Acute kidney injury in hospitalized patients with COVID-19: A Portuguese cohort

IntroductionThe incidence of acute kidney injury (AKI) in coronavirus disease 2019 (COVID-19) patients ranges from 0.5% to 35% and has been associated with worse prognosis. The purpose of this study was to evaluate the incidence, severity, duration, risk factors and prognosis of AKI in hospitalized patients with COVID-19.MethodsWe conducted a retrospective single-center analysis of 192 hospitalized COVID-19 patients from March to May of 2020. AKI was diagnosed using the Kidney Disease Improving Global Outcome (KDIGO) classification based on serum creatinine (SCr) criteria. Persistent and transient AKI were defined according to the Acute Disease Quality Initiative (ADQI) workgroup definitions.ResultsIn this cohort of COVID-19 patients, 55.2% developed AKI (n = 106). The majority of AKI patients had persistent AKI (n = 64, 60.4%). Overall, in-hospital mortality was 18.2% (n = 35) and was higher in AKI patients (28.3% vs. 5.9%, p < 0.001, unadjusted OR 6.03 (2.22–16.37), p < 0.001). In this multivariate analysis, older age (adjusted OR 1.07 (95% CI 1.02–1.11), p = 0.004), lower Hb level (adjusted OR 0.78 (95% CI 0.60–0.98), p = 0.035), duration of AKI (adjusted OR 7.34 for persistent AKI (95% CI 2.37–22.72), p = 0.001) and severity of AKI (adjusted OR 2.65 per increase in KDIGO stage (95% CI 1.32–5.33), p = 0.006) were independent predictors of mortality.ConclusionAKI was frequent in hospitalized patients with COVID-19. Persistent AKI and higher severity of AKI were independent predictors of in-hospital mortality.     

Comparison of outcomes in new-generation versus early-generation heart valve in transcatheter aortic valve implantation: A systematic review and meta-analysis

BackgroundNew-generation (NG) valves for transcatheter aortic valve implantation (TAVI) has recently been widely used in real-world practice, yet its comparative outcomes with early-generation (EG) valves remain under-explored.MethodsAn electronic literature search using PUBMED and EMBASE was conducted from inception to April 2017 for matched-cohort studies. Articles that compared the outcomes of NG vs. EG valves post TAVI with at least one of the following clinical outcome reported were included: all-cause mortality, major or life-threatening bleeding, major vascular complications (MVC), significant (more than moderate) paravalvular regurgitation (PVR), cerebrovascular events, significant (stage 2 or 3) acute kidney injury (AKI) and new permanent pacemaker implantation (PPI) that occurred either in-hospital or within 30-days.ResultsA total of 6 observational matched-cohort studies with 585 and 647 patients included in NG and EG valves, respectively, were included. EG valves were associated with a lower incidence of major or life-threatening bleeding (5.7% vs. 15.7%, p < 0.00001), significant paravalvular regurgitation (5.3% vs. 14.4%, p = 0.001), and significant AKI (4.4% vs. 7.5, p = 0.03). All-cause mortality (3.5% vs. 5.0, p = 0.43), cerebrovascular events (3.4% vs. 2.3%, p = 0.34) and new PPI (11.0% vs. 14.6%, p = 0.52) were similar between the two groups. NG demonstrated lower tendency of MVC (2.5% vs. 7.2, p = 0.09) compared to EG valves.ConclusionsNG demonstrated lower rates of significant AKI, significant PVR and major or life-threatening bleeding while all-cause mortality, new PPI, and cerebrovascular events remained similar compared to EG valves.     

Acute kidney injury in patients with cirrhosis: Prospective longitudinal study in 405 patients

BackgroundAcute kidney injury (AKI) is common in patients with cirrhosis. In 2015, the International Club of Ascites (ICA) proposed new definitions of AKI in order to improve the prediction of outcomes. Our aim was to assess the prevalence and prognostic value of ICA 2015 – AKI criteria in hospitalised patients with cirrhosis.MethodsWe prospectively collected data from 405 consecutive cirrhotic patients admitted to the hospital between November 2016 and November 2017. AKI was diagnosed at inclusion according to ICA 2015 criteria, and was assessed to predict 30-day and 90-day in-hospital mortality.ResultsAKI was diagnosed in 78 (19.3%) patients. AKI was independently associated with 90-day death (HR 7.61; 95% CI 4.75–12.19; p < 0.001). In hospital, 30-day and 90-day survival was lower in the group of patients with AKI compared to the group with no AKI (72% vs. 98%, p < 0.001; 64% vs. 96%, p < 0.001; and 49% vs. 81%, p < 0.001, respectively). Patients with stage 1a AKI had a lower 30-day and 90-day survival compared to the group of patients who did not develop AKI (71% vs. 96%, p < 0.001, and 71% vs. 91%, p < 0.01, respectively) and better survival than patients with more severe AKI (71% vs. 40%, p < 0.01).ConclusionsAKI was independently associated with mortality in patients with cirrhosis, even at the very early 1a stage. Response to treatment improved survival, and was inversely proportional to the stage of AKI, which suggests that treatment should be started at the earliest stage of AKI.     

Infection in cirrhosis: A prospective study

Introduction and objectivesMultidrug-resistant (MDR) infections in cirrhosis are associated with poor outcomes. We attempted a prospective study on infections in patients with cirrhosis evaluating microbiology of these infections and how outcomes depended on factors like bacterial resistance, appropriate antibiotics, stage of liver disease and whether outcomes were significantly different from patients who did not have infections.Materials and methodsThis was a prospective evaluation involving one hundred and fifty nine patients with cirrhosis who were admitted at Peerless Hospitex Hospital and Research Center, Kolkata, West Bengal, India, during a 24 month period. One hundred and nineteen of these patients either had an infection at the time of admission or developed infection during hospitalization. Forty patients did not have an infection at admission and did not acquire infection while admitted. Data was collected about demographics, etiology of cirrhosis, liver and renal function and microbiology.ResultsInfections were community acquired in 27.7% of patients, healthcare associated in 52.9% and nosocomial in 19.3%. Gram negative bacilli (Escherichia coli 47.4% Klebsiella pneumoniae 23%) were common. 84.9% of enterobacteriaceae produced ESBL, AmpC or Carbapenemases. Spontaneous bacteria peritonitis (SBP) and urinary tract infection (UTI) were the most common sites of infection. In hospital mortality was 21.9%. Non-survivors had higher MELD (26 vs 19, p < 0.001) and CTP scores (11.7 vs 10.3, p < 0.001). The control group had lower MELD (16.65 vs. 20.8, p < 0.001) and CTP scores (9.25 vs 10.59, p < 0.001).ConclusionsMDR infections are common in patients with cirrhosis and have serious implications for treatment and outcomes.     

Thyroid dysfunction and anti-thyroid antibodies in Egyptian patients with systemic lupus erythematosus: Correlation with clinical musculoskeletal manifestations

Aim of the workTo study the prevalence of thyroid dysfunction and anti-thyroid antibodies (ATA) in Egyptian patients with systemic lupus erythematosus (SLE), and their association with musculoskeletal manifestations of the disease.Patients and methodsCross sectional study included 100 SLE patients and 100 matched controls. Clinical manifestations at any time during disease course were reported. Detailed musculoskeletal examination was done using Ritchie articular index (RAI), 44-Swollen joint count and fibromyalgic tender points. Phalen’s test was used to diagnose carpal tunnel syndrome. Free-thyroid hormones (FT3 and FT4), thyroid stimulating hormone (TSH), anti-thyroglobulin (anti-TG) and anti-thyroid peroxidase (anti-TPO) antibodies were measured.ResultsThe prevalence of thyroid dysfunction was significantly higher in patients than controls (18% vs. 4%, p = 0.003) and all were females. Prevalence of subclinical hypothyroidism (SCHT) and clinical hypothyroidism (CHT) is 10% (p = 0.002) and 4% (p = 0.121) versus non among controls while, that of subclinical hyperthyroidism (4%) was not significantly different. Prevalence of anti-TPO and anti-TG is higher in patients than controls (35% vs 11%, p < 0.001 and 22% vs. 6%, p = 0.001). All patients with SCHT had anti-TPO and half of them had anti-TG while all patients with CHT had both antibodies. Hypothyroidism was associated significantly with aging (p = 0.01), longer disease duration (p < 0.001), high BMI, high RAI scores, arthritis, positive Phalen’s test and fibromyalgia (p < 0.001 for all) in comparison to euthyroid patients.ConclusionHypothyroidism was more prevalent in SLE patients and its detection is recommended to reduce the risk of musculoskeletal related morbidity.     

Does the preoperative mild renal dysfunction effect mortality and morbidity following valve cardiac surgery?

AimsThe objective of this study was to investigate the effect of preoperative mild renal dysfunction (RD), not requiring dialysis, on mortality and morbidity after valve cardiac surgery (VCS).PopulationWe studied 340 consecutive patients (2008–2012), who underwent VCS with or without coronary artery bypass graft (CABG).MethodsPreoperative RD was calculated with the abbreviated Modification of Diet in Renal Disease formula and was defined as a glomerular filtration rate <60 ml/min/1.73 m². Logistic regression analysis was used to assess the effect of preoperative renal dysfunction (RD) on operative and adverse outcomes.Results80 patients (30%) had preoperative mild RD. Patients with preoperative RD were older, had a higher rate of preoperative anemia (43% vs. 25%, p < 0.001), and more comorbidities. Patients with preoperative RD had worse outcomes with more reoperation (6.8% vs. 2.3%, p < 0.001).ConclusionPreoperative RD was significantly and independently associated with more red blood cell transfusions and longer hospital stay (median 9 vs. 8 days, p < 0.001). Mortality was similar in both groups (3.4% vs. 2.3%, p = 0.43). Preoperative mild RD in patients undergoing cardiac valve surgery is an independent marker of postoperative morbidity.     

Comparison of clinical characteristics between healthcare-associated pneumonia and community-acquired pneumonia in patients admitted to secondary hospitals

BackgroundSince healthcare-associated pneumonia (HCAP) is heterogeneous, clinical characteristics and outcomes are different from region to region. There can also be differences between HCAP patients hospitalized in secondary or tertiary hospitals. This study aimed to evaluate the clinical characteristics of HCAP patients admitted into secondary community hospitals.MethodsThis was a retrospective study conducted in patients with HCAP or community-acquired pneumonia (CAP) hospitalized in two secondary hospitals between March 2009 and January 2011.ResultsOf a total of 303 patients, 96 (31.7%) had HCAP. 42 patients (43.7%) resided in a nursing home or long-term care facility, 36 (37.5%) were hospitalized in an acute care hospital for ≥ 2 days within 90 days, ten received outpatient intravenous therapy, and eight attended a hospital clinic or dialysis center. HCAP patients were older. The rates of patients with CURB-65 scores of 3 or more (22.9% vs. 9.1%; p = 0.001) and PSI class IV or more (82.2% vs. 34.7%; p < 0.001) were higher in the HCAP group. Drug-resistant pathogens were more frequently detected in the HCAP group (23.9% vs. 0.4%; p < 0.001). However, Streptococcus pneumoniae was the most common pathogen in both groups. The rates of antibiotic change, use of inappropriate antibiotics, and failure of initial antibiotic therapy in the HCAP group were significantly higher. Although the overall survival rate of the HCAP group was significantly lower (82.3% vs. 96.8%; p < 0.001), multivariate analyses failed to show that HCAP itself was a prognostic factor for mortality (p = 0.826). Only PSI class IV or more was associated with increased mortality (p = 0.005).ConclusionsHCAP should be distinguished from CAP because of the different clinical features. However, the current definition of HCAP does not appear to be a prognostic for death. In addition, the use of broad-spectrum antibiotics for HCAP should be reassessed because S. pneumoniae was most frequently identified even in HCAP patients.     

Serum sclerostin in acute kidney injury patients

BackgroundMany of the mineral metabolite abnormalities encountered in chronic kidney disease (CKD) patients were found also associated with acute kidney injury (AKI). In the last decade, sclerostin was found to intimately affect bone mineral metabolism in CKD patients. Nothing is known about sclerostin in AKI.ObjectiveWe looked for serum level of sclerostin in AKI patients in comparison to normal control subjects and if there is an impact on metabolic derangement, endothelial function or clinical outcome.Cases and methodsThis is a cross sectional case control observational study of 219 AKI cases (group I) beside 219 age matched normal control subjects (group II). All cases of group I were in the intensive care because of sepsis; 86 had acute on CKD (group Ib), while 133 had de novo AKI (group Ia). All studied subjects underwent estimation of serum sclerostin, parathyroid hormone (PTH), 25 hydroxy vitamin D (25 OH vit D), fibroblast growth factor 23 (FGF23), C-reactive protein (CRP), interleukin 6 (IL6), Homeostatic Model Assessment for Insulin Resistance (Homa IR), beside the routine CBC, kidney and liver function tests, serum calcium, and phosphorus, and flow mediated vasodilation of brachial artery (FMD). Follow-up of group I cases was done till they recovered or passed away.ResultsSerum sclerostin, PTH, FGF23, phosphorus, CRP, IL6, HOMA IR, creatinine, urea, uric acid, ALT, AST and white blood cell count (WBC) were significantly higher while serum calcium, 25 OH vit D, hemoglobin, platelet count and FMD were significantly lower in group I compared to group II (P < 0.001 in all). On the other hand, there was no significant difference in serum sclerostin, PTH, FGfF23, 25 OH vit D, CRP, IL6, Homa IR and FMD between group Ia and Ib. Survivors were younger in age (median 55.5 vs. 60 years, P < 0.04), had lower AST (30.5 vs. 58 units, P < 0.001), had higher platelet count (206 vs 162 × 10⁹/L, P < 0.001), otherwise, there was no significant difference in any of the other parameters between survivors and patients that were lost. Serum sclerostin had strong correlation with FGF23 in group I (r = 0.99, P < 0.001) and group II (r = 1, P < 0.001). Homa IR had positive correlation with serum sclerostin (r = 0.148, P = 0.014) and serum FGF23 (r = 0.142, P = 0.018) in group I.ConclusionSclerostin is intimately related to FGF23. Sclerostin level increases in AKI patients. Both sclerostin and FGF23 might increase insulin resistance but have no impact on FMD. Neither sclerostin nor FGF23 interfere with AKI outcome.     

Outcomes of patients hospitalized for suspected acute coronary syndrome,in whom the diagnosis was not confirmed: Results from the CZECH-1 and CZECH-2 registries

BackgroundSuspicion of acute coronary syndrome (ACS) is one of the most common reasons for hospital admission. However, ACS is not confirmed in a high proportion of these patients during hospitalization. Very few details exist about these patients.AimTo evaluate the clinical characteristics and outcomes of hospitalized patients with a suspicion for ACS that has not been confirmed and compare these results with patients with confirmed ACS.Methods and resultsData were used from the CZECH-1 and CZECH-2 registries, collected in November 2005 and October–November 2012. Both registries contain data from all consecutive patients who have been hospitalized with an initial diagnosis of ACS. ACS was not confirmed during hospitalization in 578 of 1921 patients (30.1%) in the CZECH-1 registry and in 372 of 1221 (30.5%) in the CZECH-2 registry. In both registries, higher proportions of females (52 vs. 36%; p < 0.001 and 46 vs. 33%; p < 0.01, respectively) were observed between patients with unconfirmed ACS compared to those with confirmed ACS. A history of myocardial infarction was known in 25% of the patients with unconfirmed ACS in both registries. On admission, atrial fibrillation or other non-sinus rhythm on ECG was present in 17% of patients with unconfirmed ACS, bundle branch block in 18%, ST depression in 8%, and ST elevation in 3.6%. Coronary angiography was performed on 36% of these patients in CZECH-1 and 27% of patients in CZECH-2 (p < 0.01). In-hospital mortality of the ACS unconfirmed patients was 1.2% in the CZECH-1 registry and 2.1% in the CZECH-2 registry (p = NS). 30-day and 1-year mortality in patients with unconfirmed ACS in the CZECH-2 registry were significantly lower compared to patients with confirmed ACS (3.5 vs. 6.6%; p < 0.05 and 6.5 vs. 13%; p < 0.05, respectively). Musculoskeletal pain and acute heart failure were the most common discharge diagnosis in patients with unconfirmed ACS.ConclusionHospitalized patients in whom the suspicion of ACS had not been confirmed were more often female and a high proportion had abnormal ECG on admission. In-hospital mortality was very low, and the 1-year mortality was significantly lower compared to patients with confirmed ACS.     

Introduction of an NT-proBNP assay to an acute admission unit — A 2-year audit

BackgroundThe differential diagnosis of dyspnoea is difficult due to the low predictive value of clinical and laboratory parameters. The elevated levels of NT-proBNP in congestive heart failure may improve diagnostic accuracy. We have evaluated the effect of the introduction of an NT-proBNP assay on hospital length of stay (LOS) and mortality.MethodsThere were 11,853 AMAU patient episodes in the 22 months study period (March 2005–Dec 2006). An NT-proBNP assay was requested in 657 (5.5%) of these. Comparison between categorical variables such as diagnosis, NT-proBNP testing, LOS, and in-hospital mortality was made using Chi-square tests. Literature review suggested that an NT-proBNP cut-off ≥ 5000 ng/L should predict acute in-patient mortality. Logistic regression analysis was used to examine the association between such an elevated NT-proBNP level and outcomes.ResultsOf the 396 patients with NT-proBNP < 5000 ng/L, 8.1% died compared with 22.5% of the 178 patients dying with values ≥ 5000 ng/L (p < 0.0001). An NT-proBNP ≥ 5000 ng/L was predictive of both LOS ≥ 9 days (odds ratios (OR) 1.54 (95% CI 1.06, 2.24: p = 0.02) and LOS ≥ 14 days (OR = 1.87 (95% CI 1.29, 2.71: p = 0.0009). NT-proBNP requests increased over time, from 2.6% to 8.2% of all patients; the result fell in the diagnostic range for CHF in 60% of requests.ConclusionThe introduction of an NT-proBNP was reflected in an appropriate but rapidly increasing pattern of requests from clinicians. High NT-proBNP levels predicted in-hospital mortality and longer LOS in an acute medical population.     

Análisis de las transiciones en el modelo integrado de tratamiento sustitutivo renal en un sistema regional de salud

Introduction and objectivesThe choice of renal replacement therapy (RRT) is an important decision that determines the quality of life and survival. Most patients change from one RRT modality to another to adapt RRT to clinical and psychosocial needs. This has been called «integrated model of RRT» that implies new questions about the best sequence of techniques.Material and methodsThe study describes the impact of transitions between RRT modalities on survival using the Madrid Registry of Renal Patients (2008–2018). This study used the proportional hazards models and competitive risk models to perform an intention-to-treat (ITT), according to their 1^st RRT modality and as-treated (AT) analysis, that consider also their 1^st transition.ResultsA total of 8971 patients started RRT during this period in Madrid (6.6 Million population): 7207 (80.3%) on hemodialysis (HD), 1401 (15.6%) on peritoneal dialysis (PD) and 363 (4.2%) received a pre-emptive kidney transplantation (KTX). Incident HD-patients were older (HD group 65.3 years (SD 15.3) vs PD group 58.1 years (SD 14.8) vs KTX group 52 years (SD 17.2); p < 0.001) and had more comorbidities. They presented higher mortality (HD group 40.9% vs PD group 22.8% vs 8.3% KTX group, p < 0.001) and less access to a transplant (HD group 30.4% vs DP group 51.6%; p < 0.001). Transitions between dialysis techniques define different groups of patients with different clinical outcomes. Those who change from HD to PD do it earlier (HD → PD: 0.7 years (SD 1.1) vs PD → HD: 1.5 years (SD 1.4) p < 0.001), are younger (HD → PD: 53.5 years (SD 16.7) vs PD → HD: 61.6 years (SD 14.6); p < 0.001), presented less mortality (HD → PD: 24.5% vs PD → HD: 32.0%; p < 0.001) and higher access to a transplant (HD → PD: 49.4% vs PD → HD: 31.7%; p < 0.001). Survival analysis by competitive risks is essential for integrated RRT models, especially in groups such as PD patients, where 51.6% of the patients were considered as lost follow-up (received a KTX after during the first 2.5 years on PD). In this analysis, survival of patients who change from one technique to another, is more similar to the destination modality than the origin one.ConclusionOur data suggest that transitions between RRT-techniques describes different patients, who associate different risks, and could be analyzed in an integrated manner to define improvement actions. This approach should be incorporated into the analysis and reports of renal registries.     

Liver transplantation for NASH cirrhosis is not performed at the expense of major post-operative morbidity

BackgroundNon-alcoholic steatohepatitis (NASH) is an emerging indication for liver transplantation (LT) and coexists with multiple comorbidities. Obese and cirrhotic patients experience more perioperative complications. Limited data exist about short-term complications after LT for NASH cirrhosis.AimInvestigate short-term complications in patients transplanted for NASH cirrhosis.MethodsSingle center retrospective cohort study including patients >18 years who underwent LT between 2009–2015. Exclusion criteria were LT for acute liver failure and non-cirrhotic disease. Post-operative complications and severity within 90-days were classified using the Clavien–Dindo classification of surgical complications and comprehensive complication index (CCI). P < 0.05 was significant.ResultsOut of 169 eligible patients, 34 patients (20.1%) were transplanted for NASH cirrhosis. These patients were significantly older (59.2 vs. 54.8 years, P = 0.01), more obese (61.8% vs. 8.1%, P < 0.01), had more diabetes mellitus (73.5% vs. 20%, P < 0.01), metabolic syndrome (83.3% vs. 37.8%, P < 0.01) and cardiovascular disease (29.4% vs. 11.1%, P < 0.01). More grade 1 complications (OR 1.64, 95%CI 1.03–2.63, P = 0.04) and more grade 2 urogenital infections (OR 3.4, 95%CI 1.1–10.6, P = 0.03) were found. Major complications, CCI, 90-day mortality and graft survival were similar.ConclusionDespite significantly increased comorbidities in patients transplanted for NASH cirrhosis, major morbidity, mortality and graft survival after 90 days were comparable to patients transplanted for other indications.     

Colistimethate sodium and acute kidney injury: Incidence,risk factors,outcome and prognosis of renal function

BackgroundColistimethate sodium (CMS) treatment has increased over the last years, being acute kidney injury (AKI) its main drug-related adverse event. Therefore, this study aimed to evaluate the incidence and risk factors associated with AKI, as well as identifying the factors that determine renal function (RF) outcomes at six months after discharge.Materials and methodsThis retrospective study included adult septic patients receiving intravenous CMS for at least 48 h (January 2007–December 2014). AKI was assessed using KDIGO criteria. The glomerular filtration rate (GFR) was estimated by the 4-variable MDRD equation. Logistic and linear models were performed to evaluate the risk factors for AKI and chronic kidney disease (CKD).ResultsAmong 126 patients treated with CMS; the incidence of AKI was 48.4%. Sepsis–severe sepsis (OR 8.07, P = 0.001), sepsis–septic shock (OR 42.9, P < 0.001), and serum creatinine (SCr) at admission (OR 6.20, P = 0.009) were independent predictors.Eighty-four patients survived; the main factors for RF evolution at the 6-month follow-up was baseline eGFR (0.58, P < 0.001) and at discharge (0.34, P < 0.001). Fifty-six percent (34/61) of the patients that developed AKI survived. At six months, 32% had CKD.ConclusionsThe development of AKI in septic patients with CMS treatment was associated with sepsis severity and SCr at admission. Baseline eGFR and eGFR at discharge were and important determinant of the RF at the 6-month follow-up. These predictors may assist in clinical decision making for this patient population.     

Systemic inflammatory response syndrome in patients with liver cirrhosis

Background and study aimsPatients with liver cirrhosis present an increased susceptibility to the systemic inflammatory response syndrome (SIRS), which is considered the cause of hospital admission in about 10% of patients and is present in about 40% of those admitted for ongoing complications. We tried to assess the prevalence of the SIRS with the possible effects on the course of the disease during hospital stay.Patients and methodsTwo hundred and three patients with liver cirrhosis were examined and investigated with close monitoring during hospital stay. The main clinical endpoints were death and the development of portal hypertension-related complications.ResultsEighty-one patients met the criteria of SIRS (39.9%). We found significant correlations between SIRS and jaundice (p = 0.005), bacterial infection (p = 0.008), white blood cell count (p < 0.001), low haemoglobin concentration (p = 0.004), high serum creatinine levels (p < 0.001), high alanine aminotransferase levels (p < 0.001), serum bilirubin levels (p < 0.001), international normalised ratio (p < 0.001), serum albumin levels (p = 0.033), high Child-Pugh score (p < 0.001). During the follow-up period, 26 patients died (12.8%), 15 developed portal hypertension-related bleeding (7.3%), 30 developed hepatic encephalopathy (14.7%), and 9 developed hepatorenal syndrome type-1 (4.4%). SIRS showed significant correlations both to death (p < 0.001) and to portal hypertension-related complications (p < 0.001).ConclusionThe systemic inflammatory response syndrome occurs in patients with advanced cirrhosis and is associated with a bad prognosis.     

Impact of sustained viral response in the evolution of minimal hepatic encephalopathy: A prospective pilot study

Introduction and aimsTo determine the prevalence of minimal hepatic encephalopathy(MHE) in patients with liver cirrhosis (LC) due to hepatitis C virus (HCV) infection and to evaluate the impact of sustained viral response (SVR) on MHE.Materials and methodsWe performed a prospective study using MHE screening and follow-up on patients with HCV and LC. The patients were evaluated at the beginning of treatment and 24 weeks after treatment.Results64 patients were included. 51.6% were male, the median age was 62 years, Child-Pugh classification A/B/C 93.8%/4.7%/1.6% and median MELD was 8.3. Prior hydropic decompensation was present in 11 patients. Median values of liver stiffness, as measured by transient elastography (TE) were 22.8 kPa. Indirect signs of portal hypertension (PH) were present in 53.1% of patients, with a mean of 11.9 mmHg among the ones with a measurement of the hepatic venous pressure gradient. The prevalence of MHE before treatment was 26.6%. After treatment, 98.4% of patients achieved SVR. The presence of MHE at 24 weeks post-treatment had an statistically significant association with the presence of pre-treatment MHE (80% vs. 21.6%; p < 0.01), higher MELD scores at 24-weeks post-treatment (9.8 vs. 8; p = 0.02), higher Child-Pugh scores at 24-weeks post-treatment (p = 0.04), higher baseline INR levels (1.4 vs. 1.1; p < 0.001) and with the presence of indirect signs of PH (100% vs. 47.1%; p = 0.02). During follow-up, those patients without MHE at 24 weeks post-treatment had a higher probability of experiencing an improvement in post-treatment TE (80.9% vs. 40%, p = 0.04).ConclusionWe found that SVR may lead to MHE resolution in a considerable proportion of patients, which has potential implications for disease prognosis.     

Cardiac dysfunction in cirrhosis is not associated with the severity of liver disease

BackgroundCirrhotic cardiomiopathy is described as the presence of cardiac dysfunction in cirrhotic patients. The aim of the study was to investigate factors associated with cardiac dysfunction in cirrhotic patients.Patients and methodsSeventy-four cirrhotic patients and twenty-six controls performed a conventional echocardiography and Tissue Doppler Imaging (TDI) for systolic and diastolic function. Results were analyzed by using the Guidelines of American Society of Echocardiography.ResultsIn patients with cirrhosis, left ventricular end-diastolic diameter was increased (p < 0.001) , peak systolic velocities were decreased (11.3 ± 2.7 vs 13.9 ± 1.4 cm/s; p < 0.001) and left atrial volumes were increased (32.7 ± 8.3 vs 24 ± 8.5 ml, p < 0.001) as well as cardiac mass (90.6 ± 23 vs 70.5 ± 22 g/m², p < 0.001). Forty-seven cirrhotic patients (64%) showed diastolic dysfunction at rest: grade I in 37 and grade II in 10 patients. Systolic and/or diastolic dysfunction were not influenced by a more severe liver impairment. Diastolic dysfunction was more prevalent in patients with ascites vs those without (77% vs 56%; p = 0.04).ConclusionA mild diastolic dysfunction at rest is frequent in cirrhotic patients but cardiac load conditions are confounding factors in this diagnosis. We did not identify an association between severity of liver disease and cardiac dysfunction.     

Acute kidney injury after allogeneic hematopoietic stem cell transplantation – Predictors and survival impact: A single center retrospective study

Introduction and objectivesAcute kidney injury (AKI) is a frequent complication of hematopoietic stem cell transplantation (HSCT) and appears to be linked to increased morbidity and mortality. The aim of this study was to evaluate the incidence, etiology, predictors and survival impact of early AKI in the post-allogeneic HSCT setting.Patients and methodsWe performed a retrospective single center study that included 155 allogeneic transplant procedures from June 2017 through September 2019.ResultsAKI was observed in 50 patients (32%). In multivariate analysis, age (OR 31.55, 95% CI [3.42; 290.80], p = 0.002), evidence of disease at the time of transplant (OR 2.54, 95% CI [1.12; 5.75], p = 0.025), cytomegalovirus reactivation (OR 5.77, 95% CI [2.43; 13.72], p < 0.001) and hospital stay >35 days (OR 2.66, 95% CI [1.08; 6.52], p = 0.033) were independent predictors for AKI. Increasing age (HR 1.02, 95% CI [1.00; 1.04], p = 0.029), increasing length of hospital stay (HR 1.02, 95% CI [1.01; 1.03], p = 0.002), matched unrelated reduced intensity conditioning HSCT (HR 1.91, 95% CI [1.10; 3.33], p = 0.022), occurrence of grade III/IV acute graft-versus-host disease (HR 2.41, 95% CI [1.15; 5.03], p = 0.019) and need for mechanical ventilation (HR 3.49, 95% CI [1.54; 7.92], p = 0.003) predicted an inferior survival in multivariate analysis. Early AKI from any etiology was not related to worse survival.ConclusionPatients submitted to HSCT are at an increased risk for AKI, which etiology is often multifactorial. Due to AKI incidence, specialized nephrologist consultation as part of the multidisciplinary team might be of benefit.     

Trends in epidemiology and the treatment of acute coronary syndromes in the Czech Republic: Comparison of the CZECH-1 and CZECH-2 registries

BackgroundThe clinical spectrum of acute coronary syndrome (ACS) has changed due to a progressively ageing population over the last two decades.AimWe analysed the changes in the epidemiological and treatment strategies between two large registries that were performed in 2005 and 2012 in well-defined populations of the Czech Republic.Methods and resultsThe CZECH-1 and CZECH-2 registries enrolled all consecutive hospitalized patients with an initial diagnosis of ACS during a 1 or 2-month period, respectively. Thirty-six and 32 hospitals participated in the CZECH-1 and CZECH-2 registries, respectively. A total of 1921 patients were enrolled in the CZECH-1 registry and 1221 patients participated in the CZECH-2 registry. Patients enrolled in the CZECH-2 registry were older than those in CZECH-1 (68 ± 12 vs. 66 ± 12 years; p < 0.001). ACS was not confirmed during hospitalization in 30.5 and 30.1% (p > 0.05) of the patients in the CZECH-1 and CZECH-2 registries, respectively. Urgent angiography in patients with ST segment elevation myocardial infarction (STEMI) was performed in 92 and 94% of the patients (p > 0.05), respectively; of these, 87 and 89% subsequently underwent primary PCI. There were no signifiant differences in in-hospital (4.2 vs. 4.4%, p=0.805) or in the mortality of patients with a final diagnosis of Q-myocardial (10.3 vs. 10.7%; p = 0.870) or non-Q-myocardial infarction (4.7 vs. 3.8%; p = 0.497) between the two registries. The estimated incidence of confirmed ACS and STEMI in a representative population from both registries was 3248 and 661 cases/million individuals/year in the CZECH-1 registry and 2149 and 652 cases/million individuals/year in the CZECH-2 registry. The fall in ACS incidence was almost exclusively due to a significant decrease in the incidence of unstable angina as the final diagnosis. At discharge, the patients with confirmed ACS were administered the following medications: aspirin (95 vs. 94%; p > 0.05), clopidogrel (60 vs. 76.4%; p < 0.001), beta-blockers (78 vs. 78%; p > 0.05), angiotensin-converting enzyme (ACE) inhibitors (50 vs. 78%; p = <0.001) and statins (75 vs. 90%; p < 0.001) in the CZECH-1 and CZECH-2 registries, respectively.ConclusionIn the Czech Republic, the age of the patients hospitalized with ACS increased between 2005 and 2012. Invasive reperfusion strategy for patients with STEMI was very high in both registries. The overall outcome in patients with confirmed ACS did not change between 2005 and 2012. The estimated incidence of ACS decreased due to the fall in unstable angina pectoris.     

Neutrophil,lymphocyte and platelet ratio as a predictor of mortality in septic-acute kidney injury patients

BackgroundAKI is frequent in critically ill patients, in whom the leading cause of AKI is sepsis. The role of intrarenal and systemic inflammation appears to be significant in the pathophysiology of septic-AKI. The neutrophils to lymphocytes and platelets (N/LP) ratio is an indirect marker of inflammation. The aim of this study was to evaluate the prognostic ability of N/LP ratio at admission in septic-AKI patients admitted to an intensive care unit (ICU).MethodsThis is a retrospective analysis of 399 septic-AKI patients admitted to the Division of Intensive Medicine of the Centro Hospitalar Universitário Lisboa Norte between January 2008 and December 2014. The Kidney Disease Improving Global Outcomes (KDIGO) classification was used to define AKI. N/LP ratio was calculated as: (Neutrophil count × 100)/(Lymphocyte count × Platelet count).ResultsFifty-two percent of patients were KDIGO stage 3, 25.8% KDIGO stage 2 and 22.3% KDIGO stage 1. A higher N/LP ratio was an independent predictor of increased risk of in-hospital mortality in septic-AKI patients regardless of KDIGO stage (31.59 ± 126.8 vs 13.66 ± 22.64, p = 0.028; unadjusted OR 1.01 (95% CI 1.00–1.02), p = 0.027; adjusted OR 1.01 (95% CI 1.00–1.02), p = 0.015). The AUC for mortality prediction in septic-AKI was of 0.565 (95% CI (0.515–0.615), p = 0.034).ConclusionsThe N/LP ratio at ICU admission was independently associated with in-hospital mortality in septic-AKI patients.     

Self-perception of uselessness and mortality among older adults in China

BackgroundNegative self-perceptions of aging among older adults have been associated with higher mortality in developed countries. However, it is unclear whether an association exists in developing countries where living to older age is more selective.Design and methodsUsing five waves of data (2000, 2002, 2005, 2008, and 2011) from a national survey of adults aged 65 and older in China (n = 30,948), this study investigates how self-perceived feelings of uselessness are associated with subsequent mortality. Analyses were stratified by sex and age group (65–79, 80–89, 90–99, and 100+), and adjusted for a wide range of covariates.ResultsCompared with women who never reported perceived uselessness, results from adjusted models shows that women who always reported perceived uselessness had 42% (p < 0.001), 31% (p < 0.001), and 24% (p < 0.001) higher risks of mortality in each of the three oldest age groups, respectively. These associations were only slightly attenuated when covariates were adjusted, but non-significant once baseline health was further controlled for. For men, compared with those who never reported perceived uselessness, the adjusted models for those who always reported perceived uselessness had 62% (p < 0.001), 62% (p < 0.001), 69% (p < 0.001), and 25% (p < 0.1) higher risks of mortality in each of the four sequential age groups, respectively. The association was only slightly diminished—and many remained statistically significant—with further adjustments for psychological disposition and baseline health.ConclusionsSelf-perceived uselessness is associated with higher mortality risks in older adults in China. The association is stronger in men than in women and persists at very old ages.