Intensities of Renal Replacement Therapy in Acute Kidney Injury: A Systematic Review and Meta-Analysis

Background and objectives: Clinical trials of the intensity of renal replacement therapy (RRT) for people with acute kidney injury (AKI) have produced conflicting results. A systematic review and meta-analysis was undertaken to assess the effect of different intensities of RRT on all-cause mortality and renal recovery in AKI patients.Design, setting, participants, & measurements: MEDLINE, EMBASE, and the Cochrane Library database were systematically searched for trials published between 1950 and 2009. Inclusion criteria were completed, prospective, adult-population, randomized controlled studies. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated. Summary estimates of RR were obtained using a random effects model. Heterogeneity, metaregression, publication bias, and subgroup analyses were conducted.Results: Eight trials were identified that provided data on 3841 patients and 1808 deaths. More intense RRT (35 to 48 ml/kg per h or equivalent) had no overall effect on the risk of death (RR 0.89, 95% CI 0.76 to 1.04, P = 0.143) or recovery of renal function (RR 1.12, 95% CI 0.95 to 1.31, P = 0.181) compared with less-intensive regimens (20 to 25 ml/kg per h or equivalent). Significant heterogeneity was identified with contributing factors including publication year (P = 0.004) and Jadad score (P = 0.048).Conclusions: Within the intensity ranges studied, higher intensity RRT does not reduce mortality rates or improve renal recovery among patients with AKI. The results do not negate the importance of RRT intensity in the treatment of AKI patients but rather reinforce the need to better understand the effects of treatment modalities, doses, and timing in this varied, high-risk population.Acute kidney injury (AKI) is an increasingly common condition associated with significant morbidity and mortality. In its most severe form, necessitating renal replacement therapy (RRT), it is associated with up to 60% in-hospital mortality (1). Two large, multicenter randomized controlled trials assessing the effect of different intensities of RRT on mortality in severe AKI have been recently published (2,3). Neither study demonstrated a survival benefit for more intensive compared with less intensive RRT, nor a significant difference in rates of recovery of renal function. This contrasts the findings of earlier studies that reported a significant mortality benefit associated with intensive treatment (4,5). Thus we undertook a systematic review and meta-analysis to assess the totality of the currently available evidence regarding the effect of different intensities of RRT on mortality and renal recovery in people with AKI in the intensive care unit (ICU).     

Impact of Left Ventricular Outflow Tract Calcification on Outcomes Following Transcatheter Aortic Valve Replacement

BackgroundWe aimed to determine left ventricular outflow tract (LVOT) calcification impact following transcatheter aortic valve replacement (TAVR) with contemporary transcatheter heart valves. Recent studies reported a higher rate of 2-year mortality with greater than moderate LVOT calcium, but they have not established a reliable and validated method to assess the degree of valve calcification and utilized first-generation valves for their analyses.Materials/methodsWe conducted a retrospective analysis of patients who underwent TAVR at our institution from 2013 through 2017 with available valves. LVOT calcification quantification was assessed as a continuous variable.ResultsWe included 273 patients: 179 had a non-calcified LVOT (NOLVOTCA) and 96 had a calcified LVOT (LVOTCA). Balloon post-dilatation (BPD) was utilized in 31.3% of LVOTCA vs. 19% of NOLVOTCA (p = 0.029). The Evolut R valve was used in 40.6% vs. 23.4% (p = 0.002), while the Sapien 3 was used in 59.4% vs. 76.6% (p = 0.004), for the LVOTCA and NOLVOTCA, respectively. Paravalvular leak (PVL) at hospital discharge was higher in LVOTCA (47.5%) versus NOLVOTCA (29.1%; p = 0.004). All-cause mortality (11.5% vs. 10.1%; p = 0.5) and need for permanent pacemaker implantation were similar between the groups. There was a positive trend between LVOT calcification volume and the probability of any PVL (OR 1.012; 95% CI, 0.99–1.02).ConclusionsTAVR performed in patients with calcified LVOT is safe, but LVOT calcification adversely impacts TAVR outcomes, with a higher PVL rate despite greater usage of BPD. Calcium quantification did not predict any PVL degree post-TAVR.     

Impact of Left Ventricular Outflow Tract Calcification on Procedural Outcomes After Transcatheter Aortic Valve Replacement

ObjectivesThis study aimed to systematically assess the importance of left ventricular outflow tract (LVOT) calcification on procedural outcomes and device performances with contemporary transcatheter heart valve (THV) systems.BackgroundLVOT calcification has been associated with adverse clinical outcomes after transcatheter aortic valve replacement (TAVR). However, the available evidence is limited to observational data with modest numbers and incomplete assessment of the effect of the different THV systems.MethodsIn a retrospective analysis of a prospective single-center registry, LVOT calcification was assessed in a semiquantitative fashion. Moderate or severe LVOT calcification was documented in the presence of 2 nodules of calcification, or 1 extending >5 mm in any direction, or covering >10 % of the perimeter of the LVOT.ResultsAmong 1,635 patients undergoing TAVR between 2007 and 2018, moderate or severe LVOT calcification was found in 407 (24.9%). Patients with moderate or severe LVOT calcification had significantly higher incidences of annular rupture (2.3% vs. 0.2%; p < 0.001), bailout valve-in-valve implantation (2.9% vs. 0.8%; p = 0.004), and residual aortic regurgitation (11.1% vs. 6.3%; p = 0.002). Balloon-expandable valves conferred a higher risk of annular rupture in the presence of moderate or severe LVOT calcification (4.0% vs. 0.4%; p = 0.002) as compared with the other valve designs. There was no significant interaction of valve design or generation and LVOT calcification with regard to the occurrence of bailout valve-in-valve implantation and residual aortic regurgitation.ConclusionsModerate or severe LVOT calcification confers increased risks of annular rupture, residual aortic regurgitation, and implantation of a second valve. The risk of residual aortic regurgitation is consistent across valve designs and generations. (SWISS TAVI Registry; NCT01368250)     

左室重量指数与复杂性室性心律失常

目的探讨左室重量指数预测复杂性室性心律失常的临床价值。方法对１１６例轻、中度高血压病人行超声心动图和动态心电图监测。４０例健康人作对照组。结果复杂性室性心律失常发生率在左室重量指数法和左室实测值法左室肥厚组分别为３６．９％，１３．９％，二者差异显著（Ｐ＜０．０１）。结论左室重量指数法左室肥厚对预测复杂室性心律失常有重要价值。     

An Unusual Left Ventricular Apical Mass

Left ventricular apical masses constitute a rare finding. Imaging properties together with the clinical history of the patient usually allow an etiologic definition. We report a challenging case of an ambiguous left ventricular apical mass of uncertain nature till histological examination. Points of interest were singular clinical history and echocardiographic findings, although not conclusive in hypothesis generating. Furthermore to the best of our knowledge, this is one of the rare attempt to excise a deep left ventricular mass with a mini-invasive surgical approach.     

左心室壁瘤的外科治疗

外科治疗左心室壁瘤可以有效保护心肌,改善病人预后。近年来,更注重在切除左心室壁瘤的同时,应尽可能恢复左室的正常形态。     

Left Ventricular Mass Estimation by Echocardiography

Echocardiographic determination of left ventricular mass provides prognostic information that is independent of blood pressure. This prognostic information has a graded and continuous relationship with outcome, and is independent of traditional risk factors. This article addresses the prognostic and clinical utility of echocardiography for detection of left ventricular mass. Recommendations will be offered regarding the use of echocardiography for screening in select individuals.     

Aspects of Left Ventricular Morphology Outperform Left Ventricular Mass for Prediction of QRS Duration

Background: The knowledge of the case‐specific normal QRS duration in each individual is needed when determining the onset, severity and progression of the heart disease. However, large interindividual variability even of the normal QRS duration exists. The aims of the study were to develop a model for prediction of normal QRS complex duration and to test it on healthy individuals. Methods: The study population of healthy adult volunteers was divided into a sample for development of a prediction model (n = 63) and a testing sample (n = 30). Magnetic resonance imaging data were used to assess anatomical characteristics of the left ventricle: the angle between papillary muscles (PM _A ), the length of the left ventricle (LV_L) and left ventricular mass (LV_M). Twelve‐lead electrocardiogram (ECG) was used for measurement of the QRS duration. Multiple linear regression analysis was used to develop a prediction model to estimate the QRS duration. The accuracy of the prediction model was assessed by comparing predicted with measured QRS duration in the test set. Results: The angle between PM _A and the length of the LV_L were statistically significant predictors of QRS duration. Correlation between QRS duration and PM _A and LV _L was r = 0.57, P = 0.0001 and r = 0.45, P = 0.0002, respectively. The final model for prediction of the QRS was: QRS_Predicted= 97 + (0.35 × LV_L) ? (0.45 × PM_A). The predicted and real QRS duration differed with median 1 ms. Conclusions: The model for prediction of QRS duration opens the ability to predict case‐specific normal QRS duration. This knowledge can have clinical importance, when determining the normality on case‐specific basis. Ann Noninvasive Electrocardiol 2010;15(2):124–129     

Regression of Left Ventricular Mass After Transcatheter Aortic Valve Replacement: The PARTNER Trials and Registries

BackgroundGreater early left ventricular mass index (LVMi) regression is associated with fewer hospitalizations 1 year after transcatheter aortic valve replacement (TAVR). The association between LVMi regression and longer-term post-TAVR outcomes is unclear.ObjectivesThe purpose of this study was to determine the association between LVMi regression at 1-year post-TAVR and clinical outcomes between 1 and 5 years.MethodsAmong intermediate- and high-risk patients who received TAVR in the PARTNER (Placement of Aortic Transcatheter Valves) I, II, and S3 trials or registries and were alive at 1 year, we included patients with baseline moderate or severe left ventricular hypertrophy (LVH) and paired measurements of LVMi at baseline and 1 year. The associations between LVMi regression (percent change between baseline and 1 year) and death or rehospitalization from 1 to 5 years were examined.ResultsAmong 1,434 patients, LVMi was 146 g/m² (interquartile range [IQR]: 133 to 168 g/m²) at baseline and decreased 14.5% (IQR: 4.2% to 26.1%) to 126 g/m² (IQR: 106 to 148 g/m²) at 1 year. After adjustment, greater LVMi regression at 1 year was associated with lower all-cause death (adjusted hazard ratio [aHR]: 0.95 per 10% decrease in LVMi; 95% confidence interval [CI]: 0.91 to 0.98; p = 0.004; aHR of the quartile with greatest vs. least LVMi regression: 0.61; 95% CI: 0.43 to 0.86; p = 0.005). Severe LVH at 1 year was observed in 39%, which was independently associated with increased all-cause death (aHR of severe LVH vs. no LVH: 1.71; 95% CI: 1.20 to 2.44; p = 0.003). Similar associations were found for rates of cardiovascular mortality and rehospitalization.ConclusionsAmong patients with moderate or severe LVH treated with TAVR who are alive at 1 year, greater LVMi regression at 1 year is associated with lower death and hospitalization rates to 5 years. These findings may have implications for the timing of valve replacement and the role of adjunctive medical therapy after TAVR.     

阻塞性睡眠呼吸暂停对血压、内皮功能及左室质量的影响

目的探讨阻塞性睡眠呼吸暂停综合征(OSAS)对动态血压、血管内皮功能、肾素血管紧张素醛固酮系统(RAAS)及左室质量的影响。方法将130例有或无OSAS的高血压患者和血压正常者分为4组:对照组(NS组)、单纯高血压组(EH组)、单纯OSAS组及OSAS高血压组(OSAS EH组),进行了动态血压、超声心动图、血一氧化氮(NO)、内皮素(ET)、肾素(PRA)、血管紧张素Ⅱ(AngⅡ)和醛固酮(Ald)测定。结果(1)不论有无高血压的OSAS患者,夜间血压下降率<10%,比无OSAS组较多见(P<0.001);且OSAS EH组血压较EH组高(P<0.05～0.001)。(2)OSAS EH组和OSAS组ET(83.0±5.8,44.0±5.0)ng/L升高,与NS组比较差异有显著性(P<0.001)。而OSAS EH组与OSAS组NO(31.1±4.4,45.7±4.4)μmol/L下降,与NS组比较差异有显著性(P<0.001)。(3)血PRA、AngⅡ、Ald含量在OSAS EH组及OSAS组升高,与NS组比较差异有显著性(P<0.001)。(4)OSAS EH组、OSAS组左室质量指数(LVMI)(159.8±8.4,135.3±6.0)g/m2与NS组(121.2±6.5)g/m2比较,差异有显著性(P<0.001),且OSAS EH组与EH组(134.9±5.7)g/m2比较,差异有显著性(P<0.001)。结论OSAS患者血压昼夜节律消失,且伴有血管内皮功能紊乱、RAAS激活,由此进一步加重对心脏等靶器官的损害。     

阻塞性睡眠呼吸暂停对血压、内皮功能及左室质量的影响

目的探讨阻塞性睡眠呼吸暂停综合征(OSAS)对动态血压、血管内皮功能、肾素血管紧张素醛固酮系统(RAAS)及左室质量的影响.方法将130例有或无OSAS的高血压患者和血压正常者分为4组:对照组(NS组)、单纯高血压组(EH组)、单纯OSAS组及OSAS高血压组(OSAS EH组),进行了动态血压、超声心动图、血一氧化氮(NO)、内皮素(ET)、肾素(PRA)、血管紧张素Ⅱ(Ang Ⅱ)和醛固酮(Ald)测定.结果 (1)不论有无高血压的OSAS患者,夜间血压下降率<10%,比无OSAS组较多见(P<0.001);且OSAS EH组血压较EH组高(P<0.05～0.001).(2)OSAS EH组和OSAS组ET(83.0±5.8,44.0±5.0)ng/L升高,与NS组比较差异有显著性(P<0.001).而OSAS EH组与OSAS组NO(31.1±4.4,45.7±4.4)μmol/L下降,与NS组比较差异有显著性(P<0.001).(3)血PRA、Ang Ⅱ、Ald含量在OSAS EH组及OSAS组升高,与NS组比较差异有显著性(P<0.001).(4)OSAS EH组、OSAS组左室质量指数(LVMI)(159.8±8.4,135.3±6.0) g/m2与NS组(121.2±6.5)g/m2比较,差异有显著性(P<0.001),且OSAS EH组与EH组(134.9±5.7)g/m2比较,差异有显著性(P<0.001).结论 OSAS患者血压昼夜节律消失,且伴有血管内皮功能紊乱、RAAS激活,由此进一步加重对心脏等靶器官的损害.