Abdominal aortic calcification score can predict all-cause and cardiovascular mortality in maintenance hemodialysis patients

Purpose: Abdominal aortic calcification (AAC) assessed by using standard lateral lumbar radiographs can be graded, and composite summary scores (range, 0–24) have been shown to be highly predictive of subsequent cardiovascular morbidity and mortality in hemodialysis (HD) patients. However, few studies have sought to determine the optimal AAC score cutoff values for the prediction of mortality among HD patients.Methods: This retrospective cohort study included 408 hemodialysis patients. AAC severity was quantified by the AAC score, which was measured by lateral lumbar radiography with complete follow-up data from January 2015 to December 2021. We used receiver operating characteristic (ROC) analysis to find the cutoff AAC value for the prediction of mortality. The Kaplan–Meier method was used to analyze all-cause and cardiovascular mortality.Results: The cutoff calcification score for the prediction of mortality was 4.5 (sensitivity, 67.3%; specificity, 70.4%). The patients with AAC scores above 4.5 had significantly higher all-cause (log-rank p < 0.001) and cardiovascular (log-rank p < 0.001) mortality rates than those with AAC scores below 4.5. In the multivariate regression analyses, an AAC score above 4.5 was a significant factor associated with all-cause mortality (HR: 2.079, p = 0.002) and cardiovascular mortality (HR: 2.610, p < 0.001).Conclusions: AAC is a reliable aortic calcification marker. HD patients with an AAC score > 4.5 have significantly elevated all-cause and cardiovascular mortality compared with those with an AAC score ≤ 4.5. AAC was a better predictor than cardiac valve calcification for mortality in HD patients.     

The optimal range of serum intact parathyroid hormone for a lower risk of mortality in the incident hemodialysis patients

The serum intact parathyroid hormone (iPTH) is associated with the prognosis of hemodialysis (HD) patients, however, its optimal range for reducing mortality remains inconsistent. We designed a prospective cohort study of 346 incident HD patients to assess the association between different serum iPTH level and mortality. According to the Kidney Disease Outcomes Quality Initiative (K/DOQI) international guidelines (2003), we divided patients into three groups (iPTH < 150 pg/mL, 150–300 pg/mL and >300 pg/mL). During the median follow-up of 58 months, 157 patients (45.38%) died. Multivariate Cox regression analysis showed that iPTH < 150 pg/mL and >300 pg/mL were associated with all-cause and cardiovascular mortality. Then, we performed a sensitivity analysis of patients divided into 6 serum PTH levels groups according to the folds of the K/DOQI target range. Multivariate Cox regression analysis showed that patients with serum iPTH ≥750 pg/mL, 600–749 pg/mL, 450–599 pg/mL had significantly higher risk of all-cause and cardiovascular mortality compared with those with serum iPTH in the range of 150–299 pg/mL. The association between serum iPTH and mortality shows a U-shaped curve. The optimal serum iPTH level which confers the lowest risk of all-cause and cardiovascular mortality could range from 150 pg/mL to 450 pg/mL in this group of incident HD patients.     

Optimal targets of chronic kidney disease-mineral and bone disorder markers for Chinese patients with maintenance peritoneal dialysis: a single-center retrospective cohort study

BackgroundThe chronic kidney disease-mineral and bone disorder（CKD-MBD) is known to be associated with increased mortality in dialysis patients, but whether current global guidelines for CKD-MBD, which were primarily developed from hemodialysis, are suitable for peritoneal dialysis (PD) patients practice require further investigation.MethodsThis is a single-center retrospective cohort study. In total 491 prevalent PD patients (median follow-ups: 34 months) from Peking Union Medical College Hospital (PUMCH) from January 2004 to December 2017 were included and followed until 30 June 2018. In the first dialysis year, the average levels of serum calcium, albumin-corrected calcium (CorCa), phosphorus, and parathyroid hormone (PTH) levels were the interested predictors in Cox proportional regression model.ResultsOf these PD patients (age 58 ± 17 years), 52% were male and 36% had diabetic nephropathy. In Cox regression over first-year mean parameters, PTH <100 pg/mL (HR = 1.97, 95% CI 1.32 to 2.94, p < 0.001) and ≥300 pg/mL (HR = 2.24, 95% CI 1.32 to 3.81, p = 0.003) were associated with increased all-cause mortality than that of PTH 100–200 pg/mL. Patients with albumin-corrected serum calcium level < 2.13 mmol/L also had higher risk of death than patients with level of 2.13 to 2.38 mmol/L (HR = 2.06, 95% CI 1.06 to 4.01, p = 0.02). Serum phosphorus ≥1.45 mmol/L were associated with increased all-cause mortality. However, lacking of data on 25-hydroxy vitamin D, alkaline phosphatase, and activated vitamin-D are limitations of our analysis.ConclusionsAs one of the largest PD cohort study focusing on CKD-MBD, we demonstrated that the level of CKD-MBD markers in the first PD year are independent predictors of all-cause mortality. PTH 100–300 pg/mL might be the best target for Chinese PD patients.     

Histopathological assessment of radial artery calcification in patients with end-stage kidney disease

BackgroundA comprehensive understanding of vascular calcification pathology is significant for the development of cardiovascular disease therapy in high-risk populations. This cross-sectional study aimed to evaluate the prevalence and characteristics of radial artery calcification (RAC) and to identify the factors that are associated with RAC in end-stage kidney disease (ESKD).MethodsDetailed medical histories of 180 patients with ESKD were recorded. Fragments of the radial artery obtained during the creation of arteriovenous fistula for hemodialysis access were stained with alizarin red S.ResultsCalcification was localized in the arterial media layer. The prevalence of positive calcification staining in the radial arteries was 21.1% (n = 38). Patients with RAC had a higher glycated hemoglobin level (p < 0.01), higher prevalence of dialysis duration >5 years (p = 0.022), and diabetes mellitus (p < 0.01) than those without RAC. Multiple logistic regression models showed dialysis duration >5 years (odds ratio [OR], 9.864; 95% confidence interval [CI], 2.666–36.502; p < 0.01) and diabetes mellitus (OR, 12.689; 95% CI, 2.796–34.597; p < 0.01) were independent risk factors for RAC in patients with ESKD. Patients with dialysis duration >5 years had a higher prevalence of RAC (p = 0.012) than those with dialysis duration ≤5 years. Patients with diabetes mellitus had a higher prevalence of RAC (p < 0.01) than those without diabetes mellitus. Patients with diabetes mellitus ≥15 years had a higher prevalence of RAC (p = 0.042) than those with diabetes mellitus <15 years. Radial artery calcification level showed a significantly positive correlation with dialysis duration (p < 0.05), diabetes mellitus duration (p < 0.01), HbA1c level (p < 0.01) and Calcium level (p < 0.01).ConclusionsIn patients with ESKD, dialysis duration >5 years and diabetes predict RAC. Thus, the combination of prolonged dialysis and hyperglycemic conditions exerts a synergistic effect on RAC.     

The blood urea nitrogen/creatinine (BUN/cre) ratio was U-shaped associated with all-cause mortality in general population

ObjectivesThis study aimed to explore the relationship between the blood urea nitrogen/creatinine (BUN/Cre) ratio and all-cause or cause-specific mortality in the general population.MethodsParticipants were enrolled from the National Health and Nutrition Examination Survey (NHANES) during 1999 to 2014. Baseline variables were acquired from questionnaires and examinations. Death status were ascertained from National Death Index records. Cox proportional hazards models with cubic spines were used to estimate hazard ratios (HRs) and 95% confidence interval (CI) of all-cause mortality, cardiovascular and cancer mortality.ResultsA total of 42038 participants were enrolled in the study with a median 8.13 years of follow-up. Older people and women tend to have a higher BUN/Cre ratio. After multivariable adjustment, BUN/Cre ratio between 11.43 and 14.64 was associated with the lowest all-cause mortality compared with the participants with the lowest quartile (HR 0.83 [0.76, 0.91]; p < 0.001). The highest quartile of BUN/Cre ratio was associated with the lowest risk of cancer mortality (HR 0.64 [0.53, 0.78]; p < 0.001). Restricted cubic splines showed BUN/Cre was nonlinearly associated with all-cause mortality and linearly associated with cancer mortality.ConclusionsThis study confirmed a U-shape relationship between BUN/Cre ratio and all-cause mortality in the general population.     

Effects of intensive blood pressure control on mortality and cardiorenal function in chronic kidney disease patients

BackgroundBlood pressure (BP) variability is highly correlated with cardiovascular and kidney outcomes in patients with chronic kidney disease (CKD). However, appropriate BP targets in patients with CKD remain uncertain.MethodsWe searched PubMed, Embase, and the Cochrane Library for randomized controlled trials (RCTs) of CKD patients who underwent intensive BP management. Kappa score was used to assess inter-rater agreement. A good agreement between the authors was observed to inter-rater reliability of RCTs selection (kappa = 0.77; P = 0.005).ResultsTen relevant studies involving 20 059 patients were included in the meta-analysis. Overall, intensive BP management may reduce the incidence of cardiovascular disease mortality (RR: 0.69, 95% CI: 0.53 to 0.90, P: 0.01), all-cause mortality (RR: 0.77, 95% CI: 0.67 to 0.88, P < 0.01) and composite cardiovascular events (RR: 0.84 95% CI: 0.75 to 0.95, P < 0.01) in patients with CKD. However, reducing BP has no significant effect on the incidence of doubling of serum creatinine level or 50% reduction in GFR (RR: 1.26, 95% CI: 0.66 to 2.40, P = 0.48), composite renal events (RR 1.07, 95% CI: 0.81 to 1.41, P = 0.64) or SAEs (RR: 0.97, 95% CI: 0.90 to 1.05, P = 0.48).ConclusionIn patients with CKD, enhanced BP management is associated with reduced all-cause mortality, cardiovascular mortality, and incidence of composite cardiovascular events.     

Effect of an Elevated Preoperative International Normalized Ratio on Transfusion and Complications in Primary Total Hip Arthroplasty with the Enhanced Recovery after Surgery Protocol

ObjectiveTo verify whether an elevated preoperative international normalized ratio (INR) increases transfusion and complications independently in primary total hip arthroplasty (THA) with the management of an enhanced recovery after surgery (EARS) protocol.MethodsWe retrospectively reviewed the database of adults who underwent primary THA between 2014 and 2018 by the same surgeon. A total of 552 patients were assigned into three groups by preoperative INR class: INR ≤ 0.9, 0.9 < INR < 1.0, and INR ≥ 1.0. We regarded transfusion within 90 days during the same hospitalization as the primary outcome. We also included perioperative blood loss, maximum Hb drop, postoperative anaemia requiring medicine, and length of hospital stay (LOS) during the same hospitalization in the study. Complications and reoperation at 90 days and mortality at 90 days and 12 months were also included in the study. Univariable analyses were utilized to compare baselines and outcomes among the three groups. Multivariate logistic regressions were used to adjust for differences at baseline among the groups.ResultsAll patients had an INR < 1.5 preoperatively and were managed with the ERAS protocol. Among them, 93 (16.8%) patients had INR ≤ 0.9, 268 (48.6%) patients had 0.9 < INR < 1.0, and 191 (34.6%) patients had INR ≥ 1.0. In the univariable analyses, as the INR increased, the transfusion rates increased from 1.08% for INR ≤ 0.9, to 1.12% for 0.9 < INR < 1.0 and to 5.76% for INR ≥ 1.0 (P < 0.05). The overall complication rate increased from 10.8% for INR ≤ 0.9, to 16.4% for 0.9 < INR < 1.0, and to 22.5% for INR ≥ 1.0 (P < 0.05). The length of stay (LOS) in the INR ≥ 1.0 group was 5.7 ± 2.2 days, which was significantly longer than that in the INR ≤ 0.9 group (4.7 ± 1.6 days, P = 0.000) and 0.9 < INR < 1.0 group (5.1 ± 2.0 days, P = 0.007). No statistical significance was detected among the groups regarding blood loss, maximum Hb drop, or the incidence of postoperative anaemia that required medicine. There was no significant difference in reoperation or mortality among the groups. When controlling for demographic and comorbidity characteristics, there was no statistically significant difference in the odds of transfusion during the same hospitalization or overall complications at 90 days among the groups (P > 0.05).ConclusionsElevated preoperative INR cannot increase transfusion or complication rates independently in primary THA with the management of the ERAS protocol. With the improvement in the ERAS protocol and the use of tranexamic acid (TXA), an INR < 1.5 is still a conventional safe threshold for THA surgery.     

Use of the systemic inflammation response index (SIRI) as a novel prognostic marker for patients on peritoneal dialysis

BackgroundThe systemic inflammatory response index (SIRI), a novel inflammation maker, has proven to be associated with prognostic outcomes in various diseases. However, few studies have been conducted assessing how SIRI may influence outcomes of patients on peritoneal dialysis (PD). Herein, we assessed the predictive value of SIRI on mortality all-cause mortality, including cardiovascular disease (CVD) in PD patients.MethodsA total of 646 PD patients were enrolled in this study. PD patients received regular PD treatments at the Zhujiang Hospital from 1 January 2011 to 31 December 2018. SIRI values could be computed as follows: neutrophil count × monocyte count/lymphocyte count. Patients were divided into two groups according to the median level of SIRI. Cox regression analysis and Kaplan–Meier methods were applied to analyze the relationship between SIRI and mortality outcomes in PD patients.ResultsDuring the median 31-month follow-up period, 97 (15.0%) PD patients died from all-causes, and 47 (49.0%) died of CVD. Kaplan–Meier analyses revealed that a high SIRI corresponded to the high mortality of all-cause deaths, including CVD (both p < 0.001) in patients on PD. After adjusting for potential confounders, the higher SIRI level was significantly associated with an increased all-cause mortality (HR: 2.007, 95% CI: 1.304–3.088, p = 0.002) and cardiovascular mortality (HR: 2.847, 95% CI: 1.445–5.608, p = 0.002).ConclusionsSIRI was a promising predictor of mortality in PD patients, with a higher SIRI corresponding to increased risk of mortality.     

Cardiac surgery in older patients: hospital outcomes during a 15-year period from a complete national series

Open in a separate window OBJECTIVESThe objective was to review national trends in activity and hospital outcomes in older patients having cardiac surgery over a 15-year time period.METHODSData were collected prospectively and uploaded to the National Institute for Cardiovascular Outcomes Research electronically. Data were validated, cleaned and processed using reproducible algorithms. Mortality was death in hospital after index operation.RESULTSA total of 227 442 cardiac procedures were recorded in patients aged ≥70 years of which 46 354 were in those aged ≥80 years. Overall patients aged ≥70 years represented 43% of all adult cardiac surgery in the most recent study year. The annual proportion of surgery in patients ≥80 years increased from 4.1% to 10.8% between the first and last study years. There has been a significant linear increase in octogenarian valve [β 67.44, 95% confidence interval (CI) 55.04 to 79.83, P < 0.001] and coronary artery bypass graft surgery (β 32.53, 95% CI 6.16 to 58.90, P = 0.020) patients. In-hospital mortality reduced significantly for patients aged 70–79 years (β −0.17, 95% CI −0.20 to −0.13, P < 0.001) and all patients aged ≥80 (β −0.37, 95% CI −0.45 to −0.30, P < 0.001). The median length of hospital stay was 7 days for 70–79 and 9 days for ≥80 group, compared with 7 days for the whole cohort <70 years.CONCLUSIONSThis study represents the largest complete validated national dataset of cardiac surgery in the entire population of older patients. Octogenarians represent 11% of adult patients having cardiac surgery by the end of the study period, a three-fold increase from the start. In-hospital mortality in patients aged ≥80 years halved during study period to only 4% despite high logistic EuroSCORE of 15%. Cardiac surgery in octogenarians places a higher demand on resources, however, with an increased postoperative length of stay.     

Risk factors and outcomes of cardiovascular disease readmission within the first year after dialysis in peritoneal dialysis patients

BackgroundIn the first year of dialysis, patients are vulnerable to cardiovascular disease (CVD) hospitalization, but knowledge regarding the risk factors and long-term outcomes of cardiovascular readmission within the first year after dialysis in incident continuous ambulatory peritoneal dialysis (CAPD) patients is limited.MethodsThis retrospective cohort study was conducted in incident CAPD patients. The demographic characteristics, laboratory parameters, and CVD readmission were collected and analyzed. The primary outcome was all-cause mortality, and the secondary outcomes included CVD mortality, infection-related mortality and technique failure. A logistic regression was used to identify the risk factors associated with CVD readmission within the first year after dialysis. Cox proportional hazards models were used to evaluate the association between CVD readmission and the outcomes.ResultsIn total, 1589 peritoneal dialysis (PD) patients were included in this study, of whom 120 (7.6%) patients had at least one episode of CVD readmission within the first year after dialysis initiation. Advanced age, CVD history, and a lower level of serum albumin were independently associated with CVD readmission. CVD readmission within the first year after dialysis was significantly associated with all-cause (HR 2.66, 95%CI 1.91–3.70, p < 0.001) and CVD (HR 3.42, 95%CI 2.20–5.31, p < 0.001) mortality, but not infection-related mortality or technique failure, after adjusting for confounders.ConclusionsOur findings suggest that an advanced age, a history of CVD, and a lower level of serum albumin were independently associated with CVD readmission. Moreover, CVD readmission was associated with all-cause and cardiovascular mortality in incident CAPD patients.     

Extracellular water/total body water ratio as predictor of mortality in hemodialysis patients

BackgroundOverhydration is a predictor of mortality in hemodialysis (HD) patients. Bioimpedance spectroscopy (BIS) is used to determine the body composition. Extracellular Water/Total Body Water (ECW/TBW) ratio has been proposed to predict mortality.MethodsMulticenter, prospective, observational, proof-of-concept study to estimate the impact of ECW/TBW in global and cardiovascular mortality and the relationship with cardiovascular biomarkers. The study included 60 patients (mean age, 71.8 ± 11.4 years; mean time on HD, 52.3 ± 30.8 months) with a median follow-up of 30.5 months (IQ range, 17.2–34 months).ResultsPost-dialysis ECW/TBW was directly associated with NT-proBNP and cTnT. During the study 28 patients died, most of them (43%) due to cardiovascular events. Compared to the survivors, these subjects had a higher post-dialysis ECW/TBW ratio (p = 0.006), while for cardiovascular mortality the only significant difference was a higher pre-dialysis ECW/TBW. The ability of post-dialysis ECW/TBW ratio to predict all-cause mortality had an area under the ROC curve (AUC) of 0.71 (CI 95%, 0.57–0.81; p = 0.002), with a cutoff point of 0.5023. For cardiovascular mortality the AUC was 0.66 (CI 95%, 0.52–0.77; p = 0.045), with a cutoff point of 0.4713.ConclusionsThe post-dialysis ECW/TBW ratio measured by BIS can be a predictor of all-cause and cardiovascular mortality.     

Proton pump inhibitor usage is associated with higher all-cause mortality and CV events in peritoneal dialysis patients

ObjectivesA long period of inappropriate proton pump inhibitors (PPI) treatment has been proved to be associated with adverse prognosis in general population and hemodialysis patients. This study was conducted to clarify the impact of PPI usage on mortality and adverse cardiovascular (CV) events in peritoneal dialysis (PD) patients.Methods and designThis is a retrospective study. A total of 905 patients were enrolled from two PD centers, including 211 patients on PPI treatment and 618 patients not on PPIs. Kaplan–Meier curves were used to identify the incidence of adverse outcomes. Multivariate Cox regression models and inverse probability of treatment weighting (IPTW) were applied to analyze hazard ratios (HRs) for adverse outcomes.ResultsDuring follow-up, 162 deaths and 102 CV events were recorded. Kaplan–Meier curve demonstrated all-cause mortality (log-rank test p = .018) and CV events (log-rank test p = .024) were significantly higher in PPI usage group. Multivariate Cox regression models and IPTW showed that PPI usage was an indicator for all-cause mortality (HR = 1.35, 95%CI = 1.09–1.67, p = .006) and CV events (HR = 1.78, 95%CI = 1.35–2.32, p < .001).ConclusionsPPI usage is associated with higher all-cause mortality and CV events in PD patients. Clinicians are supposed to be more careful when using PPI and need to master the indications more rigorously in patients receiving PD treatment.     

Ferric Citrate Reduces Intravenous Iron and Erythropoiesis-Stimulating Agent Use in ESRD

Ferric citrate (FC) is a phosphate binder with shown efficacy and additional effects on iron stores and use of intravenous (iv) iron and erythropoiesis-stimulating agents (ESAs). We provide detailed analyses of changes in iron/hematologic parameters and iv iron/ESA use at time points throughout the active control period of a phase 3 international randomized clinical trial. In all, 441 subjects were randomized (292 to FC and 149 to sevelamer carbonate and/or calcium acetate [active control (AC)]) and followed for 52 weeks. Subjects on FC had increased ferritin and transferrin saturation (TSAT) levels compared with subjects on AC by week 12 (change in ferritin, 114.1±29.35 ng/ml; P<0.001; change in TSAT, 8.62%±1.57%; P<0.001). Change in TSAT plateaued at this point, whereas change in ferritin increased through week 24, remaining relatively stable thereafter. Subjects on FC needed less iv iron compared with subjects on AC over 52 weeks (median [interquartile range] dose=12.9 [1.0–28.9] versus 26.8 [13.4–47.6] mg/wk; P<0.001), and the percentage of subjects not requiring iv iron was higher with FC (P<0.001). Cumulative ESA over 52 weeks was lower with FC than AC (median [interquartile range] dose=5303 [2023–9695] versus 6954 [2664–12,375] units/wk; P=0.04). Overall, 90.3% of subjects on FC and 89.3% of subjects on AC experienced adverse events. In conclusion, treatment with FC as a phosphate binder results in increased iron parameters apparent after 12 weeks and reduces iv iron and ESA use while maintaining hemoglobin over 52 weeks, with a safety profile similar to that of available binders.     

Arterial stiffness and atherosclerosis in systemic lupus erythematosus patients

IntroductionSystemic lupus erythematosus (SLE) is characterized by early atherothrombosis. Pulse wave velocity (PWV) is a promising tool for the diagnosis of early vascular remodelling and initial atherosclerotic plaque formation. Our objective was to evaluate PWV and its relationship with coronary atherosclerosis and thrombotic biomarkers in patients with SLE.Material and methodsIn 26 patients with SLE with stable clinical conditions, mean age of 39.1 ±11.7 years and without a history of coronary artery disease, multidetector computed tomography (MDCT)-based coronary calcium scoring (CACS) was performed and PWV measured.Laboratory evaluation included serum levels of anticardiolipin and anti-β2-glycoprotein antibodies (anti-β2-GPI), lupus anticoagulant (LA), D-dimers, thrombin–antithrombin complexes (TAT), and von Willebrand factor (vWF).ResultsMultidetector computed tomography revealed coronary calcifications in 8 (30.8%) patients and the median CACS was 52.4 HU (range 2–843.2). The mean PWV was 9.0 ±3.2 m/s and was higher in patients aged > 50 years (+33.7% vs. < 50 years), those with positive LA (+28.2% vs. LA negative), TAT ≥ 10 μg/l (+18.1% vs. < 10 μg/l), vWF ≥ 200 IU/dl (+51.8% vs. < 200 IU/dl) and with coronary atherosclerosis (CACS > 0; +21.4% vs. CACS = 0).In contrast, the duration of the disease, D-dimers, anticardiolipin, and anti-β2-GPI antibodies did not influence PWV. In the group without atherosclerosis (CACS = 0, n =18), patients with vWF ≥ 200 IU/dl had a 19.3% higher PWV compared to the rest.ConclusionsIn patients with SLE, PWV was associated with the presence of coronary atherosclerotic lesions in MDCT. Furthermore, arterial stiffness was higher in patients with markers of endothelial dysfunction and a prothrombotic state, suggesting their contribution to the early stages of arterial remodelling in SLE.     

Association between red blood cell distribution width and non-valvular atrial fibrillation in hemodialysis patients: a single-center Chinese population study

BackgroundRed blood cell distribution width (RDW) has emerged as a prognostic marker of atrial fibrillation (AF) in various clinical settings. However, the relationship by which RDW was linked to AF in hemodialysis (HD) patients was not clear. We sought to reveal the relationship between RDW and AF occurrence in HD patients.MethodsWe enrolled 170 consecutive maintenance HD patients, including 86 AF patients and 84 non-AF patients. All participants’ medical history and detailed clinical workup were recorded before the first dialysis session of the week. Electrocardiography, laboratory and transthoracic echocardiography examination indices were compared between the AF group and non-AF group. Multivariable logistic regression analysis was performed to identify the independent predictors of AF occurrence in HD patients.ResultsThere were all paroxysmal AF patients in AF group. Compared to the non-AF group, patients with AF group had a significantly older age (61.0 ± 1.48 vs. 49.71 ± 1.79, p < 0.001), lower BMI (24.3 ± 4.11 vs. 25.8 ± 3.87, p < 0.05), higher RDW (15.10 ± 0.96 vs. 14.26 ± 0.82, p < 0.001) and larger LAD (39.87 ± 3.66 vs. 37.68 ± 5.08, p < 0.05). Multivariable logistic regression analyses demonstrated that values of age (OR: 1.030, 95%CI: 1.004-1.057, per one- year increase), BMI (OR: 0.863, 95%CI: 0.782–0.952, per 1 kg/m² increase), RDW (OR: 2.917, 95%CI: 1.805–4.715, per 1% increase) and LAD (OR: 1.097, 95%CI: 1.004–1.199, per 1 mm increase) were independently associated with AF occurrence (p < 0.05, respectively). The best cutoff value of RDW to predict AF occurrence was 14.65% with a sensitivity of 68.6% and a specificity of 72.6%.ConclusionsThe increased RDW was significantly associated with the paroxysmal AF occurrence in HD patients.     

Effect of Orthogeriatric Co‐Management on Geriatric Hip Fractures in China

ObjectivesAlthough geriatric hip fracture is a serious public health problem in China, the result of orthogeriatric co‐management (OGC) is rarely reported. This study aimed to evaluate the effect of OGC in Chinese patients aged ≥65 years.MethodsIn this single‐centre, pre‐post intervention, retrospective study, traditional orthopaedic care (TOC) was used until OGC was implemented in May 2015, a multidisciplinary team was organized, and clinical protocol was designed. Consecutive hip fracture patients who were ≥65 years and injured within 3 weeks were included in this study. Demographic characteristics, comorbidities, fracture patterns, surgical procedure, time to surgery, length of hospital stay, inpatient complications, and in‐hospital mortality were extracted and examined. At 1‐year after surgery, data on patients'' mobility and mortality were collected. The time to surgery, incidence of inpatient complications, mortality and functional outcomes were compared between the groups.ResultsThere were no significant differences in sex, fracture type, and surgical pattern between OGC (n = 434) and TOC (n = 452) groups. Patients in OGC group were significantly older (P < 0.001) and had a higher age‐adjusted Charlson comorbidity index (P < 0.001). However, waiting time between admission and operation was significantly lower in OGC group (P < 0.001). There was no significant difference in the mortality rate at the time of the patient being in‐hospital and at 1, 3, and 6 months after surgery. Although 1‐year mortality was higher in OGC group (P = 0.036), Cox regression analysis showed no significant correlation of OGC with 1‐year mortality. There was no significant difference in pre‐injury mobility and 1‐year follow‐up mobility assessed by Parker score. Only approximately half of the patients in both groups completely returned to their pre‐injury mobility level.ConclusionOGC significantly shortens time to surgery for geriatric hip fractures compared with TOC. However, there is no significant effect on mortality rate within 1 year and functional status at 1 year of follow‐up.     

Survival outcomes and adverse events in patients with chronic kidney disease after coronary artery bypass grafting and percutaneous coronary intervention: a meta-analysis of propensity score-matching studies

BackgroundThe present meta-analysis of propensity score-matching studies aimed to compare the long-term survival outcomes and adverse events associated with coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with chronic kidney disease (CKD).MethodsElectronic databases were searched for studies comparing CABG and PCI in patients with CKD. The search period extended to 13 February 2021. The primary outcome was all-cause mortality, and the secondary endpoints included myocardial infarction, revascularization, and stroke. Odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (CIs) were used to express the pooled effect. Study quality was assessed using the Newcastle–Ottawa scale. The analyses were performed using RevMan 5.3.ResultsThirteen studies involving 18,005 patients were included in the meta-analysis. Long-term mortality risk was significantly lower in the CABG group than in the PCI group (HR: 0.76, 95% CI: 0.70–0.83, p < .001), and similar results were observed in the subgroup analysis of patients undergoing dialysis and for different estimated glomerular filtration rate ranges. The incidence rates of myocardial infarction (OR: 0.25, 95% CI: 0.12–0.54, p < .001) and revascularization (OR: 0.17, 95% CI: 0.08–0.35, p < .001) were lower in the CABG group than in the PCI group, although there were no significant differences in the incidence of stroke between the two groups (OR: 1.24; 95% CI: 0.89–1.73, p > .05). Subgroup analysis among patients on dialysis yielded similar results.ConclusionsOur propensity score matching analysis revealed that, based on long-term follow-up outcomes, CABG remains superior to PCI in patients with CKD.     

The role of plasma volume and fluid overload in the tolerance to ultrafiltration and hypotension in hemodialysis patients

IntroductionUltrafiltration (UF) in hemodialysis (HD) patients is accompanied by irregular falls in plasma volume (PV) and blood pressure (BP).MethodsWe obtained in 321 patients (large cohort), body weight (BW), BP, samples of blood to determine hemoglobin (Hb) and hematocrit (Ht), Pre and Post HD. We estimated the % variation of the PV and its effect on the BP. In a small cohort of 38/321 patients, arterial blood was drawn Pre and Post HD and at 2, 48, and 72 h to determined Hb and Ht and % variation of the PV. Bio-impedance spectroscopy (BIS) was performed, in the same times, to estimate: dry weight (DW), total body water (TBW), extracellular water (ECW), Fluid overload (FO) and phase angle (PhA).ResultsWe divided our large cohort in two groups. The Hypotensive group with a fall equal or more than 20 mmHg (96/321,30%) and Normotensive group with a drop equal or less than 19 mmHg (225/321,70%). The UF was 2.73 ± 0.72 L in the Hypotensive group and 2.53 ± 0.85 L in the Normotensive group (p < 0.0001). The % PV was −11.7 ± 17.8 in the Hypotensive group and −8.53 ± 10.07 in the Normotensive group (p < 0.0001). The systolic blood pressure (SBP) correlated with the % change of the PV (r = -0.232; p < 0.0001). The FO was contrasted with the % of water removed by UF (r = -0.890; p < 0.0001).ConclusionThe SBP drop was secondary to the fall in the PV after UF. The FO was irregular and modulates in part the fall in the SBP.     

The Cost and Consequences of Failed Osteosynthesis of Intertrochanteric Femur Fractures: A Matched Cohort Study

BackgroundWe aimed to evaluate the cost and consequences of failed osteosynthesis of intertrochanteric femur fracture (ITFF) patients and compare with primary ITFF patients.MethodsWe retrospectively evaluated 689 patients who underwent surgery due to ITFF via cephalomedullary nail. 31 patients (5.8%) had revision surgery because of osteosynthesis failure of ITFF. Each revision case included in the study was matched with four primary ITFF cases as control group based on age, gender, year of operation, type of fracture and American Society of Anesthesiologists (ASA) grade. Total cost for the admission that patients underwent surgery, mortality rate at first year, infection rate, length of stay at hospital, length of stay at intensive care unit, and erythrocyte transfusion amounts were recorded from hospital registry records. Tip apex distances (TAD) were noted.ResultsThe mean total cost of the revision cases and primary cases was 10,027 ± 6387 and 5261 ± 1773 Turkish Liras, respectively (p < 0.001). TAD was ≥ 20 mm in 32.3% (10/31) of patients in revision group while 2.4% (3/124) of the patients in control group (p < 0.001). The mean length of stay at hospital, length of stay at intensive care unit, erythrocyte transfusion amounts, infection rate and mortality rate at first year were significantly higher in revision cases compared to matched primary control cases (p < 0.05).ConclusionRevision surgeries due to failed osteosynthesis of ITFFs with cephalomedullary nail have at least two times higher mean total cost than primary cases. The awareness of the cost, morbidity and mortality of the revision surgeries may reduce the modifiable risk factors of osteosynthesis failure including maintenance of TAD below 20 mm, obtaining optimal lag screw position and reduction quality.Level of EvidenceLevel 3, retrospective cohort study.     

Is Obesity Associated with Higher Complication Rates in Total Hip Arthroplasty for High-Riding Dysplastic Hips?

ObjectiveDevelopmental dysplasia of the hip (DDH) is a disabling pathology leading to hip problems, such as painful arthritic hip, unstable hip, etc. Total hip arthroplasty (THA) is an effective treatment modality for this condition. Obesity has been shown to be associated with increased rates of complications following orthopaedic surgeries (Journal of Arthroplasty 20:46–50). The hypothesis of this study was that patients with a body mass index (BMI) greater than 30 (obese), who undergo total hip arthroplasty for dysplastic hip, are associated with longer operative and anaesthetic times, longer hospital stays and higher re-admission rates within 30 days.MethodsAll the cases of total hip arthroplasty in patients with high-riding dysplastic hips were reviewed. Evaluation was made of a total of 68 patients comprising 64 females and 4 males, classified into two groups. Patients with BMI < 30 kg/m² formed the non-obese group and patients with BMI ≥ 30 kg/m² the obese group.ResultsThe mean age was 44.67 ± 6.49 years. BMI was < 30 in 44 (64.7%) patients and > 30 in 24 (35.3%) patients. The data analysis showed that mean surgical time, anaesthesia duration and re-admission rate were significantly higher in the group with BMI ≥ 30(obese) as compared to the group with BMI < 30 (non-obese) (p < 0.01). The complication rate was determined to be higher in the obese group (p < 0.05).ConclusionObese patients performed with total hip arthroplasty for high-riding dysplastic hips had more complications and higher rates of re-admission to hospital compared with the non-obese patients.