β-Blockers improve outcomes in kidney disease patients having noncardiac vascular surgery

Efficacy and safety of intravenous esmolol for cardiac protection in non-cardiac surgery. A systematic review and meta-analysis

Haemodynamic instability predisposes patients to cardiac complications in non-cardiac surgery. Esmolol, a short-acting cardioselective beta-adrenergic blocker might be efficient in perioperative cardiac protection, but could affect other vital organs, such as the kidneys, and post-discharge survival. We performed a systematic review on the use of esmolol for perioperative cardiac protection. We searched PubMed, Ovid Medline and Cochrane Central Register for Controlled trials. Eligible randomized controlled studies (RCTs) reported a perioperative esmolol intervention with at least one of the primary (major cardiac or renal complications during the first 30 postoperative days) or secondary (postoperative adverse effects and all-cause mortality) outcomes. We included 196 adult patients from three RCTs. Esmolol significantly reduced postoperative myocardial ischaemia, RR =0.43 [95% confidence interval, CI: 0.21-0.88], p = .02. No association with clinically significant bradycardia and hypotension compared to patients receiving control treatment could be confirmed (RR =7.4 [95% CI: 0.29-139.81], p = .18 and RR =2.21 [95% CI: 0.34-14.36], p = .41, respectively). No differences regarding other outcomes were observed. No study reported postoperative renal outcomes. Esmolol seems promising for the prevention of perioperative myocardial ischaemia. However, the association with bradycardia and hypotension remains unclear. Randomized trials investigating the effect of β1-selective blockade on clinically relevant outcomes and non-cardiac vital organs are warranted. Key messages Short-acting cardioselective esmolol seems efficient in the prevention of perioperative myocardial ischaemia. The possibly increased risk of bradycardia and hypotension with short-acting intravenous beta blockade could not be confirmed or refuted by available data. Future adequately powered trials investigating the effect of β1-selective blockade on clinically relevant outcomes and non-cardiac vital organs are warranted.

Effect of beta-blockers on perioperative outcomes in vascular and endovascular surgery: a systematic review and meta-analysis

BACKGROUND

To investigate the role of perioperative beta-blocker use in vascular and endovascular surgery.

METHODS

We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. The review protocol was registered with International Prospective Register of Systematic Reviews (registration number:CRD42016038111). We searched electronic databases to identify all randomized controlled trials and observational studies investigating outcomes of patients undergoing vascular and endovascular surgery with or without perioperative beta blockade. We used the Cochrane tool and the Newcastle-Ottawa scale to assess the risk of bias of trials and observational studies, respectively. Random-effects models were applied to calculate pooled outcome data.

RESULTS

We identified three randomized trials, five retrospective cohort studies, and three prospective cohort studies, enrolling a total of 32,602 patients. Our analyses indicated that perioperative use of beta-blockers did not reduce the risk of all-cause mortality [odds ratio (OR) 1.10, 95% confidence interval (CI) 0.59-2.04, P = 0.77], cardiac mortality (OR 2.62, 95% CI 0.86-8.05, P = 0.09), myocardial infarction (OR 0.89, 95% CI 0.59-1.35, P = 0.58), unstable angina (OR 1.34, 95% CI 0.41- 4.38, P = 0.63), stroke (OR 2.45, 95% CI 0.89-6.75, P = 0.08), arrhythmias (OR 0.76, 95% CI 0.41-1.43, P = 0.40), congestive heart failure (OR 1.12, 95% CI 0.77-1.63, P = 0.56), renal failure (OR 1.48, 95% CI 0.90-2.45, P = 0.13), composite cardiovascular events (OR 0.88, 95% CI 0.55-1.40, P = 0.58), rehospitalisation (OR 0.86, 95% CI 0.48-1.52, P = 0.60), and reoperation (OR 1.17, 95% CI 0.42-3.27, P = 0.77) in vascular surgery.

CONCLUSIONS

Beta-blockers do not improve perioperative outcomes in vascular and endovascular surgery.

Short-term and long-term outcomes after gastrectomy for gastric cancer in patients with chronic kidney disease

BACKGROUND

The incidence of chronic kidney disease (CKD) is increasing, which might be an obstacle to various aspects of gastric cancer treatment, such as perisurgical management and postsurgical follow-up. The present study aimed to evaluate the short- and long-term surgical outcomes following gastrectomy in patients with CKD.

METHODS

We retrospectively analyzed surgical complications and prognosis of patients with gastric cancer. These patients were divided into three groups according to the glomerular filtration rate (GFR): 49 patients with severe CKD (GFR < 29 ml/min/1.73 m(2)), 128 with mild CKD (GFR 30-59), and 798 in the controls (GFR ≥ 60).

RESULTS

The incidences of anastomotic leakage and intraabdominal abscess in the mild and severe CKD groups were higher than that in the control group. The incidences of wound infection, cardiovascular and pulmonary events, and in-hospital mortality in the severe CKD group were higher than those in the other two groups. Severe surgical complications were associated with co-morbidities other than CKD, serum albumin level, estimated blood loss, surgery duration in the mild and severe CKD group. The 3-year overall survival rates for the severe CKD, mild CKD, and control groups were 48.6, 80.9, and 85.0 %, respectively, indicating significant differences between the severe CKD group and other two groups.

CONCLUSIONS

Patients with severe CKD show an increased risk of morbidity and mortality following gastrectomy, and their prognosis is usually poor. Studies with a large cohort are essential to refine the risk stratification for gastrectomy in this high-risk population.

Modulation of aldosterone release by epidural analgesia impacts brain natriuretic peptide: a link to stress cardiomyopathy? Pilot study

OBJECTIVE

Data pertaining to whether stress-induced aldosterone release is associated with cardiac disorders are lacking. This study was designed to compare whether the modulation of intra-operative aldosterone release by epidural analgesia had an effect on the brain natriuretic peptide (BNP) levels.

DESIGN, PATIENTS, MEASUREMENTS

A study was pilot prospective, open label randomized one. Patients were randomized to one of two anaesthesia protocols: group 1 included 13 patients who received general anaesthesia, and group 2 included 12 patients who received combined general anaesthesia and epidural analgesia. Study protocol was by completed 25 male patients, median age 56 years, without significant comorbidities, who underwent radical cystectomy because of urinary bladder tumour. Serum aldosterone, BNP, cortisol (measured by radioimmunoassay), adrenocorticotropine hormone (ACTH) (by solid-phase ELSA), blood chemistry, complete blood count and vital signs were compared preoperatively, intra-operatively and at postoperative days (POD) 1 and 7.

RESULTS

Hemodynamics was stable in both groups. Group 1 showed threefold serum aldosterone, (P = 0·001) 20-fold ACTH (P = 0·003) and twofold cortisol (P = 0·001) increases intra-operatively, unlike group 2. Both groups had a twofold BNP increase in POD 1 that remained above normal on POD 7 only in group 1 (P = 0·02; P = 0·019 vs group 2).

CONCLUSION

Alleviation of aldosterone release by epidural analgesia modulated the postoperative serum BNP pattern in patients with a low risk for cardiac diseases who underwent noncardiac surgery.

Sympathetic blockade prevents the decrease in cardiac VEGF expression and capillary supply in experimental renal failure

Uremic cardiomyopathy of men and rodents is characterized by lower myocardial capillary supply that in rats could be prevented by central and peripheral blockade of the sympathetic nervous system. The underlying pathomechanisms remain largely unknown. We investigated whether alterations of cardiac vascular endothelial growth factor (VEGF) gene and protein expression were involved. In our long-term experiment, we analyzed whether VEGF gene and protein expression was altered in the heart of male Sprague-Dawley rats with either sham operation (sham, n = 10) or subtotal nephrectomy (SNX, n = 10). In our short-term experiment (17 sham, 24 SNX), the effect of a putative downregulation of sympathetic nervous activity by surgical renal denervation (interruption of renal afferent pathways) on cardiac gene expression of VEGF, flt-1, and flk-1 and on myocardial capillary supply was analyzed. In the long-term study, cardiac capillary supply and vascular endothelial growth factor gene and protein expression were significantly lower in SNX than in sham. In the short-term experiment, cardiac VEGF mRNA expression was significantly lower in untreated SNX (4,258 ± 2,078 units) than in both sham groups (11,709 ± 4,169 and 8,998 ± 4,823 units); this decrease was significantly prevented by renal denervation (8,190 ± 3,889, P < 0.05). We conclude that cardiac VEGF gene and protein expression is reduced in experimental renal failure, and this may be considered as one potential reason for impaired myocardial adaptation under the situation of cardiac hypertrophy. The beneficial effect of sympathetic downregulation on cardiac structure and function in renal failure may be at least in part explained by increased cardiac VEGF gene expression.

Can Laboratory Tests Predict the Prognosis of Patients after Endovascular Aneurysm Repair? Current Status and Future Directions

The purpose of this study was to determine what laboratory values predict the prognosis of patients after endovascular aneurysm repair (EVAR). MEDLINE and Cochrane Library databases were searched. This resulted in 13 relevant articles. Data were pooled, and meta-analyses were performed. A meta-analysis including 5,655 patients showed that preoperative serum creatinine > 1.5 mg/dL was a significant risk indicator for increased 30-day mortality (relative risk 3.0, 95% confidence interval 2.3–4.1, p < .0001). Four other studies showed that other cutoff values of creatinine or glomerular filtration rate can predict mortality and complications following EVAR. One study suggested that reduced preoperative hemoglobin is a risk indicator for reduced long-term survival. Increased serum creatinine, reduced glomerular filtration rate, and reduced hemoglobin are significant and strong predictors of mortality and complications after EVAR. Current evidence remains limited, and further research is needed to determine conclusively additional laboratory values that may predict the outcome of patients following EVAR.

Nontraditional risk factors for cardiovascular disease in patients with chronic kidney disease

Patients with chronic kidney disease (CKD) have a reduced lifespan, and a substantial proportion of these individuals die from cardiovascular disease. Although a large percentage of patients with CKD have traditional cardiac risk factors such as diabetes, hypertension and abnormalities in cholesterol, interventions to address these factors--which have significantly decreased cardiovascular mortality in the general population--have not shown such benefit in the CKD population. In addition, the severity and extent of cardiovascular complications in patients with CKD is disproportionate to the number and severity of traditional risk factors. This realization has focused attention on nontraditional cardiac risk factors that are particularly relevant to patients with CKD, including decreased hemoglobin levels, microalbuminuria, increased inflammation and oxidative stress, and abnormalities in bone and mineral metabolism. However, large prospective trials in patients with advanced CKD or in those requiring chronic dialysis have not shown that normalization of these nontraditional risk factors improves survival. Moreover, the mechanisms by which these nontraditional risk factors contribute to cardiovascular disease are unknown. Therefore, although current treatment of patients with CKD includes management of traditional and nontraditional risk factors, the value of modifying some nontraditional risk factors remains unclear.

Cardiovascular outcomes in the outpatient kidney transplant clinic: the Framingham risk score revisited

BACKGROUND AND OBJECTIVES

Cardiovascular disease is an important cause of morbidity and death in kidney transplant recipients. This study examines the Framingham risk score's ability to predict cardiac and stroke events. Because cyclosporine and tacrolimus have different cardiovascular risk profiles, these agents were also examined.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A prospective cohort evaluation of 540 patients were followed for a median of 4.7 yr in an outpatient kidney transplant clinic. Baseline Framingham risk scores were calculated and all cardiovascular outcomes were collected.

RESULTS

Rates per 100 patient-years were 1.79 for cardiac and 0.78 for stroke events. The ratio of observed-to-predicted cardiac events was 1.64-fold higher [95% confidence interval (CI) 1.19 to 2.94] for the cohort, 2.74-fold higher (95% CI 1.70 to 4.24) in patients age 45 to 60 with prior cardiac disease or diabetes mellitus, but not higher in other age subgroups. Stroke was not increased above predicted. Risk scores for cardiac (c = 0.65, P = 0.003) and stroke (c = 0.71, P = 0.004) events were modest predictors. 10-yr event scores for cardiac (9.3 versus 13.5%, P < 0.001) and stroke (7.1 versus 10.0%, P = 0.002) were lower for tacrolimus compared with cyclosporine-treated patients. However observed cardiac events were higher in tacrolimus recipients (2.50, 95% CI 1.09 to 5.90) in an adjusted Cox model.

CONCLUSIONS

Although risk scores are only modest predictors, patients with the highest event rates are easily identified. Treating high-risk patients with cardioprotective medications should remain a priority.