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.     

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.     

Is there a relationship between hypomagnesemia and proton-pump inhibitors in patients on chronic hemodialysis?

AimWe investigated the association among long-term proton-pump inhibitors (PPIs) use with serum magnesium (Mg) levels in chronic hemodialysis (HD) patients, as well as possible association among PPI use and increased risk of cardiovascular (CVD) morbidity in HD patients.MethodsOf 418 HD patients that were screened for inclusion, 136 were excluded due to incomplete medical data, duration of renal replacement therapy (RRT) for less than 12 months, use of Mg-based-phosphate binders or other Mg-based medications or either to presence of chronic increased GI losses. Among 282 patients included in the study, 170 patients were on PPIs.ResultsSerum Mg levels were significantly lower among PPI users vs. non-users (0.94 ± 0.2 vs. 1.03 ± 0.2 mmol/L; p < 0.0001). The median duration of PPI use was 27 ± 9.6 months (range from 12 to 108) and it was not significantly associated with Mg levels (r = 0.116; p = 0.167). Additionally, residual renal function didn't show a significant correlation with Mg concentration (r = − 0.102; p = NS) in both groups of patients. The use of PPIs was an independent and strong predictor of low Mg concentrations even in multivariate analysis (OR 3.05; 95% CI 1.2498–7.4594, p = 0.01). On the other hand, the daily dose of PPIs was not associated with low Mg levels. PPI users had a higher rate of adverse CVD events during the 1 year of follow-up in comparison to non-PPI users but that difference wasn't statistically significant (17.6% vs. 10.7%; p = 0.110).ConclusionWe have found a significant association between PPI use and lower serum Mg levels in chronic HD patients.     

Echocardiographic variables associated with mitral regurgitation after aortic valve replacement for aortic valve stenosis

BackgroundMitral regurgitation (MR) is frequently associated with aortic stenosis. Previous reports have shown that coexisting mitral insufficiency can regress after aortic valve replacement (AVR) while others recommend dealing with examination.AimThe study aimed to assess the severity of MR before and after aortic valve replacement for aortic stenosis and to define the determinants of its postoperative evolution.MethodsFor this purpose, 30 adult patients referred for aortic valve surgery underwent pre- and 1 month postoperative transthoracic echocardiography including 2D, MM, PW, CW and color Doppler examination.ResultsPostoperative MR improved in 68.4% of the 19 patients (63.3%) who had preoperative moderate MR (p = 0.002). The effect of the valve size on the postoperative MR was statistically insignificant (0.059) but was significant on regression of the mass (p = 0.001) and drop in mean PG (p = 0.04) across AV. Patients with persistent moderate MR after surgery were all in AF and had significantly larger left atrial size (45 ± 26 mm), compared to none and a smaller left atrial (37 ± 19 mm) in patients in whom MR regressed or disappeared after surgery; respectively, p < 0.05. The postoperative variables associated with moderate MR were peak PG across AV (29.4 ± 5.1 vs 38.0 ± 5.7 p = 0.004), mean PG (15.04 ± 4.4 vs 22.8 ± 5.8 p = 0.009) and LVMI (124.7 ± 19.3 vs 147.2 ± 31.6 p = 0.065).ConclusionPreoperative predictors of residual postoperative MR were large LA and AF while the postoperative variables were high peak and mean pressure gradient across the aortic valve and high LVMI.     

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.     

Acute kidney injury is associated with higher mortality and healthcare costs in hospitalized patients with cirrhosis

Introduction and ObjectivesAKI is known to be associated with increased risk of mortality, however limited information is available on how AKI impacts healthcare costs and resource utilization in hospitalized patients with cirrhosis. Previous studies have had variable definitions of AKI, resulting in inconsistent reporting of the true impact of AKI in patients with cirrhosis.MethodsData from the Nationwide Inpatient Sample (NIS) which contains data from 44 states and 4378 hospitals, accounting for over 7 million discharges were analyzed. The inclusion data were all discharges in the 2012 NIS dataset with a discharge diagnosis of cirrhosis.ResultsA total of 32,605 patients were included in the analysis, incidence of AKI was 12.12% in patients with cirrhosis. Crude mortality was much higher for patients with cirrhosis and AKI (14.9% vs. 1.8%, OR 9.42, p < 0.001) than for patients without AKI. In addition, mean LOS was longer (8.5 vs. 4.3 days, p < 0.001) and median total hospital charges were higher for patients with AKI ($43,939 vs. $22,270, p < 0.001). In multivariate logistic regression, controlling for covariates and mortality risk score, sepsis, ascites and SBP were predictors of AKI.ConclusionsAKI is relatively common in hospitalized patients with cirrhosis. Presence of AKI results in significantly higher inpatient mortality as well as LOS and resource utilization. Median hospitalization cost was twice as high in AKI patients. Early identification of patients at high risk for AKI should be implemented to reduce mortality and contain costs. Prognosis could be enhanced by utilizing biomarkers which could rapidly detect AKI.     

STEMI vs NSTEACS management trends in non-invasive hospital

ObjectivesTo compare the clinical features, management, and in-hospital outcomes of patients with ST elevation myocardial infarction (STEMI) and non-ST elevation acute coronary syndrome (NSTEACS), in the Western Region of Saudi Arabia.MethodsA total of 71 patients were enrolled in a longitudinal study at a tertiary hospital without cardiac catheterization facility. These data were collected from Saudi Project for Assessment of Coronary Events registry.ResultsTwenty-three patients with STEMI were compared to 48 patients with NSTEACS. Mean age for STEMI was younger, 57.4 ± 13.7 years compared to 63.2 ± 13.9 years respectively (p = 0.19). Forty-four percent arrived at the hospital by ambulance. History of hypertension and hyperlipidemia were more frequent in NSTEACS (p = 0.05), while both groups showed no difference in diabetes mellitus, 17% vs 22% and smoking, 30% vs 17%. In-hospital medications were: Aspirin (100%) both groups, Clopidogrel (91% vs 100%) (p = 0.03). There was more aggressive use of beta-blockers (74% vs 95%) (p = 0.01) and statins (87% vs 100%) (p = 0.01) in NSTEACS.In-hospital outcomes showed one recurrent myocardial infarction and one death in NSTEACS group (2%). Other outcome in the two groups showed recurrent ischemia (13% vs 29%) (p = 0.14) and cardiogenic shock (9% vs 2%) (p = 0.17). No stroke or major bleeding was reported in both groups.ConclusionNSTEACS patients in western province of KSA present at an older age are mostly males and have higher prevalence of hypertension and hyperlipidemia compared with STEMI patients. It is therefore important to identify patients with high-risk profile and put implement measures to reduce these factors.     

Evaluación multicéntrica del sobredimensionamiento de la prótesis transcatéter SAPIEN 3. Impacto en el fallo del dispositivo y nuevos implantes de marcapasos

Introduction and objectivesA certain degree of prosthesis oversizing (OS) is recommended for the SAPIEN 3 to achieve device success. However, an increase in OS may increase permanent pacemaker implantation (PPI) rates. We therefore investigated the influence of OS on device failure and PPI.MethodsA total of 804 patients were treated with SAPIEN 3 at 3 centers. Multislice computed tomography-derived OS was calculated and analyzed both as a continuous variable and categorized in 5% increments with −4% to 0% as reference.ResultsDevice failure occurred in 8.8% of patients. Median OS was lower in patients with device failure vs those with device success (+4% vs +8%; P = .038). A nonlinear risk pattern was shown for OS with a significantly reduced device failure rate within 4% to +22% of OS. There was no case of paravalvular leakage II+ between +10% to +20% of OS. The overall PPI rate was 16.2% and the median OS was significantly larger in patients with PPI (PPI: +9% vs no PPI: +7%; P = .025), while implantation depth did not vary in patients with vs without PPI (6.9 ± 1.7 mm vs 6.6 ± 1.9 mm; P = .101). The risk of PPI increased with increasing OS and was highest in the 2 highest categories.ConclusionsAn increase in OS reduces the risk for device failure but increases the risk for PPI. There was no ideal range of OS to minimize both device failure and PPI.Full English text available from: www.revespcardiol.org/en     

Transcatheter aortic valve implantation using the SAPIEN 3 valve to treat aortic regurgitation: The French multicentre S3AR study

BackgroundTranscatheter aortic valve implantation now has a major role in the treatment of patients with severe aortic stenosis. However, evidence is scarce on its feasibility and safety to treat patients with pure aortic regurgitation.AimsWe sought to evaluate the results of transcatheter aortic valve implantation using the balloon-expandable SAPIEN 3 transcatheter heart valve (Edwards Lifesciences, Irvine, CA, USA) in patients with pure aortic regurgitation on native non-calcified valves.MethodsWe conducted a retrospective and prospective French multicentre observational study. We included all patients with symptomatic severe pure aortic regurgitation on native non-calcified valves, contraindicated to or at high risk for surgical valve replacement, who underwent transcatheter aortic valve implantation using the SAPIEN 3 transcatheter heart valve.ResultsA total of 37 patients (male sex, 73%) with a median age of 81 years (interquartile range 69–85 years) were screened using transthoracic echocardiography and computed tomography and were included at eight French centres. At baseline, 83.8% of patients (n = 31) had dyspnoea New York Heart Association class ≥ III. The device success rate was 94.6% (n = 35). At 30 days, the all-cause mortality rate was 8.1% (n = 3) and valve migration occurred in 10.8% of cases (n = 4). Dyspnoea New York Heart Association class ≤ II was seen in 86.5% of patients (n = 32), and all survivors had aortic regurgitation grade ≤ 1. At 1-year follow-up, all-cause mortality was 16.2% (n = 6), 89.7% (n = 26/29) of survivors were in New York Heart Association class ≤ II and all had aortic regurgitation grade ≤ 2.ConclusionTranscatheter aortic valve implantation using the SAPIEN 3 transcatheter heart valve seems promising to treat selected high-risk patients with pure aortic regurgitation on non-calcified native valves, contraindicated to surgical aortic valve replacement.     

Transcatheter aortic valve replacement under monitored anesthesia care versus general anesthesia with intubation

AimsMost transcatheter aortic valve replacement (T-AVR) using the Edwards SAPIEN transcatheter heart valve (Edwards Lifesciences, Irvine, CA) is done under general anesthesia. The present study aimed to examine the feasibility and safety of T-AVR under monitored anesthesia care and aimed to compare the clinical outcome to the outcome of patients who underwent general anesthesia.MethodsThe analysis included 92 consecutive patients undergoing T-AVR via the transfemoral approach guided by transesophageal echocardiography using the Edwards SAPIEN valve. The cohort was divided into two groups: I, monitored anesthesia care (n = 70; 76.1%) and II, intubation (n = 22; 23.9%). Monitored anesthesia care was given by anesthesiologists in one of two protocol regimens: Ketamine & Propofol or Dexmedetomidine. The crossover rate to general anesthesia and the clinical outcome of these two groups were compared.ResultsBaseline clinical characteristics of the two groups were similar, except for higher logistic EuroSCORE and prior stroke in the monitored anesthesia care group. Surgical access of the femoral artery was performed in 15 (68.1%) from the general anesthesia group and in 24 (34.2%) from the monitored anesthesia care group, p = 0.05. The median procedure duration was significantly lower in the monitored anesthesia care group (91 vs. 155 min, p = 0.008) and there was a trend to lower median intensive care unit stay and hospital stay (27 vs. 72 h, p = 0.07 and 5 vs. 7.5 days, p = 0.06, respectively). Of the patients with monitored anesthesia care, 8 (11.4%) converted to general anesthesia.ConclusionT-AVR using the Edwards SAPIEN valve can be performed in the majority of cases with controlled monitored anesthesia care, thereby avoiding the necessity of general anesthesia and resulting in shorter procedure time and in-hospital length of stay.     

Clinical outcomes of acute ischemic stroke patients treated by direct catheter-based trombectomy depending on their baseline characteristics

BackgroundDirect catheter-based thrombectomy (d-CBT) was proven to be an effective treatment for proximal occlusions of the major intracranial arteries in acute stroke patients. The aim of this study was to compare clinical outcomes of patients treated by d-CBT depending on their baseline characteristics.MethodsA single center, prospective, observational registry of consecutive patients (pts) treated by d-CBT for an acute ischemic stroke. The degree of dependence after a stroke was measured by the modified Rankin scale (mRS) at 3 months follow-up and pts were divided into 2 subgroups based on functional independence/dependence (mRS 0–2 vs. 3–6).ResultsA total of 111 consecutive patients (mean age 65.9 ys, men 55%) have been enrolled. A favorable outcome (mRS ≤ 2 at 3 months) was reached in 39.8% (44 pts). The pts with favorable outcome (mRS ≤ 2) compared to pts with poor outcome (mRS 3–6) were younger (61 ys vs. 70 ys, p < 0.01), had higher prevalence of cigarette smoking (45.5% vs. 25.4%, p < 0.002) and had lower prevalence of known atrial fibrilation (25% vs. 53.7%, p < 0.001). There were no significant differences between the subgroups in: sex (men 50% vs. 58%, p = 0.27), body mass index (27.8 vs. 29.2, p = 0.21), arterial hypertension (70.5% vs. 77.6%, p = 0.26), diabetes mellitus (15.9% vs. 25.4%, p = 0.15), chronic kidney disease (11.4% vs. 22.4%, p = 0.08) and NIHSS on admission (15 vs. 18, p = 0.69).ConclusionsMechanical thrombectomy achieved better clinical results in younger patients, in smokers and in patients with stroke not caused by atrial fibrillation.     

Antifungal treatment administered in OPAT programs is a safe and effective option in selected patients

IntroductionOutpatient parenteral antimicrobial therapy (OPAT) has been recognised as a useful, cost-effective and safe alternative to inpatient treatment. Nevertheless, the most common antimicrobials used are antibiotics, and there is less information about the use of antifungal therapy (AT). The aim of this study is to analyse a cohort of patients treated with AT administered via OPAT and to compare them with patients from the rest of the cohort (RC) treated with antibiotics.MethodsProspective observational study with post hoc (or retrospective) analysis of a cohort of patients treated in the OPAT program. We selected the patients treated with antifungals between July 2012 and December 2018. We recorded demographic and clinical data to analyse the validity of the treatment and to compare the differences between the AT and the RC.ResultsOf the 1101 patients included in the OPAT program, 24 (2.18%) were treated with AT, 12 Liposomal Amphotericin B, 6 echinocandins and 6 fluconazole. This result is similar to other cohorts. There were differences between the AT vs RC in the number of patients with neoplasia (58.3% vs 28%; p = 0.001), IC Charlson > 2 (58.3% vs 38.8; p = 0.053), duration of treatment (15 days vs 10.39 days; p = 0.001) and patients with central catheters (54.2% vs 21.7%; p = 0.0001). These differences are justified because there were more hematologic patients included in the AT group. Nevertheless, there were no differences in adverse reactions (25% vs 32.3%; p = 0.45) or re-admissions (12.5% vs 10%; p = 0.686) and OPAT with AT was successful in 21/24 patients (87.5%).ConclusionsAT can be successfully administered in OPAT programs in selected patients, that are clinically stable and monitored by an infectious disease physician.     

Effects of 12 weeks of probiotic supplementation on quality of life in colorectal cancer survivors: A double-blind,randomized, placebo-controlled trial

BackgroundProbiotics may help resolve bowel symptoms and improve quality of life. We investigated the effects of 12 weeks of probiotics administration in colorectal cancer patients.MethodsWe conducted a double-blind, randomized, placebo-controlled trial. The participants took probiotics (Lacidofil) or placebo twice a day for 12 weeks. The cancer-related quality of life (FACT), patient's health-9 (PHQ-9), and bowel symptom questionnaires were completed by each participant.ResultsWe obtained data for 32 participants in the placebo group and 28 participants in the probiotics group. The mean ages of total participants were 56.18 ± 8.86 years and 58.3% were male. Administration of probiotics significantly decreased the proportion of patients suffering from irritable bowel symptoms (0 week vs. 12 week; 67.9% vs. 45.7%, p = 0.03), improved colorectal cancer-related FACT (baseline vs. 12 weeks: 19.79 ± 4.66 vs. 21.18 ± 3.67, p = 0.04) and fatigue-related FACT (baseline vs. 12 weeks: 43.00 (36.50–45.50) vs. 44.50 (38.50–49.00), p = 0.02) and PHQ-9 scores (0 weeks vs. 12 weeks; 3.00 (0–8.00) vs. 1.00 (0–3.00), p = 0.01). We found significant differences in changes of the proportion of patients with bowel symptoms (p < 0.05), functional well-being scores (p = 0.04) and cancer-related FACT scores (p = 0.04) between the two groups.ConclusionProbiotics improved bowel symptoms and quality of life in colorectal cancer survivors.     

Optimization of azathioprine dose in combined treatment with anti-TNF-alpha in inflammatory bowel disease

IntroductionThe dose of thiopurine drugs in combined treatments with anti-TNF in inflammatory bowel disease (IBD) has not been clearly established. The purpose of this study is to assess whether the dose of azathioprine influences clinical and biochemical response/remission rates, and anti-TNF drug levels/antibody formation.Material and methodsPatients with IBD on combined maintenance treatment with azathioprine and infliximab or adalimumab were selected. Based on the dose of azathioprine, two groups were defined (standard: 2–2.5 mg/kg/day; and decreased: less than 2 mg/kg/day).ResultsIn the IFX group, there were no statistically significant differences (p = 0.204) in the rates of remission (39% vs 41.3%), response (10% vs 21.7%) or failure (51.5% vs 37%) depending on the dose of thiopurine drugs. No differences were found between AZA-dose dependent IFX levels (2.46 vs 3.21 μg/mL; p = 0.211). In the adalimumab group, there were no statistically significant differences (p = 0.83) in the rates of remission (66% vs 56%), response without remission (15.38% vs 25%) or failure (18% vs 18%) depending on the dose of thiopurines. With respect to ADA-levels, no differences were found in both groups (7.69 vs 8.23 μg/mL; p = 0.37).ConclusionIn our experience, no statistically significant differences were found in either anti-TNF levels or clinical-biological response/remission rates based on doses of azathioprine.     

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.     

Metabolic manipulation in dilated cardiomyopathy: Assessing the role of trimetazidine

ObjectivesTo study the role of metabolic modulator (trimetazidine: TMZ) in dilated cardiomyopathy (DCM). Optimizing altered substrate metabolism in heart failure (HF) with metabolic modulators allows more efficacious energy production from glucose than from free fatty acids.Methods100 patients of DCM (47.7 years, NYHA class 2.17, LVEF 27.3%) were randomized to TMZ (20 mg tid, n = 50) vs conventional therapy (n = 50). Functional status, BNP and various echocardiographic parameters were assessed at 3–6 months.ResultsAt 3 months, TMZ group had significantly improved NYHA class (2.25 vs 1.85), 6 min walk test (349.7 vs 402 m), LVD-36 score (25.5 vs 21) and BNP (744.7 vs 248.3 pg/ml), all p 0.001. Significant improvement was also seen in LV end-systolic (LVESV, 87.1 ± 27.5 vs 78.5 ± 24.9 ml/m², p 0.001), LV end-diastolic volumes (LVEDV, 117.6 ± 29.3 vs 110.9 ± 27.4 ml/m², p 0.001), LVEF (27 vs 30.9%, p 0.001) and LV wall stress (90.2 ± 18.9 vs 71.1 ± 13.2 dyn/cm², p 0.0001). The % change in LVESV, LVEDV, LVEF and LV wall stress was −9.5%, −5.4%, +8.4% and −21.8%. Other echo parameters also improved after 3 months of TMZ (E/A ratio 1.9 vs 1.2, p = 0.001, E/A VTI 2.7 vs 1.6, p = 0.001, myocardial performance index, MPI 0.8 vs 0.7, p = 0.0001), Tissue Doppler parameters (E/E′ septal (19.7 vs 12.5, p = 0.001) and E/E′ lateral (13.3 vs 9.4, p = 0.0001)). Patients in control group had no change in NYHA class, LVD-36 scores, LV volumes or LVEF at 3 months although BNP and LV wall stress reduced to a slight extent. Patients on TMZ had further improvement in NYHA class, walk test, BNP levels and echocardiographic parameters at 6 months.ConclusionsMetabolic modulators (TMZ) may help in improving LV function in DCM. In this study, benefit was noted by 3 months with further improvement at 6 months.     

Ferroportin Q248H mutation,hyperferritinemia and atypical type 2 diabetes mellitus in South Kivu

BackgroundThe ferroportin Q248H mutation is relatively common in sub-Saharan Africa. No previous study examined its relationship with atypical diabetes mellitus (DM) in this area.ObjectiveTo determine the potential interactions between ferroportin Q248H mutation, hyperferritinemia and DM in South Kivu (RDC).MethodologyPresence of ferroportin Q248H mutation and iron status were investigated in diabetic patients (n = 179, age (mean) 57.7 years, CRP (median) 0.16 mg/L) and non-diabetic subjects (n = 86, age 44.5 years, CRP 0.07 mg/L) living in the city of Bukavu. Hyperferritinemia was considered for values greater than 200 and 300 μg/L in women and in men, respectively.ResultsThe prevalence of ferroportin Q248H mutation [12.1%] was non-significantly higher in diabetics than non-diabetics [14.0% vs. 8.1%, p = 0.17]. Similarly, hyperferritinemia frequency was higher in diabetic patients with Q248H mutation [44.0% vs. 14.3%, p = 0.16] and in mutation carriers [37.0% vs 16.5%, p = 0.001] than in the control groups, respectively. The association between Q248H mutation and DM was nevertheless not significant [adjusted OR 1.70 (95% CI: 0.52–5.58), p = 0.37], whereas hyperferritinemia [OR 2.72 (1.24–5.98), p = 0.01] showed an independent effect after adjustment for age and metabolic syndrome.ConclusionsThe present work suggests a potential association between abnormal iron metabolism, ferroportin Q248H mutation and atypical DM in Africans, which may be modulated by environmental factors.     

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.     

The impact of acid suppression medications and non-steroidal anti-inflammatory drugs on clinical and histologic features in celiac disease

IntroductionThe prevalence of celiac disease (CD) in the US has increased in past decades, as has use of proton pump inhibitors (PPIs), histamine-2-receptor antagonists (H2RAs), aspirin (ASA) and nonsteroidal anti-inflammatory drugs (NSAIDs). We aimed to measure the association between medication use and distribution of villous flattening (VF) among newly diagnosed CD patients.MethodsWe performed a cross-sectional study of adult patients with newly-diagnosed CD at two institutions. We collected data on regular use of these medications, clinical presentation, CD serologic status, and distribution of VF. We compared current ASA/NSAID users to non-users, and current PPI/H2RA users to non-users, with regard to these clinical characteristics.ResultsOf 148 patients with newly-diagnosed CD, current users of ASA/NSAIDs were older than non-users (47 vs 39 years, p = 0.003) and users of PPI/H2RAs were older than non-users (48 vs 39 years, p = 0.004). PPI/H2RA users comprised 12% of seropositive patients, compared to 55% of seronegative patients (p < 0.01). Patient gender and distribution of villous flattening in the bulb and distal duodenum did not differ by PPI/H2RA or ASA/NSAID use.ConclusionsPPI/H2RA use was associated with seronegative CD. Given the effect of these medications on gastric milieu, the impact of these drugs on presentation and course of CD deserves further investigation.     

Transcatheter aortic valve implantation improves outcome compared to open-heart surgery in kidney transplant recipients requiring aortic valve replacement

BackgroundCardiovascular disease is the most frequent cause of mortality for kidney transplant recipients. Open heart surgery has particularly high mortality and morbidity. As an alternative to traditional aortic valve replacement (AVR) for patients with high-grade aortic stenosis, transcatheter aortic valve implantation (TAVI) was developed as an innovative therapy for patients considered at high surgical risk.MethodsWe considered all kidney transplant recipients as high-risk patients, which are candidates for TAVI. In 2010 and 2011, eight kidney transplant recipients with severe aortic stenosis underwent TAVI (6 transfemoral; 2 transapical; group I). The outcome of these patients was compared retrospectively to 18 kidney transplant recipients with aortic stenosis, who underwent conventional AVR (group II).ResultsBoth groups had similar baseline characteristics, including estimated perioperative risk (EuroSCORE group I vs. group II: 9.5 ± 5.9 vs. 10.4 ± 10.5; p = 0.829).All TAVI procedures were performed successfully with excellent functional results. In the TAVI group (group I), all patients were alive at the 12-month follow-up with one cardiovascular event (stroke). In contrast, the surgical group experienced a 30-day-mortality of 11.1% (n = 2) and a 1-year-mortality of 16.7% (n = 3).ConclusionsBased on our center's experience, TAVI appears to be an effective and safe alternative to conventional surgery for AVR in patients with prior renal transplantation. Renal transplantation is not currently identified as a risk factor in our traditional scoring system, and may need to be considered independently when weighing alternatives for AVR.