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.     

Association between neutrophil-to-lymphocyte ratio in the first seven days of sepsis and mortality

IntroductionThe neutrophil-to-lymphocyte ratio (NLR) in the diagnosis of sepsis has been found to be higher in non-survivors than in survivors, and that is associated with mortality. A higher NLR in non-survivors than in survivors has been reported in two studies during patient follow-up; however, NLR was not controlled for sepsis severity. Thus, the objective of this study was to determine whether there is an association between NLR in the first seven days and mortality controlling for sepsis severity.MethodsThis observational study, which included septic patients, was conducted in the Intensive Care Units of 3 Spanish hospitals. NLR was recorded on the first, fourth, and eighth day of sepsis. Multiple logistic regression analyses were carried out to determine the association between NLR during the first 7 days of sepsis diagnosis and mortality controlling for sepsis severity.ResultsThirty-day non-surviving patients (n = 68) compared to surviving patients (n = 135) showed higher NLR on the first (p < 0.001), fourth (p < 0.001), and eighth (p < 0.001) day of sepsis diagnosis. Multiple logistic regression analysis found an association between NLR at days first (p < 0.001), fourth (p = 0.004), and eighth (p = 0.01) of sepsis diagnosis and mortality controlling for SOFA and lactic acid in those days.ConclusionsThe new finding of our study was the association between NLR in the first seven days of sepsis and mortality controlling for sepsis severity.     

Factors affecting prognosis of the patients with severe hyponatremia

IntroductionHyponatremia is one of the most common electrolyte abnormalities in clinical practice. Data regarding factors that have impact on mortality of severe hyponatremia and outcomes of its therapeutic management is insufficient. The present study aimed to examine the factors associated with mortality and the outcomes of treatment in patients with severe hyponatremia.Materials and methodsPatients with serum Na ≤ 115 mequiv./L who were admitted to Ordu State Hospital and Ordu University Training and Research Hospital between 2014 and 2018 were included in the study. Demographic and laboratory features, severity of the symptoms, comorbid diseases, medications, and clinical outcome measures of the patients were obtained retrospectively from their medical records. Factors associated with in-hospital mortality, overcorrection and undercorrection were assessed.ResultsA total of 145 patients (median age 69 years and 58.6% female) met inclusion criteria. Diuretic use was the most common etiologic factor for severe hyponatremia that present in 50 (34.5%) patients. Sixty-seven (46.2%) patients had moderately severe while 8 patients (5.5%) had severe symptoms. The median increase in serum Na 24 h after admission in the study population was 8.9 mequiv./L (?6 to 19). Nonoptimal correction was seen in 92 (63.4%) patients. Hypertonic saline use was associated with overcorrection (OR, 3.07; 95% CI: 1.47–6.39; p = 0.002). Avoidance of hypertonic saline (aOR, 2.52; 95% CI: 1.12–5.66; p = 0.029) and having neuropsychiatric disorder (aOR, 2.60; 95% CI: 1.10–6.11; p = 0.025) were associated with undercorrection. In-hospital mortality rate was 12.4% and having CKD and cancer, undercorrection of sodium and presence of severe symptoms were significantly associated with in-hospital mortality.ConclusionSevere hyponatremia in hospitalized patients is associated with substantial mortality. The incidence of non-optimal correction of serum Na is high; under-correction, presence of severe symptoms, chronic kidney disease and cancer were the factors that increase mortality rate.     

Association of serum soluble Fas concentrations and mortality of septic patients

IntroductionScarce data on Fas, one of the main receptors that activates the apoptosis extrinsic pathway, in septic patients exists. Higher blood soluble Fas (sFas) concentrations in non-survivor septic patients compared with survivors have been found in small studies; however, the association of blood sFas concentrations with mortality controlling for sepsis severity has not been stablished due to this small sample size in those studies. Thus, our main objective study was to determine whether an association between blood sFas concentrations and sepsis mortality controlling for sepsis severity exists.MethodsWe included septic patients in this observational and prospective study carried out in three Spanish Intensive Care Units. We obtained serum samples at sepsis diagnosis sepsis for sFas levels determination.ResultsThirty-day non-surviving patients (n = 85) compared to surviving patients (n = 151) had higher serum sFas levels (p < 0.001). We found in multiple logistic regression analysis an association of serum sFas levels with mortality controlling for age and SOFA (OR = 1.004; 95% CI = 1.002–1.006; p < 0.001), and for age and APACHE-II (OR = 1.004; 95% CI = 1.002–1.006; p < 0.001). Serum sFas levels showed and area under the curve for mortality prediction of 71% (95% CI = 65–71%; p < 0.001). Kaplan–Meier analysis showed higher mortality rate in patients with serum sFas levels > 83.5 ng/mL (Hazard ratio = 3.2; 95% CI = 2.1–5.0; p < 0.001).ConclusionsThat an association between blood sFas concentrations and sepsis mortality controlling for sepsis severity exists was our main new finding study.     

Severe acute kidney injury and multiple myeloma: Evaluation of kidney and patient prognostic factors

BackgroundPatients with multiple myeloma (MM) manifesting acute kidney injury (AKI) and who later recover renal function and independence from renal replacement therapy (RRT) are considered to have a better outcome. The aim of this work was to study the factors associated with renal function recovery (independence of hemodialysis) and longer survival in these patients.MethodsA retrospective single center study including patients with a diagnosis of MM and severe AKI, defined as stage 3 of the Kidney Disease: Improving Global Outcomes (KDIGO) criteria: 3.0 times baseline increase in serum creatinine (sCr) or increase in sCr to ≥ 4.0 mg/dL or initiation of RRT, was conducted. Data was registry-based and collected between January 2000 and December 2011. We examined demographic and laboratorial data, presenting clinical features, precipitating factors, need for RRT and chemotherapy. Death was considered the primary endpoint.ResultsLower serum β2-microglobulin was the only independent factor associated with recovery of renal function and independence of RRT (OR 0.95, 95% CI: 0.91–0.99, P = 0.02). The median survival after AKI was 10.7 ± 12.1 months. The factors associated with longer survival were independence of RRT (HR 2.21; 95% CI: 1.08–4.49; P = 0.02), lower CRP (HR 1.07; 95% CI: 1.03–1.12; P = 0.001) and younger age (HR 1.03; 95% CI: 1.01–1.06; P = 0.005).ConclusionsOur study suggests that MM patients with lower serum β2-microglobulin have a higher likelihood of recovering renal function after severe AKI. Independence of RRT, lower CRP and younger age are associated with longer survival.     

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.     

Utility of the neutrophil to lymphocyte ratio for predicting in-hospital mortality after levosimendan infusion in patients with acute decompensated heart failure

BackgroundThe aim of this study was to investigate the effect of a levosimendan infusion on hematological variables in patients with acute decompensated heart failure (ADHF). The predictive value of these variables for in-hospital mortality was also evaluated.MethodsA total of 553 patients (368 males; mean age, 63.4 ± 14.9 years) with acute exacerbations of advanced heart failure (ejection fraction ≤35%) and treated with either dobutamine or levosimendan were included in this retrospective analysis. The patients that received levosimendan therapy were divided into two groups according to in-hospital mortality: group 1 (21%) included patients who died during hospitalization (n = 45), while group 2 (79%) included patients with a favorable outcome (n = 174) after levosimendan infusion. Changes in several hematological variables between admission and the third day after levosimendan infusion were evaluated.ResultsThe demographic characteristics and risk factors of the two groups were similar. A comparison of changes in laboratory variables after the infusion of levosimendan revealed significant improvement only in those patients who had not died (group 2) during hospitalization. The neutrophil to lymphocyte (N/L) ratio after levosimendan infusion was an independent predictor of in-hospital mortality (odds ratio: 1.310, 95% CI: 1.158–1.483, p < 0.001). In a receiver-operating characteristic curve analysis, a value of 5.542 for the N/L ratio after levosimendan administration was identified as an effective cut-off point for predicting in-hospital mortality (area under the curve = 0.737; 95% confidence interval = 1100–1301; p < 0.001).ConclusionsLevosimendan treatment was associated with significant changes in hematological variables in patients with ADHF. A sustained higher N/L ratio after levosimendan infusion is associated with an increased risk of in-hospital mortality in patients with ADHF.     

Acute kidney injury and chronic kidney disease after liver transplant: A retrospective observational study

Background and rationaleChronic kidney disease remains an important risk factor for morbidity and mortality among LT recipients, but its exact incidence and risk factors are still unclear.Material and methodsWe carried out a retrospective cohort study of consecutive adults who underwent liver transplant (January 2009–December 2018) and were followed (at least 6 months) at our institution. CKD was defined following the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guidelines. Long-term kidney function was classified into 4 groups: no CKD (eGFR, ≥60 mL/min/1.73 m²), mild CKD (eGFR, 30–59 mL/min/1.73 m²), severe CKD (eGFR, 15–29 mL/min/1.73 m²), and end-stage renal disease (ESRD).ResultsWe enrolled 410 patients followed for 53.2 ± 32.6 months. 39 had CKD at baseline, and 95 developed de novo CKD over the observation period. There were 184 (44.9%) anti-HCV positive, 47 (11.5%) HBsAg positive, and 33 (8.1%) HBV/HDV positive recipients. Recipient risk factors for baseline CKD were advanced age (P = 0.044), raised levels of serum uric acid (P < 0.0001), and insulin dependent DM (P = 0.0034). Early post-transplant AKI was common (n = 95); logistic regression analysis found that baseline serum creatinine was an independent predictor of early post-LT AKI (P = 0.0154). According to our Cox proportional hazards model, recipient risk factors for de novo CKD included aging (P < 0.0001), early post-transplant AKI (P = 0.007), and baseline serum creatinine (P = 0.0002). At the end of follow-up, there were 116 LT recipients with CKD – 109 (93.9%) and 7 (6.1%) had stage 3 and advanced CKD, respectively. Only two of them are undergoing long-term dialysis.ConclusionThe incidence of CKD was high in our cohort of LT recipients, but only a slight decline in kidney function over time was recorded. Prevention of post-transplant AKI will improve kidney function in the long run. We need more studies to analyze the function of kidneys among LT recipients over extended follow-ups and their impact on mortality.     

Acute kidney injury in an internal medicine ward in a Portuguese quaternary hospital

BackgroundThe term acute kidney injury (AKI) was proposed to reflect the wide spectrum of traditional acute renal failure. RIFLE classification stratifies AKI into three classes of severity and two classes of outcome. AKIN classification proposes an improvement regarding RIFLE in the stratification of AKI, while recently published KDIGO guidelines comprise characteristics of both RIFLE and AKIN. There are no published studies on the utility and measure of agreement between classifications in patients admitted to internal medicine wards.MethodsProspective study undertaken in two internal medicine wards in a Portuguese hospital. Patients admitted for a minimum of 72 h, with a diagnosis of AKI or acute-on-chronic kidney disease at admission or during hospitalisation, were included. RIFLE, AKIN and KDIGO criteria were applied for identification of AKI and stratification into risk groups.ResultsSixty-nine patients were included, with a mean age of 79.7 ± 10.0 years and mean GFR of 21.7 ± 8.8 mL/min/1.73 m². Hypovolaemia due to dehydration was the main cause of AKI (53.6%) and, thereby, RIFLE classification identified a higher number of patients as having AKI, compared to AKIN (94.2% vs. 84.1%). Most patients (69.6%) recovered to their baseline renal function, however fifteen patients (21.7%) died, 53.3% presenting more severe kidney disease.ConclusionsOur results demonstrate good concordance and correlation between RIFLE, AKIN and KDIGO criteria for the diagnosis of AKI (p < 0.001 at initial and final assessment). The authors support the need for further improvement of the classification, ultimately through the use of new biomarkers capable of earlier identification of patients at risk.     

Comparison of non-invasive models for predicting liver damage in chronic hepatitis B patients

IntroductionInexpensive blood tests have been well established as alternatives to liver biopsies to evaluate liver fibrosis in CHB patients. Here, we aim to compare their diagnostic accuracy in assessing liver fibrosis and necroinflammation.Patients and methodsA retrospective study was performed to evaluate the predictive value of non-invasive models in chronic hepatitis B patients with liver fibrosis by the area under receiver operating characteristic curve (AUROC). The clinical data of 160 patients were collected from medical records.ResultsOf the 160 consecutive treatment-naïve CHB patients, 29 (16%) had significant fibrosis and 34 (21%) had severe necroinflammation. The AUROC of the gamma-glutamyl transpeptidase to platelet ratio (GPR) (0.761, 95% CI 0.671–0.850) for predicting significant fibrosis was significantly higher than that of the aspartate transaminase-to-platelet ratio index (APRI) (0.680, 95% CI 0.585–0.774, p = 0.034), but comparable with the fibrosis index based on four factors (Fib-4) (0.746, 95% CI 0.656–0.836, p = 0.703), while for predicting severe necroinflammation, the performance of the GPR (AUROC = 0.869, 95% CI 0.800–0.937) was better than the APRI (AUROC = 0.816, 95% CI 0.740–0.892, p = 0.085) and Fib-4 (0.792, 95% CI 0.711–0.873, p = 0.023).DiscussionGPR is a satisfactory model to stage liver fibrosis and to grade necroinflammation activity, representing a convenient non-invasive alternative to liver biopsy in China.     

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.     

Serum ferritin at admission in hospitalized COVID-19 patients as a predictor of mortality

IntroductionSome COVID-19 patients have higher mortality and the responsible factors for this unfavorable outcome is still not well understood.ObjectiveTo study the association between ferritin levels at admission, representing an inflammatory state, and hospital mortality in COVID-19 patients.MethodsFrom May through July 2020, SARS-CoV-2 positive patients with moderate to severe clinical symptoms were evaluated at admission, regarding clinical and laboratory data on renal and hepatic function, hematologic parameters, cytomegalovirus co-infection, and acute phase proteins.ResultsA total of 97 patients were included; mean age = 59.9 ± 16.3 years, 58.8% male, 57.7% non-white, in-hospital mortality = 45.4%. Age, ferritin, C-reactive protein, serum albumin and creatinine were significantly associated with mortality. Ferritin showed area under the curve (AUC) of 0.79 (p < 0.001) for the cut-off of 1873.0 ng/mL, sensitivity of 68.4% and specificity of 79.3% in predicting in-hospital mortality. Age ≥60 years had an odds ratio (OR) of 10.5 (95% CI = 1.8–59.5; p = 0.008) and ferritin ≥1873.0 ng/mL had an OR of 6.0 (95% CI = 1.4–26.2; p = 0.016), both independently associated with mortality based on logistic regression analysis.ConclusionThe magnitude of inflammation present at admission of COVID-19 patients, represented by high ferritin levels, is independently predictive of in-hospital mortality.     

The neutrophil-to-lymphocyte ratio as a marker of vasculitis activity,severe infection and mortality in anca-associated vasculitis: A retrospective study

IntroductionAnti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a multisystemic disease. Despite the improvement in mortality rate since the introduction of immunosuppression, long-term prognosis is still uncertain not only because of the disease activity but also due to treatment associated adverse effects. The neutrophil-to-lymphocyte ratio (NLR) has been demonstrated as an inflammatory marker in multiple settings. In this study, we aimed to investigate the prognostic ability of the NLR in AAV patients.MethodsWe conducted a retrospective analysis of the clinical records of all adult patients with AVV admitted to the Nephrology and Renal Transplantation Department of Centro Hospitalar Universitário Lisboa Norte from January 2006 to December 2019. NLR was calculated at admission. The outcomes measured were severe infection at 3 months and one-year mortality. The prognostic ability of the NLR was determined using the receiver operating characteristic (ROC) curve. A cut-off value was defined as that with the highest validity. All variables underwent univariate analysis to determine statistically significant factors that may have outcomes. Only variables which significantly differed were used in the multivariate analysis using the logistic regression method.ResultsWe registered 45 cases of AVV. The mean age at diagnosis was 67.5 ± 12.1 years and 23 patients were male. The mean Birmingham Vasculitis Activity Score (BVAS) at presentation was 26.0 ± 10.4. Twenty-nine patients were ANCA-MPO positive, 7 ANCA-PR3 positive and 9 were considered negative ANCA vasculitis. At admission, mean serum creatinine (SCr) was 4.9 ± 2.5 mg/dL, erythrocyte sedimentation rate (ESR) was 76.9 ± 33.8 mm/h, hemoglobin was 9.5 ± 1.7 g/dL, C-reactive protein was 13.2 ± 5.8 mg/dL and NLR was 8.5 ± 6.8. Thirty-five patients were treated with cyclophosphamide, eight patients with rituximab for induction therapy. Twenty patients developed severe infection within the first three months after starting induction immunosuppression. In a multivariate analysis, older age (73.6 ± 10.5 vs. 62.6 ± 11.3, p = 0.002, adjusted OR 1.08 [95% CI 1.01–1.16], p = 0.035) and higher NLR (11.9 ± 7.4 vs. 5.9 ± 5.0, p = 0.002, adjusted OR 1.14 [95% CI 1.01–1.29], p = 0.035) were predictors of severe infection at 3 months. NLR ≥4.04 predicted severe infection at 3 months with a sensitivity of 95% and specificity of 52% and the AUROC curve was 0.0794 (95% CI 0.647–0.900). Nine patients died within the first year. Severe infection at 3 months was independently associated with mortality within the first year (OR 6.19 [95% CI 1.12–34.32], p = 0.037).ConclusionsNLR at diagnosis was an independent predictor of severe infection within the first 3 months after immunosuppression start, and severe infection within the first three months was consequently correlated with one-year mortality. NLR is an easily calculated and low-cost laboratory inflammation biomarker and can prove useful in identifying AAV patients at risk of infection and poorer prognosis.     

Facteurs de risque de mortalité hospitalière au cours de l’embolie pulmonaire en milieu de pneumologie

ObjectivesThe objective of our work is to identify the risk factors for hospital mortality during pulmonary embolism in a pneumology department.Material and methodAll patients admitted to the pneumology department of Habib-Bourguiba hospital between 2014 and 2019, with a final diagnosis of PE are analyzed.ResultsOne hundred patients were included, 62% of whom were female, with an average age of 63 ± 16 years. Pulmonary fibrosis was noted in eight patients. On admission, the mean Simplified Pulmonary Embolism Severity Index score was 1.46 ± 1.05. The mean duration of hospitalization was 10.6 ± 7 days. The hospital mortality rate was 12%. The independent risk factors for intra-hospital mortality were arterial hypotension (OR: 6.13; 95% CI: 2.88–14.35; p = 0.001), cancer (OR: 2.66; 95% CI: 1.22–9.54; p = 0.026), a VD/LV ratio at echocardiography > 0.9 (OR: 1.84; 95% CI: 1.06–7.69; p = 0.039) and severe hypoxemia (OR: 4.86; 95% CI: 2.19–11,34; p = 0.006).ConclusionPulmonary embolism mortality remains high despite improvements in diagnostic and therapeutic management. It is important for our country to take these results into consideration for a better management of patients admitted for pulmonary embolism, and to improve survival.     

Clinical utility of low-pressure implantation of drug-eluting stent into very small vessels

BackgroundAlthough drug-eluting stents (DES) reduce restenosis, the best strategy for DES implantation in small vessels has not been established.PurposeWe investigated the clinical usefulness of low-pressure implantation of a 2.5-mm DES for small vessels less than 2.5 mm in diameter.MethodsIn 118 patients, a 2.5-mm DES was implanted for small vessels less than 2.5 mm in diameter between 2007 and 2009 in our hospital. The patients were divided into two groups by initial deployment pressure: low-pressure (LP; n = 46) and nominal-pressure (NP; n = 72).ResultsPatients with impaired glucose tolerance were more frequent (p = 0.02) and the target vessel diameter was significantly smaller (p = 0.01) in the LP group than in the NP group. A smaller minimum lumen diameter (MLD) was obtained (LP: 2.22 ± 0.27 mm vs. NP: 2.34 ± 0.26 mm, p = 0.02) after DES implantation with a smaller balloon-to-artery ratio (p = 0.03) in the LP group. However, at mid-term follow-up (7.7 ± 3.9 months), MLD (p = 0.55) and the binary restenosis rate (LP: 2.6% vs. NP: 11.1%, p = 0.12) were not significantly different between the LP and NP groups. Furthermore, by Kaplan–Meier analysis, the incidence of major adverse cardiac events was not different between the groups during the long-term follow-up (32.4 ± 8.6 months).ConclusionThe present study indicates that low-pressure implantation of 2.5-mm DES for very small vessels may be feasible with regard to short- and long-term clinical outcomes.     

Can systemic immune inflammation index at admission predict in-hospital mortality in chronic kidney disease patients with SARS-CoV-2 infection?

Background and aimPatients with chronic kidney disease (CKD) are susceptible to SARS-CoV-2 infection and more prone to develop severe disease. It is important to know predictors of poor outcomes to optimize the strategies of care.Methods93 patients with CKD and 93 age-sex matched patients without CKD were included in the study. Data on demographic, clinical features, hematological indices and outcomes were noted and compared between the groups. Neutrophile to lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), systemic immune inflammation index (SII) (platelet counts × neutrophil counts/lymphocyte counts) and lymphocyte-to-CRP ratio (LCR) were calculated on admission and the association of these markers with disease mortality in CKD patients was identified.ResultsCKD patients had higher risk of severe disease, and mortality compared to non-CKD patients (72% vs 50.5%, p = 0.003, 36.6% vs 10.8%, p < 0.001, respectively) and were more likely to have higher values of immuno-inflammatory indices (leukocyte count, neutrophil, NLR, SII and C-reactive protein, etc.) and lower level of lymphocyte and LCR. Also, higher levels of NLR, SII, PLR and lower level of LCR were seen in CKD patients who died compared to those recovered. In a receiver operating characteristic curve analysis, NLR, SII, PLR and LCR area under the curve for in-hospital mortality of CKD patients were 0.830, 0.811, 0.664 and 0.712, respectively. Among all parameters, NLR and SII gave us the best ability to distinguish patients with higher risk of death. Based on the cut-off value of 1180.5, the sensitivity and specificity of the SII for predicting in-hospital mortality were found to be 67.5% and 79.6%, respectively. The corresponding sensitivity and specificity of the NLR were 85.2% and 66.1%, respectively, at the cut-off value of 5.1. Forward stepwise logistic regression analysis showed that NLR (≥5.1), SII (≥1180.5) and LCR (≤9) were predictors for in-hospital mortality.ConclusionWe report for the first time that SII is able to distinguish COVID-19 infected CKD patients of worse survival and it is as powerful as NLR in this regard. As SII is easily quantified from blood sample data, it may assist for early identification and timely management of CKD patients with worse survival.     

Hyponatremia is an independent predictor of adverse clinical outcomes in hospitalized patients due to worsening heart failure

Background and purposeHyponatremia is common and is associated with poor in-hospital outcomes in patients hospitalized with heart failure (HF). However, it is unknown whether hyponatremia is associated with long-term adverse outcomes. The purpose of this study was to clarify the characteristics, clinical status on admission, and management during hospitalization according to the serum sodium concentration on admission, and determine whether hyponatremia was associated with in-hospital as well as long-term outcomes in 1677 patients hospitalized with worsening HF on index hospitalization registered in the database of the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD).Methods and subjectsWe studied the characteristics and in-hospital treatment in 1659 patients hospitalized with worsening HF by using the JCARE-CARD database. Patients were divided into 2 groups according to serum sodium concentration on admission <135 mEq/mL (n = 176; 10.6%) or ≥135 mEq/mL (n = 1483; 89.4%).ResultsThe mean age was 70.7 years and 59.2% were male. Etiology was ischemic in 33.9% and mean left ventricular ejection fraction was 42.4%. After adjustment for covariates, hyponatremia was independently associated with in-hospital death [adjusted odds ratio (OR) 2.453, 95% confidence interval (CI) 1.265–4.755, p = 0.008]. It was significantly associated also with adverse long-term (mean 2.1 ± 0.8 years) outcomes including all-cause death (OR 1.952, 95% CI 1.433–2.657), cardiac death (OR 2.053, 95% CI 1.413–2.983), and rehospitalization due to worsening HF (OR 1.488, 95% CI 1.134–1.953).ConclusionsHyponatremia was independently associated with not only in-hospital but also long-term adverse outcomes in patients hospitalized with worsening HF.     

Prognostic Significance of Acute Kidney Injury After Reperfused ST-Elevation Myocardial Infarction: Synergistic Acceleration of Renal Dysfunction and Left Ventricular Remodeling

BackgroundAcute kidney injury (AKI) after myocardial infarction is associated with poor clinical outcome. However, mechanisms of the adverse effect of AKI on clinical outcome after reperfused ST-elevation myocardial infarction (STEMI) have not been fully elucidated.Methods and ResultsWe examined 141 consecutive patients with reperfused first anterior STEMI. AKI was defined as an increase in serum creatinine of ≥0.3 mg/dL within 48 hours after admission. Patients with AKI had higher incidence of in-hospital cardiac death (P = .0004) and major adverse cardiac events (MACE, P = .020) during a mean of 39 ± 40 (range, 1 to 96) months than those without, in association with adverse left ventricular (LV) remodeling. White blood cell count on admission and peak C-reactive protein were higher in patients with than those without AKI. Plasma norepinephrine on admission, interleukin-6, brain natriuretic peptide, and malondialdehyde-modified low-density lipoprotein 2 weeks after STEMI were higher in patients with AKI than those without AKI. Cox proportional hazards model analysis revealed AKI was an independent predictor of MACE (hazard ratio = 2.38, P = .019).ConclusionsAKI was a strong predictor of MACE in association with adverse LV remodeling. Enhanced inflammatory response, oxidative stress, and neurohormonal activation may synergistically accelerate renal dysfunction and LV remodeling after STEMI.     

Impact of diabetes on hospital adverse cardiovascular outcomes in acute coronary syndrome patients: Data from the Saudi project of acute coronary events

BackgroundDiabetes mellitus (DM) is a major public health problem in Saudi Arabia. DM patients who present with acute coronary syndrome (ACS) have worse cardiovascular outcomes. We characterized clinical features and hospital outcomes of diabetic patients with ACS in Saudi Arabia.MethodsACS patients enrolled in the Saudi Project for Assessment of Acute Coronary Syndrome (SPACE) study from December 2005 to December 2007, either with DM or newly diagnosed during hospitalization were eligible. Baseline demographics, clinical presentation, therapies, and in-hospital outcomes were compared with non-diabetic patients.ResultsOf the 5055 ACS patients enrolled in SPACE, 2929 (58.1%) had DM (mean age 60.2 ± 11.5, 71.6% male, and 87.6% Saudi nationals). Diabetic patients had higher risk-factor (e.g., hypertension, hyperlipidemia) prevalences and were more likely to present with non–ST-elevation myocardial infarction (40.2% vs. 31.4%, p < 0.001), heart failure (25.4% vs. 13.9%, p < 0.001), significant left ventricular systolic dysfunction and multi-vessel disease. Diabetic patients had higher in-hospital heart failure, cardiogenic shock, and re-infarction rates. Adjusted odds ratio for in-hospital mortality in diabetic patients was 1.83 (95% CI, 1.02–3.30, p = 0.042).ConclusionsA substantial proportion of Saudi patients presenting with ACS have DM and a significantly worse prognosis. These data highlight the importance of cardiovascular preventative interventions in the general population.