Prognostic Impact of Pre- and Post-Procedural Renal Dysfunction on Late All-Cause Mortality Outcome Following Transcatheter Edge-to-Edge Repair of the Mitral Valve: A Systematic Review and Meta-Analysis

IntroductionImpaired renal function, a well-recognized complication of severe heart failure is associated with adverse outcomes following cardiovascular interventions. There are conflicting data reported about its impact on late all-cause mortality following transcatheter edge-to-edge mitral valve repair (TEER) with MitraClip (MC) implantation.AimTo evaluate the impact of pre- and post- procedural renal dysfunction on late (≥12 months) all-cause mortality following TEER with MC.MethodsElectronic databases PubMed, Embase, and Web of Science were systematically reviewed from inception to February 2021 for studies evaluating MC outcomes, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A random-effects model meta-analysis was performed and heterogeneity of the included studies was assessed using I-squared test.ResultsOut of 2606 articles, 15 studies with 19,545 patients were included. Pre-procedural renal dysfunction i.e. chronic kidney disease (CKD) was independently associated with higher late all-cause mortality (Hazard ratio [HR] 1.57, 95% CI 1.25–1.97, I² = 57%) after TEER with MC. A similar association was observed irrespective of CKD severity (HR 1.62 95% CI 1.21–2.16, I² = 0% and HR 2.86, 95% CI 1.87–4.39, I² = 26% for CKD stage 3 and ≥ stage 4 respectively). In addition, the development of post-procedural renal dysfunction was independently associated with higher late all-cause mortality (HR = 2.32, 95% CI 1.71–3.15, I² = 42%) after TEER with MC.ConclusionPre- and post-procedural renal dysfunction is a strong independent predictor of late all-cause mortality following TEER with MC and this should be considered during periprocedural planning for these patients.     

Pre-existing chronic kidney disease and acute kidney injury among critically ill patients

BackgroundThe impact of pre-existing chronic kidney disease (CKD) and acute kidney injury (AKI) on health outcomes in critically ill patients is unclear. Yet, CKD complicated by AKI in critically ill patients is common.Objectives: To compare risk of death within one-month of admission in critically ill patients with and without pre-existing CKD who developed AKI.MethodsA multicenter retrospective comparative study using medical records review was conducted. Study participants consisted of 826 adult patients who received mechanical ventilation for at least 6 h in the critical care units from January 2012 to December 2017. Assessment of kidney function was established by serum creatinine. Severity and staging of AKI were defined using RIFLE criteria: Risk, Injury, Failure, Loss and End stage of renal disease. Chronic kidney disease was defined as eGFR > 60 ml/mg/1.73 m² on admission.ResultsPre-existing CKD was present in 55% of patients and 7% had AKI within 7 days of admission. The overall mortality rate among these patients was 87.3%. The mortality rate was highest in patients with CKD (70.1%) followed by that of patients without pre-existing CKD but with AKI (20.7%) and that of patients with pre-existing CKD (7.1%) and AKI. Risks associated with mortality were APACHE II score (1.03; 95% CI 1.02–1.05;(P<0.001) and AKI (1.68; 95% CI 1.12–2.5;P<0.01) in patients with pre-existing CKD. Only APACHI-II (1.03; 95% CI 1.0–1.1; p < 0.001) was predictive of death in patients without pre-existing CKD.Conclusion: Pre-existing comorbid CKD increases risks of death among critically ill patients compared to patients without CKD and regardless of whether they develop AKI or not. Early identification of CKD and recognition of the risk for mortality among these patients may result in earlier intervention that could reduce mortality.     

Comparison of Coronary Artery Bypass Grafting and Drug-Eluting Stents in Patients with Left Main Coronary Artery Disease and Chronic Kidney Disease: A Systematic Review and Meta-Analysis

BackgroundTreatment of left main coronary artery disease (LMCAD) in patients with chronic kidney disease (CKD) with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) remains controversial. Therefore, we performed a meta-analysis to evaluate the optimal choice of therapy when treating LMCAD in patients with CKD.MethodWe performed an electronic database search of Pubmed, Embase, and Cochrane Library for all studies that compared PCI with CABG when treating LMCAD in the setting of CKD. Major adverse cardiac and cerebrovascular events (MACCE) were the primary outcome. Secondary outcomes included myocardial infarction (MI), cerebrovascular events, all-cause mortality, and repeat revascularization.ResultsOur analysis included 5 studies (2 randomized controlled trial and 3 retrospective) representing a total of 1212 patients. Mean follow up was 3.4 ± 1.3 years. Our study demonstrated a significant reduction in MACCE for patients treated with CABG compared with PCI (odd ratio [OR] 0.72; 95% confidence interval [CI] 0.55–0.95, P = 0.02, I² = 0%). We also found a significant reduction in both MI (OR 0.55; 95% CI 0.34–0.87; P = 0.01; I² = 0%) and repeat revascularization (OR 0.22; 95% CI 0.10–0.51; P < 0.001, I² = 63%) in the CABG group. However, CABG was associated with increased risks of cerebrovascular disease events compared with PCI (OR 2.04; 95% CI 1.02–4.08; P = 0.04, I² = 0%).ConclusionIn patients with CKD requiring LMCAD intervention, CABG is associated with a lower risk of MACCE, MI, and repeat revascularization, however it was associated with an increased risk of cerebrovascular accidents when compared to patients who received PCI therapy. Further RCTs with sufficient power are required to confirm these findings.     

Acute Kidney Injury Following Aortic Valve Replacement in Patients Without Chronic Kidney Disease

BackgroundThe data on acute kidney injury (AKI) in patients without chronic kidney disease (CKD) after transcatheter aortic valve replacement (TAVR) are limited. The study sought to compare the incidence of AKI and its impact on 5-year mortality after TAVR and surgical aortic valve replacement (SAVR) in patients without CKD.MethodsThis registry included data from 6463 consecutive patients who underwent TAVR or SAVR. CKD was defined as estimated glomerular filtration rate <60 mL/min/1.73 m². AKI was defined according to the Kidney Disease Improving Global Outcomes criteria. For sensitivity analysis, propensity-score matching between TAVR and SAVR was performed.ResultsThe study included 4555 consecutive patients (TAVR, n = 1215 and SAVR, n = 3340) without CKD. Propensity-score matching identified 542 pairs. Patients who underwent TAVR had a significantly lower incidence of AKI in comparison to those who underwent SAVR (unmatched 4.7% vs 16.4%, P < 0.001, multivariable analysis: odds ratio, 0.29, 95% confidence interval [CI], 0.20-0.41; matched 5.9% vs 19.0%, P < 0.001). Patients with AKI had significantly increased 5-year mortality compared with those without AKI (unmatched 36.0% vs 19.1%, log-rank P < 0.001; matched 36.3% vs 24.0%, log-rank P < 0.001). The adjusted hazard ratios for 5-year mortality were 1.58 (95% CI, 1.20-2.08) for AKI grade 1, 3.27 (95% CI, 2.09-5.06) for grade 2, and 4.82 (95% CI, 2.93-8.04) for grade 3.ConclusionsTAVR in patients without CKD was associated with a significantly less frequent incidence of AKI compared with SAVR. AKI significantly increased the risk of 5-year mortality after either TAVR or SAVR, and increasing severity of AKI was incrementally associated with 5-year mortality.     

Kidney dysfunction and short term all-cause mortality after transcatheter aortic valve implantation

BackgroundAcute kidney injury (AKI) after transcatheter aortic valve implantation (TAVI) has been associated with worse outcomes. However, the impact on outcome of AKI in TAVI-patients is not well established.MethodsInoperable patients with severe aortic stenosis (AS) undergoing TAVI in 2010-2018 were enrolled in this study. AKI and chronic kidney disease (CKD) were defined according to KDIGO guidelines. Patients were divided in two groups according to post-procedural AKI development. The primary endpoint was 30-day all-cause mortality across the two groups.ResultsA total of 373 patients (mean age 82.3 ± 6) were analyzed. Compared to non-AKI patients, those who developed AKI, were treated more frequently with trans-apical TAVI (66% vs 35%, p<0.01), with greater amount of contrast medium (200.6 vs 170.4 ml, p=0.02) and in presence of clinically significant peripheral artery disease (PAD, 33% vs 21%, p=0.04). Trans-apical access (OR 3.24, 95% CI 1.76-5.60, p<0.01) was associated with a 3-fold risk of AKI. After adjustment for age, Society of Thoracic Surgery risk score (STS), PAD, access type, EF and contrast medium amount, patients with AKI presented an increased risk of 30-day all-cause mortality (HR=1.25, 95%CI 1.09-1.69, p=0.008). Patients with CKD IV and V, who developed AKI, presented a 9-fold 30-day mortality risk (HR=9.71, 95% CI 2.40-39.2, p=0.001).ConclusionIn our analysis, AKI was a strong predictor of 30-day all-cause mortality. Particularly, patients with severe CKD with AKI showed the highest 30-day mortality risk. Thus, this group of patients might benefit from closer monitoring and specific kidney protection therapies.     

Accelerated-strategy renal replacement therapy for critically ill patients: A systematic review and meta-analysis

Background:The aim of this study was to investigate the clinical effect and safety of accelerated-strategy initiation of renal replacement therapy (RRT) in critically ill patients.Methods:PubMed, Embase, OVID, EBSCO, and the Cochrane Library databases were searched for relevant articles from inception to December 30, 2020. Only RCTs that compared the clinical efficacy and safety between accelerated-strategy RRT and standard-strategy RRT among critically ill adult patients with acute kidney injury (AKI) were included. The primary outcome was 28-day mortality.Results:A total of 5279 patients in 12 RCTs were included in this meta-analysis. The 28-day mortality rates of patients treated with accelerated and standard RRT were 37.3% (969/2596) and 37.9% (976/2573), respectively. No significant difference was observed between the groups (OR, 0.92; 95% CI, 0.70–1.12; I² = 60%). The recovery rates of renal function were 54.5% and 52.5% in the accelerated- and standard-RRT groups, respectively, with no significant difference (OR, 1.03; 95% CI, 0.89–1.19; I² = 56%). The rate of RRT dependency was similar in the accelerated- and standard-RRT strategies (6.7% vs 5.0%; OR, 1.11; 95% CI, 0.71–1.72; I² = 20%). The accelerated-RRT group displayed higher risks of hypotension, catheter-related infection, and hypophosphatemia than the standard-RRT group (hypotension: OR, 1.26; 95% CI, 1.10–1.45; I² = 36%; catheter-related infection: OR, 1.90; 95% CI, 1.17–3.09; I² = 0%; hypophosphatemia: OR, 2.11; 95% CI, 1.43–3.15; I² = 67%).Conclusions:Accelerated RRT does not reduce the risk of death and does not improve the recovery of kidney function among critically ill patients with AKI. In contrast, an increased risk of adverse events was observed in patients receiving accelerated RRT. However, these findings were based on low quality of evidence. Further large-scale RCTs is warranted.     

Association between the antepartum oral glucose tolerance test and the risk of future diabetes mellitus among women with gestational diabetes: A systematic review and meta-analysis

ObjectivesThe antepartum oral glucose tolerance test (OGTT) has re-emerged as associated with risk of diabetes among women with gestational diabetes (GDM). This systematic review summarized evidence on associations between antepartum OGTT and risk of diabetes in GDM (PROSPERO CRD42018100316).MethodsMEDLINE, EMBASE, Web of Science, and CENTRAL were searched from January 1, 1982 to February 2020. Studies assessing associations between antepartum OGTT and risk of diabetes among women with GDM were included. Data on study characteristics, participants, OGTT values, and diabetes outcomes were extracted. Estimates on the association between antepartum OGTT and diabetes at follow-up were recorded. Pooled odds ratios for developing diabetes were calculated by study design.Findings and conclusionsOf 6423 citations, 17 studies were included. Both elevated fasting blood glucose (FBG; OR: 3.62 ([95% CI 1.30, 10.12], I² = 36%, p < 0.05)) and 2 h OGTT (OR: 3.96 [1.17, 13.40], I² = 87%, p < 0.05) were associated with diabetes. These associations were attenuated (FBG: OR: 1.91 ([95% CI 0.80, 24.54], I² = 83%, p = NS) and 1.58 ([95% CI 0.92, 2.74] I² = 83%, p = NS) for prospective and retrospective data, respectively; 2 h OGTT: ORa: 1.95 ([95% CI 0.43, 8.93], I² = 94%, p = NS)) after adjustments for common confounders. Further research is needed before clinical recommendations can be made.     

Acute Kidney Injury Following Tricuspid Transcatheter Edge-to-Edge Repair

BackgroundLittle is known about the incidence and clinical relevance of postprocedural acute kidney injury (AKI) in patients undergoing transcatheter edge-to-edge repair (TEER) for tricuspid regurgitation (TR).ObjectivesThe aim of this study was to investigate the prognostic impact of postprocedural AKI following TEER for TR.MethodsTwo hundred sixty-eight patients who underwent TEER for TR at 2 centers were retrospectively analyzed. Postprocedural AKI was defined as an increase in serum creatinine of ≥0.3 mg/dL within 48 hours or ≥50% within 7 days after the procedure compared with baseline. The association between AKI and the composite outcome, consisting of all-cause mortality and rehospitalization for heart failure within 1 year after the procedure, was determined.ResultsThe mean age of the patients was 79.0 ± 6.8 years, and 43.3% were men. Postprocedural AKI occurred in 42 patients (15.7%). Age, male sex, an estimated glomerular filtration rate of <60 mL/min/1.73 m², and absence of procedural success were associated with the occurrence of AKI. Patients with AKI had a higher incidence of in-hospital mortality than those without AKI (9.5% vs 0.9%; P = 0.006). Moreover, AKI was associated with the incidence of the composite outcome within 1 year after TEER for TR (adjusted HR: 2.39; 95% CI: 1.45-3.94; P = 0.001).ConclusionsPostprocedural AKI occurred in 15.7% of patients undergoing TEER for TR, despite the absence of iodinated contrast agents, which was associated with worse clinical outcomes. These findings highlight the clinical impact of AKI following TEER for TR and should help in identifying patients at high risk for AKI.     

Ticagrelor for Asian patients with acute coronary syndrome in real-world practice: A systematic review and meta-analysis of observational studies

Objective

We aimed to assess the efficacy and safety of ticagrelor compared to clopidogrel in Asian patients with acute coronary syndrome (ACS) in real-world practice.

Association of Chronic Kidney Disease With In-Hospital Outcomes of Endovascular Stroke Interventions

BackgroundData on the differential impact of chronic kidney disease (CKD) on the outcomes of endovascular stroke interventions (ESI) for acute ischemic stroke (AIS) are limited.MethodsAdult patients who underwent ESI for AIS between October 1st, 2015 and September 30th, 2019, were identified in a national multicenter database. The primary endpoints were in-hospital mortality and poor functional outcomes. Secondary endpoints included intracranial hemorrhage, mechanical ventilation, pneumonia, myocardial infarction, blood transfusion, length of stay, and cost. A multilevel mixed-effects regression model was used to derive adjusted outcomes.ResultsA total of 22,193 AIS patients who underwent ESI at 99 centers were included. Among those, 18,881 (85%) had no CKD, and 3312 (15%) had CKD. Patients with CKD were older and had a higher prevalence of key comorbidities. After multivariable risk adjustment, patients with CKD had significantly higher in-hospital mortality (Odds Ratio [OR] 1.55 [95% Confidence Interval] [CI] 1.40–1.73, p < 0.01), and poor functional outcomes (OR 1.38, 95%CI 1.26–1.50, p < 0.01). Major complications, including mechanical ventilation, pneumonia, blood transfusion, and myocardial infarction, were more common among CKD patients, who also had longer hospitalizations and accrued higher cost.ConclusionThe presence of CKD in patients with AIS treated with ESI is an independent predictor of in-hospital mortality and poor functional outcomes at discharge.     

Meta-Analysis of Efficacy and Safety of Proton Pump Inhibitors with Dual Antiplatelet Therapy for Coronary Artery Disease

BackgroundThere is inconsistency in the literature regarding the clinical effects of proton pump inhibitors (PPI) when added to dual antiplatelet therapy (DAPT) in subjects with coronary artery disease (CAD). We performed meta-analysis stratified by study design to explore these differences.Methods and results39 studies [4 randomized controlled trials (RCTs) and 35 observational studies) were selected using MEDLINE, EMBASE and CENTRAL (Inception-January 2018). In 221,204 patients (PPI = 77,731 patients, no PPI =143,473 patients), RCTs restricted analysis showed that PPI did not increase the risk of all-cause mortality (Risk Ratio (RR): 1.35, 95% Confidence Interval (CI), 0.56–3.23, P = 0.50, I² = 0), cardiovascular mortality (RR: 0.94, 95% CI, 0.25–3.54, P = 0.92, I² = 56), myocardial infarction (MI) (RR: 0.97, 95% CI, 0.62–1.51, P = 0.88, I² = 0) or stroke (RR: 1.11, 95% CI, 0.25–5.04, P = 0.89, I² = 26). However, PPI significantly reduced the risk of gastrointestinal (GI) bleeding (RR: 0.32, 95% CI, 0.20–0.52, P < 0.001, I² = 0). Conversely, analysis of observational studies showed that PPI significantly increased the risk of all-cause mortality (RR: 1.25, 95% CI, 1.11–1.41, P < 0.001, I² = 82), cardiovascular mortality (RR: 1.25, 95% CI, 1.03–1.52, P = 0.02, I² = 71), MI (RR: 1.30, 95% CI, 1.16–1.47, P < 0.001, I² = 82) and stroke (RR: 1.60, 95% CI, 1.43–1.78, P < 0.001, I² = 0), without reducing GI bleeding (RR: 0.74, 95% CI, 0.45–1.22, P = 0.24, I² = 79).ConclusionMeta-analysis of RCTs endorsed the use of PPI with DAPT for reducing GI bleeding without worsening cardiovascular outcomes. These findings oppose the negative observational data regarding effects of PPI with DAPT.     

Radial vs. Femoral Access for Percutaneous Coronary Artery Intervention in Patients With ST-Elevation Myocardial Infarction

BackgroundWe aimed to compare the safety and efficacy of transradial vs transfemoral access for coronary angiography and intervention in patients presenting with ST-segment elevation myocardial infarction (STEMI) without cardiogenic shock.MethodsPubMed, Embase and Cochrane Central were searched for randomized controlled trials (RCTs) comparing outcomes of STEMI patients who underwent transradial angiography (TRA) compared to transfemoral angiography (TFA). Our outcomes of interest were major adverse cardiac events (MACE), all-cause mortality, severe bleeding, access site bleeding, myocardial infarction, stroke, and major vascular complications. Summary statistics are reported as odds ratios (OR) with 95% confidence intervals (CI).ResultsIn a pooled analysis of 17 RCTs with 12,118 randomized patients, the use of transradial compared to transfemoral approach in STEMI patients without cardiogenic shock was associated with a significant reduction in MACE [OR 0.85 (95% CI 0.73–0.99; p = 0.04; NNT = 111; I² = 0%)] and all-cause mortality [OR 0.71 (95% CI 0.57–0.88; p < 0.01; NNT = 111; I² = 0%)]. Severe bleeding [OR 0.57 (95% CI 0.44–0.74; p < 0.01; NNT = 77; I² = 0%)], access-site bleeding [OR 0.39 (95% CI 0.26–0.59; p < 0.01; NNT = 67; I² = 24%)], and major vascular complications [OR of 0.31 (95% CI 0.17–0.55; p < 0.01; NNT = 125; I² = 0%)] were lower in TRA compared to TFA. There was no difference in stroke (0.6% vs 0.5%) or recurrent myocardial infarction (2.01% vs 2.02%) between the two approaches.ConclusionsFor coronary intervention in STEMI patients without cardiogenic shock, there is a clear mortality benefit with the TRA over TFA. Further studies are needed to see if this mortality benefit persists over the long-term.     

Influence of diabetes mellitus on inflammatory bowel disease course and treatment outcomes. A systematic review with meta-analysis

BackgroundDiabetes Mellitus (DM) may occur in IBD and influence the disease progression.AimTo compare disease course and treatment outcomes in IBD patients with and without DM.MethodsThis is a systematic review with meta-analysis comparing patients with IBD plus DM with patients with IBD only. Primary endpoints: need for surgery, IBD-related complications, hospitalizations, sepsis, mortality. Quality of life and costs were assessed.ResultsFive studies with 71,216 patients (49.1% with DM) were included. Risk for IBD-related complications (OR=1.12, I² 98% p = 0.77), mortality (OR=1.52, I² 98% p = 0.37) and IBD-related surgery (OR=1.20, I² 81% p = 0.26) did not differ. Risk of IBD-related hospitalizations (OR=2.52, I² 0% p < 0.00001) and sepsis (OR=1.56, I² 88% p = 0.0003) was higher in the IBD+DM group. Risk of pneumonia and urinary tract infections was higher in the IBD+DM group (OR=1.72 and OR=1.93), while risk of C. Difficile infection did not differ (OR=1.22 I² 88% p = 0.37). Mean Short Inflammatory Bowel Disease Questionnaire score was lower in the IBD+DM group (38.9 vs. 47, p = 0.03). Mean health care costs per year were $10,598.2 vs $3747.3 (p < 0.001).ConclusionDM might negatively affect the course of IBD by increasing the risk of hospitalization and infections, but not IBD-related complications and mortality.     

Effect of direct oral anticoagulants versus vitamin K antagonists or warfarin in patients with left ventricular thrombus outcomes: A systematic review and meta-analysis

IntroductionLeft ventricular thrombus commonly occurs as a complication of acute anterior myocardial infarction and nonischemic cardiomyopathies with severe left ventricular systolic dysfunction. Its frequency is still high despite medical advances. Current guidelines recommend the use of vitamin k antagonists as first-line therapy, however, the off-label use of direct oral anticoagulants is becoming more frequent and attractive, given the better pharmacological and clinical profile, with the improvement of the patient's quality of life.AimTo provide an update on the currently existing evidence regarding the outcomes of efficacy and safety of direct oral anticoagulants (DOACs) as first-line therapy in left ventricular thrombus, in comparison to vitamin K antagonists (VKAs).MethodsA systematic review and meta-analysis of studies on the effects of direct oral anticoagulants versus vitamin K antagonists on left ventricular thrombi and on the results was performed.ResultsFourteen studies were included in the meta-analysis, with a total of 2498 patients (n=631 direct oral anticoagulants and n=1867 for VKAs). No significant differences were found in efficacy and safety outcomes (odds ratio (OR) 0.86; 95% confidence interval (CI), 0.55–1.33; p=0.50; I²=32%) and (OR 1.0; 95% CI, 0.78–1.30; p=0.93; I²=2%) respectively. No difference was noted in all-cause mortality (OR 0.92; 95% CI, 0.58–1.45; p=0.74; I²=0%). Thrombus resolution was observed in 288/416 in direct oral anticoagulants vs. 732/1085 patients treated with VKAs (OR 1.14; 95% CI, 0.77–1.66; p=0.50; I²=33%).ConclusionsThe findings of this meta-analysis suggest the potential utility of DOACs as a first-line strategy in patients with left ventricular thrombus.     

Effectiveness and safety of NER1006 versus standard bowel preparations: A meta-analysis of randomized phase-3 clinical trials

BackgroundA 1 L PEG-based preparation for colonoscopy (NER1006) has been recently developed.AimsWe conducted a meta-analysis of randomized controlled trials (RCTs) to explore the effectiveness and safety of NER1006 versus traditional preparations.MethodsPubMed/Medline and Embase were systematically searched through January 2020 for phase-3 RCTs comparing NER1006 versus standard preparations.ResultsThree RCTs (1879 participants) met the inclusion criteria and were included. The analysis showed a higher cleansing success for NER1006 compared standard preparations (OR=1.28; 95% CI 1.00–1.62; p = 0.047, I²=0%) as well as a greater high-quality cleansing of the right colon (OR=2.13; 95% CI 1.16–3.94; p = 0.015, I²=76.0%) when assessed by the Harefield Cleansing Scale (HCS).The pooled estimate of the NER1006 effect on ADR showed a higher, although not significant, ADR of the right colon (OR=1.19; 95% CI 0.73–1.92; p = 0.485, I²=53%). When considering the impact of NER1006 on mild to moderate treatment-emergent adverse events (TEAEs), we observed a significant pooled estimate of TEAEs (OR=2.31; 95% CI 1.82–2.94; p<0.001, I²=0%).ConclusionsWhen compared to traditional preparations, NER1006 showed a better overall cleansing of the colon as well as a greater high-quality cleansing of the right colon, with comparable ADR. A higher incidence of mild to moderate TEAEs was observed for NER1006, in the absence of serious adverse events.     

Prognostic Role of Metabolic Syndrome in COVID-19 Patients: A Systematic Review Meta-Analysis

Background: The prevalence and prognostic implications of metabolic syndrome (MetS) in patients infected by the SARS-CoV-2 remain unclear. We performed a systematic review and meta-analysis of prevalence and mortality risk in COVID-19 patients with MetS. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed in abstracting data and assessing validity. We searched MEDLINE and Scopus to locate every article published up to 1 September 2021, reporting data on MetS among COVID-19 patients. The pooled prevalence of MetS was calculated using a random effects model and presented using the related 95% confidence interval (CI), while the mortality risk was estimated using the Mantel-Haenszel random effects models with odds ratio (OR) and related 95% CI. Statistical heterogeneity was measured using the Higgins I² statistic. Results: Six studies, enrolling 209.569 COVID-19 patients [mean age 57.2 years, 114.188 males (54.4%)] met the inclusion criteria and were included in the final analysis. The pooled prevalence of dyslipidaemia was 20.5% of cases (95% CI: 6.7–47.8%, p = 0.03), with high heterogeneity (I² = 98.9%). Pre-existing MetS was significantly associated with higher risk of short-term mortality (OR: 2.30, 95% CI: 1.52–3.45, p < 0.001), with high heterogeneity (I² = 89.4%). Meta-regression showed a direct correlation with male gender (p = 0.03), hypertension (p < 0.001), DM (p = 0.01) and hyperlipidaemia (p = 0.04), but no effect when considering age (p = 0.75) and chronic pulmonary disease (p = 0.86) as moderators. Conclusions: MetS represents a major comorbidity in about 20% of COVID-19 patients and it is associated with a 230% increased risk of short-term mortality.     

Transradial Percutaneous Coronary Intervention in Patients With Advanced Chronic Kidney Disease

BackgroundMultiple randomized clinical trials have demonstrated that transradial intervention (TRI) improves clinical outcomes after percutaneous coronary intervention (PCI) compared with transfemoral intervention (TFI). However, chronic kidney disease (CKD) patients have more procedure-related complications; TRI is frequently avoided for future creation of arteriovenous fistulas essential for hemodialysis. Therefore, limited information on TRI among CKD patients exists. We aimed to assess the impact of TRI on CKD patients.MethodsConsecutive PCI patients with advanced CKD registered in a multicenter Japanese registry between 2008 and 2017 (N = 20,420) were analyzed. Advanced CKD was defined as estimated glomerular filtration rate <30 mL/min/1.73 m². Outcomes of interest were periprocedural bleeding (transfusion or decreasing hemoglobin by >3.0 g/dL within 72 h after PCI), acute kidney injury (AKI: absolute increase of 0.3 mg/dL or a relative increase of 50% in serum creatinine from baseline), and hemodialysis initiation after PCI. To account for baseline differences between patients with TRI and TFI, 1:1 propensity matching was performed.ResultsOverall, 498 patients (3.7%) had advanced CKD, and 199 (40.0%) underwent TRI. After propensity matching, 324 patients were included (age, 74.9 ± 9.9 years; male, 63.6%; ACS, 46.0%). TRI was associated with reduced periprocedural AKI risks (12.4% versus 26.5%; p < 0.01) and hemodialysis initiation (3.1% versus 12.4%; p = 0.01) compared with TFI. TRI showed a trend toward lower rates of bleeding complications than those of TFI, but the difference was not statistically significant (1.9% versus 6.2%; p = 0.15).ConclusionsTRI might be beneficial over TFI in PCI patients with advanced CKD.     

Risk factors for acute kidney injury and 30-day mortality after liver transplantation

Introduction. The aim of this study is to evaluate the risk factors for acute kidney injury (AKI) and 30-day mortality after liver transplantation.Material and methods. This is a retrospective cohort of consecutive adults undergoing orthotopic liver transplantation (OLT) at a referral hospital in Brazil, from January 2013 to January 2014. Risk factors for AKI and death were investigated.Results. A total 134 patients were included, with median age of 56 years. AKI was found in 46.7% of patients in the first 72 h after OLT. Risk factors for AKI were: viral hepatitis (OR 2.9, 95% CI = 1.2-7), warm ischemia time (OR 1.1, 95% CI = 1.01-1.2) and serum lactate (OR 1.3, 95%CI = 1.02-1.89). The length of intensive care unit (ICU) stay was longer in AKI group: 4 (3-7) days vs. 3 (2-4) days (p = 0.001), as well as overall hospitalization stay: 16 (9-26) days vs. 10 (8-14) days (p = 0.001). The 30-day mortality was 15%. AKI was an independent risk factor for mortality (OR 4.3, 95% CI = 1.3-14.6). MELD-Na ≥ 22 was a predictor for hemodialysis need (OR 8.4, 95%CI = 1.5-46.5). Chronic kidney disease (CKD) was found in 36 patients (56.2% of AKI patients).Conclusions. Viral hepatitis, longer warm ischemia time and high levels of serum lactate are risk factors for AKI after OLT. AKI is a risk factor for death and can lead to CKD in a high percentage of patients after OLT. A high MELD-Na score is a predictor for hemodialysis need.     

Clinical characteristics and outcomes of diffuse alveolar hemorrhage in patients with systemic lupus erythematosus

ObjectiveTo identify the clinical characteristics of diffuse alveolar hemorrhage (DAH) compared to other types of acute diffuse lung infiltration in SLE patients, and the factors associated with mortality in these patients.MethodsWe studied a retrospective cohort including SLE patients with acute diffuse lung infiltration on thoracic CT between January 2004 and August 2014. We divided them into 2 groups, a DAH and a non-DAH group, and compared the clinical characteristics and outcomes in the 2 groups. We also evaluated the risk factors for mortality in SLE patients with diffuse lung infiltration.ResultsOf 47 patients with diffuse lung infiltration, 24 patients (51.1%) satisfied the criteria for DAH and the remaining 23 patients (48.9%) were assigned to the non-DAH group. There were no significant differences between the demographic features of the 2 groups. However, decreased hemoglobin (OR = 3.46; 95% CI: 1.38–8.67; p < 0.01) and C4 (OR = 1.21; 95% CI: 1.03–1.42; p = 0.02) levels, and presence of hypoxia (OR = 23.09; 95% CI: 1.47–365.34; p = 0.03) at the time of diagnosis were associated with SLE-DAH. In addition, severe conditions requiring mechanical ventilation (OR = 64.61; 95% CI: 1.98–2112.02; p = 0.02) were associated with increased mortality, whereas DAH did not increase mortality compared with non-DAH in SLE patients with diffuse lung infiltration.ConclusionsIn SLE patients with acute diffuse lung infiltration, it is important to promptly evaluate the DAH when patients have low levels of hemoglobin or C4, and symptoms of hypoxia. Mortality is associated with severe conditions requiring mechanical ventilation rather than with DAH in patients with diffuse lung infiltration.     

The Impact of Atrial Fibrillation on Hospitalization Outcomes of Endovascular Repair of Abdominal Aortic Aneurysm

ObjectiveWe aimed to study the impact of atrial fibrillation (AF) on hospitalization outcomes of abdominal aortic artery (AAA) endovascular aneurysm repair (EVAR) at a large-scale sample size representative of the entire United States (U.S.) population.MethodsWe included all adults who were hospitalized in the U.S. for AAA repair with EVAR between 2016 and 2017 using the International Classification of Diseases—10th Revision, Clinical procedural diagnosis codes. The primary outcome was all-cause in-hospital mortality. Secondary outcomes were stroke, myocardial infarction, respiratory failure, acute kidney injury (AKI), bleeding event, vascular complications, aortic dissection, length of stay (LOS), and hospitalization cost. Hospitalization outcomes were modeled using logistic regression for binary outcomes and Poisson or log-gamma regression for count or right-skewed numeric outcomes, respectively.ResultsWe included a total of 39,330 records for patients with AAA who underwent EVAR. There were 5.940 patients with AF. On multivariable analysis, EVAR patients with AF had significantly higher odds for mortality with adjusted OR 2.06 (95%CI: 1.09–3.91). They also had significantly higher odds for AKI (A-OR: 1.79 (95%CI: 1.38–2.32), p < 0.001), acute myocardial infarction (A-OR: 2.72 (95%CI: 1.39–5.32), p = 0.004), post procedural bleedings (A-OR: 1.51 (95%CI: 1.20–1.89), p < 0.001), LOS (1.35 (95%CI: 1.24–1.47) p < 0.001) and higher cost (A-OR: 1.06 (9% CI, 1.03–1.09) p < 0.001). There was no significant difference in risk of stroke, vascular complications, and aortic dissection.ConclusionAF is an important independent predictor for mortality and adverse outcomes in patients with AAA undergoing EVAR.