney injury and chronic kidney disease, electrolyte abnormalities, and nephrolithiasis. Additionally, the diagnosis and treatment of anorexia nervosa-associated kidney diseases are challenging, reflecting complications such as refeeding syndrome, as well as the limitations of serum creatinine level in this population to estimate kidney function and the psychosocial challenges inherent with treating systemic manifestations of psychiatric conditions. In this review, we discuss kidney diseases and kidney-associated conditions that occur in individuals with anorexia nervosa, summarizing many of the challenges in treating patients with this disease.

Effects of sevelamer hydrochloride on mortality, lipid abnormality and arterial stiffness in hemodialyzed patients: a propensity-matched observational study

BACKGROUND

Cause-and-effect associations between sevelamer hydrochloride (HCl) and mortality have yet to be clarified. The effects of sevelamer HCl on mortality, lipid abnormality and arterial stiffness were examined in patients with chronic kidney disease stage 5D.

METHODS

The effects of sevelamer HCl were studied by a single-center cohort study that was conducted from January 1, 2005 to December 31, 2008 (n = 483). By the end of the study, 172 patients (Sevelamer group) had succeeded in continuing sevelamer HCl for >6 months (median 37 months), and 300 patients (Control group) had received calcium carbonate (n = 264) or no phosphate binder (n = 36). The mortality and other outcomes were compared between these two groups after matching by a propensity score calculated using age, gender, diabetes prevalence, and dialysis vintage.

RESULTS

All-cause [hazard ratio (HR) 0.4, P = 0.02] and cardiovascular (CV)-cause [HR 0.29, P = 0.03] cumulative mortality were significantly lower in the matched Sevelamer group than in the matched Control group. The matched Sevelamer group showed increased high-density lipoprotein cholesterol (P = 0.003) and no change in pulse wave velocity (PWV) and ankle-brachial index (ABI), whereas the matched Control group showed increased serum low-density lipoprotein (LDL) cholesterol (P = 0.003), increased PWV (P = 0.03), and decreased ABI (P = 0.0009). Change in serum LDL cholesterol level correlated inversely with sevelamer HCl dosage (P = 0.02).

CONCLUSIONS

Reduced mortality in patients with sevelamer HCl may, at least in part, be explained by an improvement in dyslipidemia and arterial stiffness by sevelamer HCl.

Renal involvement in psychological eating disorders

Psychological eating disorders--anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder--are an increasing public health problem with severe clinical manifestations: hypothermia, hypotension, electrolyte imbalance, endocrine disorders and kidney failure; they are of interest to nephrologists, but pathophysiological mechanisms in determining the renal involvement are still unclear. We describe pathophysiology, histological features and clinical manifestations of the most frequent psychological eating disorders: AN and BN. Regarding AN, we analyze the recent literature, and identify 3 principal pathways towards renal involvement: chronic dehydration-hypokalemia, nephrocalcinosis and chronic rhabdomyolysis. Regarding BN, we describe the correlation between obesity and many proinflammatory cytokines, chemokines, growth factors and adipokines, having potential metabolic and hemodynamic effects on the kidney and an important role in the pathogenesis of obesity-related renal injury, independently of hypertension and diabetes.

Anorexia nervosa: a case report of a teenager presenting with bradycardia, general fatigue, and weakness

BACKGROUND

Anorexia nervosa is a disease with high prevalence in adolescents and carries the highest mortality of any psychiatric disorder.

CASE

We present a case of a 17-year-old female presenting to the emergency department with bradycardia that was subsequently diagnosed with anorexia nervosa. We also review the clinical features, diagnosis, complications, and emergency department management of this disease.

CONCLUSIONS

Patients with anorexia may present with multiple medical complaints, and it is imperative that the emergency physician be familiar with the syndrome so as to correctly identify and treat patients with this disease.

Prevalence, determinants and prognosis of pulmonary hypertension among hemodialysis patients

BACKGROUND

The prevalence, determinants and prognosis of pulmonary hypertension among long-term hemodialysis patients in the USA are poorly understood.

METHODS

A cross-sectional survey of prevalence and determinants of pulmonary hypertension was performed, followed by longitudinal follow-up for all-cause mortality. Pulmonary hypertension was defined as an estimated systolic pulmonary artery pressure of >35 mmHg using echocardiograms performed within an hour after the end of dialysis.

RESULTS

Prevalent in 110/288 patients (38%), the independent determinants of pulmonary hypertension were the following: left atrial diameter (odds ratio 10.1 per cm/m(2), P < 0.0001), urea reduction ratio (odds ratio 0.94 per %, P < 0.01) and vitamin D receptor activator use (odds ratio 0.41 for users, P < 0.01). Over a median follow-up of 2.15 years, 97 (34%) patients died yielding a crude mortality rate (CMR) of 114.2 per 1000 patient-years. Of these, 58 deaths occurred among 110 patients with pulmonary hypertension (53%, CMR 168.9/1000 patient-years) and 39 among 178 without pulmonary hypertension (22%, CMR 52.5/1000 patient-years) [unadjusted hazard ratio (HR) for death 2.12 (95% confidence interval 1.41-3.19), P < 0.001]. After multivariate adjustment, pulmonary hypertension remained an independent predictor for all-cause mortality [HR 2.17 (95% confidence interval 1.31-3.61), P < 0.01].

CONCLUSIONS

Among hemodialysis patients, pulmonary hypertension is common and is strongly associated with an enlarged left atrium and poor long-term survival. Reducing left atrial size such as through volume control may be an attractive target to improve pulmonary hypertension. Improving pulmonary hypertension in this group of patients may improve the dismal outcomes.

The Role of Statin Therapy for Primary Prevention: What is the Evidence?

Almost one third of annual worldwide mortality is attributed to cardiovascular disease (CVD), making it the leading cause of global death. Dyslipidemia is a well-established risk factor for CVD and plays a pivotal role in the pathogenesis of atherosclerosis. Statins, which inhibit 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase and lower low-density lipoprotein cholesterol, have emerged as the most effective therapy to date against atherothrombotic CVD. Although their role in secondary prevention of CVD is undisputed, it remains a topic for debate as to how widely they should be used for primary prevention. The Framingham Risk Score and the National Cholesterol Education Program Adult Treatment Panel III guidelines are the cornerstones for the current guidelines for primary prevention statin therapy. Although these guidelines serve as help to evaluate cardiovascular risk and effectively identify many patients who will benefit from statin therapy, there is a growing population of "intermediate-risk" patients who may be undertreated. Additional noninvasive tests may complement the traditional risk scores, potentially expanding the indications for statins.

Predicting mortality and hospital admission in patients with COPD: significance of NT pro-BNP, clinical and echocardiographic assessment

AIMS

To quantify the ability of N-terminal pro-brain natriuretic peptide (NT pro-BNP) to predict mortality and hospitalization in patients with chronic obstructive airways disease (COPD).

METHODS

Prospective single-centre observational study of 140 consecutive patients aged at least 18 years with COPD between 27 March 2004 and 28 February 2008 (median follow-up 3.9 years).

RESULTS

Sixty-five (46%) men, 26 (19%) O2 therapy, 115 (82%) smokers, 38 (27%) patients receiving diuretics, 15 (11%) left-ventricular ejection fraction less than 45%. Median [interquartile range (IQR)] NT pro-BNP concentration 16.2 (25.4) pmol/l. NT pro-BNP was higher in those with a dilated left atrium (P<0.001), aortic stenosis (P=0.02), left-ventricular systolic dysfunction (P=0.027), right ventricular impairment (P=0.011), atrial fibrillation (P<0.001), patients receiving diuretics (P=0.010) and angiotensin-converting enzyme (ACE) inhibitors (P=0.006). One-year mortality and hospitalization rates were 2.9 and 25.4%. The median (IQR) time to hospitalization and length of first hospital stay: 383.5 (605) and 4.0 (7.0) days. NT pro-BNP was an excellent discriminator of right-ventricular impairment (C statistic=0.90) and predicted survival (highest quartile versus lowest quartile relative risk=3.02, P=0.001), but not hospital admission. After adjustment this association was not significant.

CONCLUSION

NT pro-BNP predicts survival, but not hospital admission in patients with COPD. The ability of NT pro-BNP to independently predict death or hospitalization is superseded by the presence of a dilated left atrium, aortic stenosis and left-ventricular systolic dysfunction.

Posterior reversible encephalopathy syndrome

Posterior reversible encephalopathy syndrome (PRES) is characterized by headache, altered mental status, visual disturbances, and seizures. Radiological features typically include edema of the posterior cerebral regions, especially of the parietooccipital lobes. Atypical imaging features, such as involvement of anterior cerebral regions, deep white matter, and the brain stem are also frequently seen. Vasoconstriction is common in vascular imaging. Different conditions have been associated with PRES, but toxemia of pregnancy, solid organ or bone marrow transplantation, immunosuppressive treatment, cancer chemotherapy, autoimmune diseases, and hypertension are most commonly described. The pathophysiology of PRES is unclear and different hypotheses are being discussed. Posterior reversible encephalopathy syndrome is best managed by monitoring and treatment in the setting of a neurointensive care unit. The prognosis is usually benign with complete reversal of clinical symptoms within several days, when adequate treatment is immediately initiated. Treatment of severe hypertension, seizures, and withdrawal of causative agents represent the hallmarks of specific therapy in PRES. Delay in diagnosis and treatment may lead to permanent neurological sequelae. Therefore, awareness of PRES is of crucial importance for the intensivist.

Magnesium supplementation helps to improve carotid intima media thickness in patients on hemodialysis

BACKGROUND

The atherosclerotic process progresses more dynamically in hemodialysis (HD) patients than in the general population. In HD patients, lower magnesium levels were reported to be associated with increased atherosclerosis of the common carotid artery. We tested the hypotheses that magnesium supplementation helps to improve carotid intima media thickness (IMT) in HD patients.

MATERIALS AND METHODS

A total of 47 patients on HD were included in the study. Patients were randomly divided into two groups: group A (Mg group), in which patients were given magnesium citrate orally at a dosage of 610 mg every other day for 2 months and group B (control group), in which patients received only calcium acetate therapy as a phosphate binder. At baseline and 2 months later, all patients underwent a carotid artery ultrasound scan to measure carotid IMT.

RESULTS

At the end of 2 months, mean serum calcium, phosphorus, and calcium x phosphorus product were not changed in both groups. As expected, mean serum Mg level significantly increased in the Mg group at the end of 2 months. In addition, serum parathyroid hormone (PTH) level significantly decreased in the Mg group at the end of 2 months (P = 0.003). Baseline carotid IMT was similar between the groups. Bilateral carotid IMT was significantly improved in patients treated with magnesium citrate compared to initial values (P = 0.001 for left, P = 0.002 for right).

CONCLUSION

Based on the present data, magnesium may play an important protective role in the progression of atherosclerosis in patients on dialysis. Further studies are needed to assess more accurately the role of magnesium in atherosclerotic regression in dialysis patients.

Light chain deposition disease presenting as paroxysmal atrial fibrillation: a case report

INTRODUCTION

Light chain deposition disease (LCDD) can involve the heart and cause severe heart failure. Cardiac involvement is usually described in the advanced stages of the disease. We report the case of a woman in whom restrictive cardiomyopathy due to LCDD presented with paroxysmal atrial fibrillation.

CASE PRESENTATION

A 55-year-old woman was admitted to our emergency department because of palpitations. In a recent blood test, serum creatinine was 1.4 mg/dl. She was found to have high blood pressure, left ventricular hypertrophy and paroxysmal atrial fibrillation. An ACE-inhibitor was prescribed but her renal function rapidly worsened and she was admitted to our nephrology unit. On admission serum creatinine was 9.4 mg/dl, potassium 6.8 mmol/l, haemoglobin 7.7 g/dl, N-terminal pro-brain natriuretic peptide 29894 pg/ml. A central venous catheter was inserted and haemodialysis was started. She underwent a renal biopsy which showed kappa LCDD. Bone marrow aspiration and bone biopsy demonstrated kappa light chain multiple myeloma. Echocardiographic findings were consistent with restrictive cardiomyopathy. Thalidomide and dexamethasone were prescribed, and a peritoneal catheter was inserted. Peritoneal dialysis has now been performed for 15 months without complications.

DISCUSSION

Despite the predominant tubular deposition of kappa light chain, in our patient the first clinical manifestation of LCDD was cardiac disease manifesting as atrial fibrillation and the correct diagnosis was delayed. The clinical management initially addressed the cardiovascular symptoms without paying sufficient attention to the pre-existing slight increase in our patient's serum creatinine. However cardiac involvement is a quite uncommon presentation of LCDD, and this unusual case suggests that the onset of acute arrhythmias associated with restrictive cardiomyopathy and impaired renal function might be related to LCDD.