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Gökdemir BN, Çekmen N. Vasoplegic Syndrome and Anaesthesia: A Narrative Review. Turk J Anaesthesiol Reanim 2023; 51:280-289. [PMID: 37587654 PMCID: PMC10440482 DOI: 10.4274/tjar.2023.221093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 02/23/2023] [Indexed: 08/18/2023] Open
Abstract
Vasoplegic syndrome (VS) is defined as low systemic vascular resistance, normal or high cardiac output, and resistant hypotension unresponsive to vasopressor agents and intravenous volume. VS is a frequently encountered complication in cardiovascular and transplantation surgery, burns, trauma, pancreatitis, and sepsis. The basis of the pathophysiology is associated with an imbalance of vasodilator and vasoconstrictive structure in vascular smooth muscle cells and is highly complex. The pathogenesis of VS has several mechanisms, including overproduction of iNO, stimulation of ATP-dependent K+ channels and NF-κB, and vasopressin receptor 1A (V1A-receptor) down-regulation. Available treatments involve volume and inotropes administration, vasopressin, methylene blue, hydroxocobalamin, Ca++, vitamin C, and thiamine, and should also restore vascular tone and improve vasoplegia. Other treatments could include angiotensin II, corticosteroids, NF-κB inhibitor, ATP-dependent K+ channel blocker, indigo carmine, and hyperbaric oxygen therapy. Despite modern advances in treatment, the mortality rate is still 30-50%. It is challenging for an anaesthesiologist to consider this syndrome's diagnosis and manage its treatment. Our review aims to review the diagnosis, predisposing factors, pathophysiology, treatment, and anaesthesia approach of VS during anaesthesia and to suggest a treatment algorithm.
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Affiliation(s)
- Begüm Nemika Gökdemir
- Department of Anaesthesiology and Reanimation, Başkent University Faculty of Medicine, Ankara, Turkey
| | - Nedim Çekmen
- Department of Anaesthesiology and Reanimation, Başkent University Faculty of Medicine, Ankara, Turkey
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Zhang Y, Xue J, Zhou L, Si J, Cheng S, Cheng K, Yu S, Ouyang M, Chen Z, Chen D, Zeng W. The predictive value of high-sensitive troponin I for perioperative risk in patients undergoing gastrointestinal tumor surgery. EClinicalMedicine 2021; 40:101128. [PMID: 34522874 PMCID: PMC8427204 DOI: 10.1016/j.eclinm.2021.101128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The incidence of cardiovascular events in perioperative period of gastrointestinal tumor surgery cannot be ignored, and studies have shown that level of postoperative troponin is related to the postoperative risk of non-cardiac surgery. However, the relationship between pre-operative troponin levels and perioperative risk of gastrointestinal tumor surgery is unclear. Thus, we aimed to evaluate the value of high-sensitive cardiac troponin I (hs-cTnI) prior to gastrointestinal tumor surgery for perioperative risk assessment. METHODS In this retrospective cohort study, 1259 patients who underwent gastrointestinal tumor surgery and had been tested for hs-cTnI on admission within 7 days prior to surgery were retrospectively recruited from January 2018 to June 2020. The primary combined endpoint including in-hospital all-cause mortality, acute myocardial infarction, cardiac arrest or ventricular fibrillation and acute decompensated heart failure. The secondary endpoint included total hospital stay and requirement of intensive care treatment. FINDINGS Compared with patients with normal hs-cTnI, those with elevated hs-cTnI (> 0·028 ng/ml) were more likely to experience the combined endpoint (28·2% versus 2·7%, P < 0·001) and there was also an increasing rate of in mortality in elevated hs-cTnI group (2·4% versus 0·3%, P = 0·057). The length of total hospital stay was significantly longer in patients with elevated hs-cTnI (24·8 ± 16·3 versus 19·5 ± 7·9, P = 0·003) and the number of patients requiring intensive care treatment was also higher (22·6% versus 4·2%, P < 0·001). The area under the ROC curve assessing hs-cTnI in predicting in-hospital mortality was 0·787 [95% confidence interval (CI) 0·612-0·963, P = 0·015] and for combined endpoint was 0·822 [95% CI 0·766-0·879, P < 0·001]. Hs-cTnI > 0·028 ng/ml was associated with significantly higher cardiovascular event rate in patients with the revised cardiac index ≤ 1. The positive likelihood ratio of hs-cTnI (> 0·028 ng/ml) for predicting combined endpoint reaches 10.5 in patients with Lee index = 0. In multivariate logistic analyses, hs-cTnI was one of the best predictors for the combined endpoint [odds ratio (OR) 5·924 (95%CI: 2·869-12·233), P < 0·001]. INTERPRETATION Hs-cTnI provides powerful prognostic information for patients undergoing gastrointestinal tumor surgery, and therefore provides reliable prognostic information incremental to revised cardiac index.
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Affiliation(s)
- Yitao Zhang
- The department of cardiovascular internal medicine, the sixth affiliated hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Jiaojie Xue
- The department of cardiovascular internal medicine, the sixth affiliated hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Ling Zhou
- Ultrasonic department, hospital of South China University of Technology, Guangzhou 510000, China
| | - Jinhong Si
- The department of internal medicine, the sixth affiliated hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Shiyao Cheng
- The department of cardiovascular internal medicine, the sixth affiliated hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Kanglin Cheng
- The department of cardiovascular internal medicine, the sixth affiliated hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Shuqi Yu
- The department of cardiovascular internal medicine, the sixth affiliated hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Mao Ouyang
- The department of cardiovascular internal medicine, the sixth affiliated hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Zhichong Chen
- The department of cardiovascular internal medicine, the sixth affiliated hospital of Sun Yat-sen University, Guangzhou 510655, China
- Corresponding authors.
| | - Daici Chen
- Department of clinical laboratory, the sixth affiliated hospital of Sun Yat-sen University, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Disease, Guangzhou 510655, China
- Corresponding authors.
| | - Weijie Zeng
- The department of cardiovascular internal medicine, the sixth affiliated hospital of Sun Yat-sen University, Guangzhou 510655, China
- Corresponding authors.
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Holt RIG, Barnard-Kelly K, Dritsakis G, Thorne KI, Cohen L, Dixon E, Patel M, Newland-Jones P, Partridge H, Luthra S, Ohri S, Salhiyyah K, Picot J, Niven J, Cook A. Developing an intervention to optimise the outcome of cardiac surgery in people with diabetes: the OCTOPuS pilot study. Pilot Feasibility Stud 2021; 7:157. [PMID: 34404479 PMCID: PMC8368047 DOI: 10.1186/s40814-021-00887-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 07/09/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Cardiothoracic surgical outcomes are poorer in people with diabetes compared with those without diabetes. There are two important uncertainties in the management of people with diabetes undergoing major surgery: (1) how to improve diabetes management in the weeks leading up to an elective procedure and (2) whether that improved management leads to improved postoperative outcomes. The aim of this study was to develop and pilot a specialist diabetes team-led intervention to improve surgical outcomes in people with diabetes. DESIGN Open pilot feasibility study SETTING: Diabetes and cardiothoracic surgery departments, University Hospital Southampton NHS Foundation Trust PARTICIPANTS: Seventeen people with diabetes undergoing cardiothoracic surgery INTERVENTION: Following two rapid literature reviews, a prototype intervention was developed based on a previously used nurse-led outpatient intervention and tested. PRIMARY OUTCOME Feasibility and acceptability of delivering the intervention SECONDARY OUTCOMES: Biomedical data were collected at baseline and prior to surgery. We assessed how the intervention was used. In depth qualitative interviews with participants and healthcare professionals were used to explore perceptions and experiences of the intervention and how it might be improved. RESULTS Thirteen of the 17 people recruited completed the study and underwent cardiothoracic surgery. All components of the OCTOPuS intervention were used, but not all parts were used for all participants. Minor changes were made to the intervention as a result of feedback from the participants and healthcare professionals. Median (IQR) HbA1c was 10 mmol/mol (3, 13) lower prior to surgery than at baseline. CONCLUSION This study has shown that it is possible to develop a clinical pathway to improve diabetes management prior to admission. The clinical and cost-effectiveness of this intervention will now be tested in a multicentre randomised controlled trial in cardiothoracic centres across the UK. TRIAL REGISTRATION ISRCTN; ISRCTN10170306 . Registered 10 May 2018.
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Affiliation(s)
- Richard I G Holt
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK.
- Southampton National Institute for Health Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
| | - Katharine Barnard-Kelly
- Barnard Health-Health Psychology Research, Fareham, UK
- Faculty of Health & Social Science, Bournemouth University, Poole, UK
| | - Giorgos Dritsakis
- Clinical Trials Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Kerensa I Thorne
- Clinical Trials Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Lauren Cohen
- Barnard Health-Health Psychology Research, Fareham, UK
| | - Elizabeth Dixon
- Clinical Trials Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Mayank Patel
- Diabetes Department, University Hospital Southampton, Southampton, UK
| | | | - Helen Partridge
- Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK
| | - Suvitesh Luthra
- Division of Cardiac Surgery, Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton, UK
| | - Sunil Ohri
- Division of Cardiac Surgery, Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton, UK
| | - Kareem Salhiyyah
- Division of Cardiac Surgery, Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton, UK
- Middle East University, Amman, Jordan
| | - Jo Picot
- Southampton Health Technology Assessments Centre, University of Southampton, Southampton, UK
| | - John Niven
- Clinical Trials Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Andrew Cook
- Clinical Trials Unit, Faculty of Medicine, University of Southampton, Southampton, UK
- Southampton Health Technology Assessments Centre, University of Southampton, Southampton, UK
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Impacto de los inhibidores del sistema renina-angiotensina en el pronóstico tras recambio valvular aórtico quirúrgico o percutáneo. Metanálisis. Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.02.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Takagi H, Kuno T, Hari Y, Nakashima K, Yokoyama Y, Ueyama H, Ando T. Meta-analysis of impact of renin-angiotensin system inhibitors on survival after transcatheter aortic valve implantation. Minerva Cardiol Angiol 2021; 69:299-309. [PMID: 33703852 DOI: 10.23736/s2724-5683.20.05289-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION To determine whether renin-angiotensin system inhibitor (RASI) prescription is associated with better survival after transcatheter aortic valve implantation (TAVI), we performed the first meta-analysis of currently available studies. EVIDENCE ACQUISITION To identify all studies reporting impact of RASI prescription on survival after TAVI, we searched PubMed, Web of Science, Google Scholar, etc. through October 2019. We extracted adjusted (if unavailable, unadjusted) hazard ratios (HRs) with their confidence intervals (CIs) of midterm (up to ≥6-month) all-cause mortality for RASI prescription from each study and combined study-specific estimates using inverse variance-weighted averages of logarithmic HRs in the random-effects model. EVIDENCE SYNTHESIS We identified 13 eligible studies with a total of 26,132 TAVI patients and included them in the present meta-analysis. None was a randomized controlled trial, 5 were observational studies comparing patients with versus without RASI prescription (including 3 propensity score matched studies), and 8 were observational studies investigating RASI prescription as one of covariates. The primary meta-analysis of all studies demonstrated that RASI prescription was associated with significantly lower midterm mortality (HR=0.83; 95% CI: 0.76 to 0.92; P=0.0002). Although we identified significant funnel plot asymmetry (P=0.036 by the rank correlation test) suggesting publication bias, correcting for it using the trim-and-fill method did not substantially alter the result favoring RASI prescription (corrected HR=0.85; 95% CI: 0.76 to 0.95; P=0.004). CONCLUSIONS RASI prescription may be associated with better midterm survival after TAVI.
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Affiliation(s)
- Hisato Takagi
- Shizuoka Medical Center, Department of Cardiovascular Surgery, Shizuoka, Japan - .,Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan -
| | - Toshiki Kuno
- Department of Medicine, Mount Sinai Beth Israel Medical Center, New York, NY, USA
| | - Yosuke Hari
- Shizuoka Medical Center, Department of Cardiovascular Surgery, Shizuoka, Japan.,Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kouki Nakashima
- Shizuoka Medical Center, Department of Cardiovascular Surgery, Shizuoka, Japan.,Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | | | - Hiroki Ueyama
- Department of Medicine, Mount Sinai Beth Israel Medical Center, New York, NY, USA
| | - Tomo Ando
- Division of Interventional Cardiology, Department of Cardiology, New York Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
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Abstract
Postoperative acute kidney injury (AKI) is a common complication of surgery that is associated with significant adverse outcomes, including increased morbidity and mortality. The perioperative burden of AKI risk factors is complex and potentially large, including high-risk nephrotoxic medications, hypotension, hypovolemia, radiologic contrast, anemia, and surgery-specific factors. Understanding the pathogenesis, risk factors, and potential cumulative impact of perioperative nephrotoxic exposures is particularly important in the prevention and reduction of perioperative AKI. This review outlines the possible strategies to reduce perioperative nephrotoxicity and the development of postoperative AKI.
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Affiliation(s)
- Heather Walker
- Division of Population Health and Genomics, University of Dundee, Dundee, United Kingdom; Renal Unit, Ninewells Hospital, Dundee, United Kingdom
| | - Samira Bell
- Division of Population Health and Genomics, University of Dundee, Dundee, United Kingdom; Renal Unit, Ninewells Hospital, Dundee, United Kingdom.
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Amat-Santos IJ, Santos-Martínez S, Julca F, Catalá P, Rodríguez-Gabella T, Redondo-Diéguez A, Hinojosa W, Veras C, Campo A, Serrador Frutos A, Carrasco-Moraleja M, San Román JA. Impact of renin-angiotensin system inhibitors on outcomes after surgical or transcatheter aortic valve replacement. A meta-analysis. ACTA ACUST UNITED AC 2020; 74:421-426. [PMID: 32402685 DOI: 10.1016/j.rec.2020.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 02/25/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND OBJECTIVES To determine whether renin-angiotensin system inhibitor (RASi) prescription is associated with better outcomes after transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). METHODS All comparative studies of RASi vs no RASi prescription in patients undergoing TAVI/SAVR were gathered from PubMed, Web of Science, and Google Scholar through August, 2019. We extracted hazard ratios (HRs) with their confidence intervals (CIs) for mortality from each study and combined study-specific estimates using inverse variance-weighted averages of logarithmic HRs in the random effects model. RESULTS We identified 6 eligible studies with a total of 21 390 patients (TAVI: 17 846; SAVR: 3544) and included them in the present meta-analysis. The 6 studies were observational comparative studies (including 3 propensity score matched and 3 cohort studies) of RASi vs no RASi prescription. The analysis demonstrated that RASi prescription was associated with significantly lower mortality in the whole group of patients undergoing aortic valve intervention (HR, 0.64; 95%CI, 0.47-0.88; P <.001). However, subgroup analysis suggested differences according to the selected therapy, with TAVI showing better mortality rates in the RASi group (HR, 0.67; 95%CI, 0.49-0.93) but not in the SAVR group (HR, 0.61; 95%CI, 0.29-1.30). No funnel plot asymmetry was identified, suggesting minimum publication bias. Sensitivity analyses sequentially eliminating dissimilar studies did not substantially alter the primary result favoring RASI prescription. CONCLUSIONS These findings suggest a mortality benefit of RASi in patients with AS treated with aortic valve replacement that might be particularly relevant following TAVI. Future randomized studies are warranted to confirm this relevant finding.
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Affiliation(s)
- Ignacio J Amat-Santos
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, CIBERCV, Valladolid, Spain; Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain.
| | - Sandra Santos-Martínez
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, CIBERCV, Valladolid, Spain
| | - Fabián Julca
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, CIBERCV, Valladolid, Spain
| | - Pablo Catalá
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, CIBERCV, Valladolid, Spain
| | - Tania Rodríguez-Gabella
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, CIBERCV, Valladolid, Spain
| | - Alfredo Redondo-Diéguez
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, CIBERCV, Valladolid, Spain
| | - Williams Hinojosa
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, CIBERCV, Valladolid, Spain
| | - Carlos Veras
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, CIBERCV, Valladolid, Spain
| | - Alberto Campo
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, CIBERCV, Valladolid, Spain
| | - Ana Serrador Frutos
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, CIBERCV, Valladolid, Spain
| | | | - José A San Román
- Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, CIBERCV, Valladolid, Spain; Departamento de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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Chou YH, Huang TM, Wu VC, Chen WS, Wang CH, Chou NK, Chiang WC, Chu TS, Lin SL. Associations between preoperative continuation of renin-angiotensin system inhibitor and cardiac surgery-associated acute kidney injury: a propensity score-matching analysis. J Nephrol 2019; 32:957-966. [PMID: 31595420 DOI: 10.1007/s40620-019-00657-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/30/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Cardiac surgery-associated acute kidney injury (CSA-AKI) is associated with high risk for complications and mortality. Whether renin-angiotensin system (RAS) inhibitor should be continued or withdrawn in patients with long-term use before cardiac surgery has been lack of consensus. METHODS We performed this prospective observational cohort study and recruited cardiac surgery patients in the surgical intensive care units between 2000 and 2011. These patients were divided into users and non-users of RAS inhibitor. Propensity score matching and multivariable models were performed to investigate the association between renal outcome, mortality, and preoperative use of RAS inhibitor. RESULTS Preoperative use of RAS inhibitor was identified as the independent protective factor for AKI development (OR 0.41, 95% CI 0.23, 0.63), AKI severity (stage 3 vs. stage 1, OR 0.35, 95% CI 0.18, 0.69), and renal recovery (OR 3.41, 95% CI 1.84, 5.36). Nevertheless, there was no significant protective effect of RAS inhibitor on in-hospital dialysis, in-hospital mortality, and ensuing development of chronic kidney disease (CKD) after AKI. We created a prediction model of CSA-AKI and indicated that preoperative use of RAS inhibitor provided more protective effect in low-risk than high-risk population. CONCLUSION Preoperative use of RAS inhibitor was associated with less AKI development and severity, and higher renal recovery. Although more risk reduction of AKI development was shown in low-risk group by our prediction model, continued use of RAS inhibitor before cardiac surgery could provide protective effect in all patients.
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Affiliation(s)
- Yu-Hsiang Chou
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital Jin-Shan Branch, New Taipei City, Taiwan.,Graduate Institute of Physiology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tao-Min Huang
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan
| | - Vin-Cent Wu
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan
| | - Wei-Shan Chen
- Cardiovascular Division, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Hsien Wang
- Cardiovascular Division, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Nai-Kuan Chou
- Cardiovascular Division, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.,The Center for Law, Technology and Ethics, National Taiwan University, Taipei, Taiwan.,Graduate Institute of Biomedical Electronics and Bioinformatics, College of Electrical Engineering and Computer Science, National Taiwan University, Taipei, Taiwan
| | - Wen-Chih Chiang
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan.
| | - Tzong-Shinn Chu
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan
| | - Shuei-Liong Lin
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan.,Graduate Institute of Physiology, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.,Research Center for Developmental Biology and Regenerative Medicine, National Taiwan University, Taipei, Taiwan
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Orozco Vinasco DM, Triana Schoonewolff CA, Orozco Vinasco AC. Vasoplegic syndrome in cardiac surgery: Definitions, pathophysiology, diagnostic approach and management. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2019; 66:277-287. [PMID: 30736984 DOI: 10.1016/j.redar.2018.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/22/2018] [Accepted: 12/24/2018] [Indexed: 06/09/2023]
Abstract
Vasoplegic syndrome is a state of vasopressor resistant systemic vasodilation in the presence of a normal cardiac output. Its definition, pathophysiology, risk factors, diagnosis and therapeutic approach will be reviewed in this paper. It occurs frequently during cardiac surgery and is associated with high morbidity and mortality. A search in the LILACS, MEDLINE, and GOOGLE SCHOLAR databases was conducted to find the most relevant papers during the last 18 years. Prompt identification and diagnosis of patients at risk must be undertaken in order to implement an optimal therapeutic approach. This latter includes early treatment with vasopressors with different mechanisms of action.
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Affiliation(s)
- D M Orozco Vinasco
- Departamento de Anestesia cardiovascular, Clínica Colsubsidio Calle 100, Instituto del Corazón de Bucaramanga sede Bogotá, Bogotá, Colombia.
| | - C A Triana Schoonewolff
- Departamento de Anestesia cardiovascular, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - A C Orozco Vinasco
- Departamento de Anestesia, Hospital Universitario Severo Ochoa, Leganés Madrid, España
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Association of pre-operative troponin levels with major adverse cardiac events and mortality after noncardiac surgery. Eur J Anaesthesiol 2018; 35:815-824. [DOI: 10.1097/eja.0000000000000868] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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U-shape association of serum albumin level and acute kidney injury risk in hospitalized patients. PLoS One 2018; 13:e0199153. [PMID: 29927987 PMCID: PMC6013099 DOI: 10.1371/journal.pone.0199153] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 06/03/2018] [Indexed: 12/31/2022] Open
Abstract
Background While an association between hypoalbuminemia and increased risk of acute kidney injury (AKI) is well-established, the risk of AKI development and its severity among patients with elevated serum albumin is unclear. The aim of this study was to evaluate the risk of AKI in hospitalized patients stratified by various admission serum albumin levels. Methods This single-center retrospective study was conducted at a tertiary referral hospital. All adult hospitalized patients who had admission albumin levels available between January 2009 and December 2013 were enrolled. Admission albumin was categorized based on its distribution into six groups (≤2.4, 2.5–2.9, 3.0–3.4, 3.5–3.9, 4.0–4.4, and ≥4.5 mg/dL). The primary outcome was the incidence of hospital-acquired AKI (HAKI). Logistic regression analysis was performed to obtain the odds ratio of AKI for various admission albumin strata using the albumin 3.5 to 3.9 mg/dL (lowest incidence of AKI) as the reference group. Results Of the total 9,552 studied patients, HAKI occurred in 1,556 (16.3%) patients. The incidence of HAKI among patients with admission albumin ≤2.4, 2.5–2.9, 3.0–3.4, 3.5–3.9, 4.0–4.4, and ≥4.5 mg/dL was 18.3%, 14.3%, 15.5%, 14.2%, 16.7%, and 26.0%, respectively. After adjusting for potential confounders, admission serum albumin levels ≤2.4 and ≥4.5 mg/dL were associated with an increased risk of HAKI with odds ratios of 1.52 (95% CI 1.18–1.94) and 2.16 (95% CI 1.74–2.69), respectively. While stage 1 HAKI was significantly more frequent among patients with admission albumin ≥4.5 mg/dL (23.0% vs. 11.6%, P<0.001), incidence of stage 3 HAKI was higher in those with albumin ≤2.4 mg/dL (2.8% vs 0.3%, P<0.001). Conclusion Admission serum albumin levels ≤2.4 and ≥4.5 mg/dL were associated with an increased risk for HAKI. Patients with admission albumin ≥4.5 mg/dL had HAKI with a lower intensity when compared with those who had admission albumin levels ≤2.4 mg/dL.
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Thongprayoon C, Cheungpasitporn W, Mao MA, Sakhuja A, Erickson SB. Admission calcium levels and risk of acute kidney injury in hospitalised patients. Int J Clin Pract 2018; 72:e13057. [PMID: 29314467 DOI: 10.1111/ijcp.13057] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 12/15/2017] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The risk of acute kidney injury (AKI) development among hospitalised patients with elevated calcium levels on admission remains unclear. The aim of this study was to assess the risk of AKI in hospitalised patients stratified by various admission serum calcium levels. METHODS This is a single-centre retrospective study conducted at a tertiary referral hospital. All hospitalised adult patients who had admission calcium levels available between 2009 and 2013 were enrolled. Admission calcium was categorised based on its distribution into six groups (≤7.9, 8.0-8.4, 8.5-8.9, 9.0-9.4, 9.5-9.9, and ≥10.0 mg/dL). The primary outcome was hospital-acquired AKI. Logistic regression analysis was performed to obtain the odds ratio of AKI for various admission calcium strata using calcium levels of 8.0-8.4 mg/dL (lowest incidence of AKI) as the reference group. RESULTS A total of 12 784 patients were studied. Hospital-acquired AKI occurred in 1779 (13.9%) patients. The incidence of AKI among patients with admission calcium ≤7.9, 8.0-8.4, 8.5-8.9, 9.0-9.4, 9.5-9.9 and ≥10 mg/dL was 14.7%, 11.7%, 11.8%, 14.6%, 15.8% and 17.3%, respectively. After adjusting for potential confounders, admission calcium levels ≤7.9, 9.0-9.4, 9.5-9.9 and ≥10 mg/dL were associated with increased risk of AKI with odds ratios of 1.36 (95%CI 1.08-1.72), 1.29 (95%CI 1.08-1.56), 1.38 (95%CI 1.14-1.68) and 1.51 (95%CI 1.19-1.91), respectively. CONCLUSION Admission hypocalcaemia and hypercalcaemia are associated with an increased risk for hospital acquired AKI. Patients with admission hypercalcaemia (≥10 mg/dL) carry a 1.51-fold risk for AKI development during hospitalisation.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Michael A Mao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ankit Sakhuja
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stephen B Erickson
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Admission hyperphosphatemia increases the risk of acute kidney injury in hospitalized patients. J Nephrol 2017; 31:241-247. [PMID: 28975589 DOI: 10.1007/s40620-017-0442-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 09/01/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Evidence on the association between elevated admission serum phosphate and risk of in-hospital acute kidney injury (AKI) is limited. The aim of this study was to assess the risk of AKI in hospitalized patients stratified by admission serum phosphate level. METHODS This is a single-center retrospective study conducted at a tertiary referral hospital. All hospitalized adult patients who had admission phosphate measurement available between January and December 2013 were enrolled. Admission phosphate was categorized into 6 groups (< 2.4, 2.4-2.9, 2.9-3.4, 3.4-3.9, 3.9-4.4, and ≥ 4.4 mg/dl). The primary outcome was in-hospital AKI occurring after hospital admission. Logistic regression analysis was performed to obtain the odds ratio of AKI for various admission phosphate strata using the phosphate 2.4-2.9 mg/dl level (lowest incidence of AKI) as the reference group. RESULTS After excluding patients with end-stage renal disease (ESRD), without serum phosphate measurement, and those with AKI at time of admission, a total of 5036 patients were studied. Phosphate levels of < 2.4 and ≥ 4.4 mg/dl were found in 458 (9.1%) and 585 (11.6%) patients, respectively. In-hospital AKI occurred in 595 (11.8%) patients. The incidence of AKI among patients with admission phosphate < 2.4, 2.4-2.9, 2.9-3.4, 3.4-3.9, 3.9-4.4, and ≥ 4.4 mg/dl was 10.5, 9.5, 11.8, 10.0, 12.8, and 17.9%, respectively. After adjusting for potential confounders, admission serum phosphate > 4.4 mg/dl was associated with an increased risk of developing AKI with an odds ratio of 1.72 (95% confidence interval 1.20-2.47), whereas admission serum phosphate levels < 4.4 mg/dl were not associated with development of AKI during hospitalization. CONCLUSION Elevated admission phosphate is associated with an increased risk for in-hospital AKI.
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Manning MW, Cooter M, Mathew J, Alexander J, Peterson E, Ferguson TB, Lopes R, Podgoreanu M. Angiotensin Receptor Blockade Improves Cardiac Surgical Outcomes in Patients With Metabolic Syndrome. Ann Thorac Surg 2017; 104:98-105. [PMID: 28131423 PMCID: PMC5479726 DOI: 10.1016/j.athoracsur.2016.10.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 09/25/2016] [Accepted: 10/10/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Perioperative use of angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEis) in patients undergoing cardiac operations remains controversial. The current practice of discontinuing renin-angiotensin-system inhibitors preoperatively may negate their beneficial effects in vulnerable populations, including patients with metabolic syndrome, who exhibit elevated renin-angiotensin system activity. We hypothesized that preoperative ARB use is associated with reduced incidence of postoperative complications, compared with ACEi or no drug, in patients with metabolic syndrome undergoing coronary artery bypass grafting. METHODS We used propensity matching to derive a cohort of 1,351 patients from 2,998 who underwent coronary artery bypass grafting based on preoperative use of ARBs, ACEis, or no renin-angiotensin-system inhibitors. Our primary end point was a composite of adverse events occurring within 30 days after the operation: new-onset atrial fibrillation/flutter, arrhythmia requiring cardioversion, perioperative myocardial infarction, acute renal failure, need for dialysis, cerebrovascular accidents, acute respiratory failure, or perioperative death. RESULTS At least one adverse event occurred in 524 (38.8%) of matched cohort patients (1,184 [39.6% of all patients]). Adjusting for European System for Cardiac Operative Risk Evaluation and metabolic syndrome in the matched cohort, preoperative use of ARBs was associated with a lower incidence of adverse events in patients with metabolic syndrome compared with preoperative use of no renin-angiotensin-system inhibitors (odds ratio, 0.43; 95% confidence interval, 0.19 to 0.99) or ACEis (odds ratio, 0.38; 95% confidence interval, 0.16 to 0.88). CONCLUSIONS Preoperative use of ARBs, but not ACEis, confers a benefit within 30 days after cardiac operations in patients with metabolic syndrome, suggesting potential efficacy differences of these drug classes in reducing cardiovascular morbidity and death in ambulatory vs surgical patients.
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Affiliation(s)
- Michael W Manning
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North California.
| | - Mary Cooter
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North California
| | - Joseph Mathew
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North California
| | - John Alexander
- Division of Cardiology, Duke University Medical Center, Durham, North California; Duke Clinical Research Institute, Duke University Medical Center, Durham, North California
| | - Eric Peterson
- Division of Cardiology, Duke University Medical Center, Durham, North California; Duke Clinical Research Institute, Duke University Medical Center, Durham, North California
| | - T Bruce Ferguson
- Department of Cardiovascular Sciences, East Carolina Heart Institute, East Carolina University, Greenville, North California
| | - Renato Lopes
- Division of Cardiology, Duke University Medical Center, Durham, North California; Duke Clinical Research Institute, Duke University Medical Center, Durham, North California
| | - Mihai Podgoreanu
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North California; Duke Clinical Research Institute, Duke University Medical Center, Durham, North California
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Thongprayoon C, Cheungpasitporn W, Srivali N, Kittanamongkolchai W, Greason KL, Kashani KB. Incidence and risk factors of acute kidney injury following transcatheter aortic valve replacement. Nephrology (Carlton) 2017; 21:1041-1046. [PMID: 26714182 DOI: 10.1111/nep.12704] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 12/20/2015] [Indexed: 12/24/2022]
Abstract
AIM This study aimed to determine the incidence and risk factors of acute kidney injury (AKI) following transcatheter aortic valve replacement (TAVR). METHODS We included all adult patients undergoing TAVR for aortic stenosis from 1 January 2008 to 30 June 2014 at a tertiary referral hospital. AKI was defined based on Kidney Disease: Improving Global Outcomes criteria. We performed a multivariate logistic regression to identify factors associated with post-procedural AKI occurrence. RESULTS Three hundred eighty-six patients met the inclusion criteria, of which 106 (28%) developed AKI. In multivariate analysis, AKI development was independently associated with a transapical approach (odds ratio (OR), 2.81; 95% confidence interval (CI), 1.72-4.65 compared with transfemoral approach) and the need for an intra-aortic balloon pump (OR, 9.11; 95% CI, 1.77-68.29). Higher baseline renal function (OR, 0.78 per 10 mL/min per 1.73 m2 increment in glomerular filtration rate; 95% CI, 0.68-0.87) was significantly associated with a decreased risk of AKI. After adjustment for the Society of Thoracic Surgeons' risk score, post-procedural AKI development remained significantly associated with an increased in-hospital (OR, 4.74; 95% CI, 1.39-18.48) and 6-month mortality (OR, 4.66; 95% CI, 2.32-9.63). CONCLUSION In a cohort of patients undergoing TAVR for aortic stenosis, AKI commonly occurred and was significantly associated with increased mortality. Baseline renal function, procedure approach and the need for circulatory support were important predictive factors for post-procedural AKI occurrence.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Narat Srivali
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Kevin L Greason
- Division of Cardiovascular Surgery, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Cheungpasitporn W, Thongprayoon C, Kashani K. Updates on the risk factors of acute kidney injury after transcatheter aortic valve replacement. J Renal Inj Prev 2016; 6:16-17. [PMID: 28487866 PMCID: PMC5414513 DOI: 10.15171/jrip.2017.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 10/19/2016] [Indexed: 11/10/2022] Open
Affiliation(s)
- Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Charat Thongprayoon
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY, USA
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Disque A, Neelankavil J. Con: ACE Inhibitors Should Be Stopped Prior to Cardiovascular Surgery. J Cardiothorac Vasc Anesth 2016; 30:820-2. [DOI: 10.1053/j.jvca.2016.01.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Indexed: 01/14/2023]
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Thongprayoon C, Cheungpasitporn W, Srivali N, Harrison AM, Gunderson TM, Kittanamongkolchai W, Greason KL, Kashani KB. AKI after Transcatheter or Surgical Aortic Valve Replacement. J Am Soc Nephrol 2015; 27:1854-60. [PMID: 26487562 DOI: 10.1681/asn.2015050577] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 09/16/2015] [Indexed: 12/16/2022] Open
Abstract
Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement (SAVR) for patients with symptomatic severe aortic stenosis who are at high risk of perioperative mortality. Previous studies showed increased risk of postoperative AKI with TAVR, but it is unclear whether differences in patient risk profiles confounded the results. To conduct a propensity-matched study, we identified all adult patients undergoing isolated aortic valve replacement for aortic stenosis at Mayo Clinic Hospital in Rochester, Minnesota from January 1, 2008 to June 30, 2014. Using propensity score matching on the basis of clinical characteristics and preoperative variables, we compared the postoperative incidence of AKI, defined by Kidney Disease Improving Global Outcomes guidelines, and major adverse kidney events in patients treated with TAVR with that in patients treated with SAVR. Major adverse kidney events were the composite of in-hospital mortality, use of RRT, and persistent elevated serum creatinine ≥200% from baseline at hospital discharge. Of 1563 eligible patients, 195 matched pairs (390 patients) were created. In the matched cohort, baseline characteristics, including Society of Thoracic Surgeons risk score and eGFR, were comparable between the two groups. Furthermore, no significant differences existed between the TAVR and SAVR groups in postoperative AKI (24.1% versus 29.7%; P=0.21), major adverse kidney events (2.1% versus 1.5%; P=0.70), or mortality >6 months after surgery (6.0% versus 8.3%; P=0.51). Thus, TAVR did not affect postoperative AKI risk. Because it is less invasive than SAVR, TAVR may be preferred in high-risk individuals.
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Affiliation(s)
| | | | - Narat Srivali
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine
| | | | | | | | - Kevin L Greason
- Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine,
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Cheungpasitporn W, Thongprayoon C, Harrison AM, Erickson SB. Admission hyperuricemia increases the risk of acute kidney injury in hospitalized patients(.). Clin Kidney J 2015; 9:51-6. [PMID: 26798461 PMCID: PMC4720187 DOI: 10.1093/ckj/sfv086] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 08/05/2015] [Indexed: 12/22/2022] Open
Abstract
Background The association between elevated admission serum uric acid (SUA) and risk of in-hospital acute kidney injury (AKI) is limited. The aim of this study was to assess the risk of developing AKI in all hospitalized patients with various admission SUA levels. Methods This is a single-center retrospective study conducted at a tertiary referral hospital. All hospitalized adult patients who had admission SUA available from January 2011 through December 2013 were analyzed in this study. Admission SUA was categorized based on its distribution into six groups (<3.4, 3.4–4.5, 4.5–5.8, 5.8–7.6, 7.6–9.4 and >9.4 mg/dL). The primary outcome was in-hospital AKI occurring after hospital admission. Logistic regression analysis was performed to obtain the odds ratio (OR) of AKI of various admission SUA levels using the most common SUA level range (5.8–7.6 mg/dL) as the reference group. Results Of 1435 patients enrolled, AKI occurred in 263 patients (18%). The incidence of AKI and need for dialysis was increased in patients with higher admission SUA levels. After adjusting for potential confounders, SUA >9.4 mg/dL was associated with an increased risk of developing AKI, with ORs of 1.79 [95% confidence interval (CI) 1.13–2.82]. Conversely, admission SUA <3.4 and 3.4–4.5 mg/dL were associated with a decreased risk of developing AKI, with ORs of 0.38 (95% CI 0.17–0.75) and 0.50 (95% CI 0.28–0.87), respectively. Conclusions Elevated admission SUA was associated with an increased risk for in-hospital AKI.
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Affiliation(s)
- Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine , Mayo Clinic , Rochester, MA , USA
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MA, USA; Department of Anesthesiology, Mayo Clinic, Rochester, MA, USA
| | - Andrew M Harrison
- Medical Scientist Training Program, Mayo Clinic , Rochester, MA , USA
| | - Stephen B Erickson
- Division of Nephrology and Hypertension, Department of Medicine , Mayo Clinic , Rochester, MA , USA
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Cheungpasitporn W, Thongprayoon C, Erickson SB. Admission hypomagnesemia and hypermagnesemia increase the risk of acute kidney injury. Ren Fail 2015; 37:1175-9. [DOI: 10.3109/0886022x.2015.1057471] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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