Prevention of contrast‐induced acute kidney injury in patients with stable chronic renal disease undergoing elective percutaneous coronary and peripheral interventions: Randomized comparison of two preventive strategies

Objective : We compared use of intravenous (IV) normal saline (NS) to sodium bicarbonate (NaHCO₃) with or without oral N‐acetylcysteine (NAC) for prevention of contrast‐induced acute kidney injury (CI‐AKI). Background : CI‐AKI is associated with significant adverse clinical events. Use of NAC has produced variable results. Recently, intravenous hydration with NaHCO₃ for CI‐AKI prophylaxis has been adopted as standard treatment for patients with stable chronic renal disease undergoing catheterization procedures. Methods : We prospectively enrolled 320 patients with baseline renal insufficiency scheduled to undergo catheterization. Patients were randomly assigned to receive either IV NS ± NAC (n = 161) or IV dextrose 5% in water containing 154 mEq/l of NaHCO₃ ± NAC (n = 159). IV NS was administered at 1 ml/kg body weight for 12 hr preprocedure and 12 more hr postprocedure. IV NaHCO₃ was administered at 3 ml/kg body weight for 1 hr preprocedure followed by 1 ml/kg body weight postprocedure. A 1,200 mg oral dose of NAC was given 2–12 hr preprocedure and 6–12 hr postprocedure in 50% of patients in each study arm. CI‐AKI was defined as an increase of >0.5 mg/dl or >25% above baseline creatinine. Results : Overall incidence of CI‐AKI was 10.3%. There was no significant difference in incidence among the two groups (NS ± NAC 11.8% vs. NaHCO₃ ± NAC 8.8%, p = ns). Incidence of CI‐AKI increased with increasing age (p = 0.001), contrast agent use >3 ml/kg body weight (p = 0.038) and diuretic use (p = 0.005). Conclusion : Incidence of CI‐AKI was no different in the NaHCO₃ group compared to NS group, and NAC did not reduce CI‐AKI in the two study arms. © 2011 Wiley Periodicals, Inc.     

Hypoplastic left heart syndrome and valvular pulmonary stenosis. A rare association that limits the management options

A term baby had cyanosis 2 hours after delivery; echocardiography showed hypoplastic left heart syndrome HLHS and valvular pulmonary stenosis PS. The opinions of the cardiac centers in Saudi Arabia were taken; however, the baby was not accepted probably because the associated PS made him a poor candidate for a Norwood procedure and because cardiac transplant is not available for infants in Saudi Arabia. He died after 15 days. This mother should have fetal echocardiography in future pregnancies, and if HLHS is suspected she might be advised to seek medical advice antenatally at highly specialized cardiac centers abroad, as delivery there may increase the chance of surgical intervention.     

The impact of recipient history of cardiovascular disease on kidney transplant outcome

Cardiovascular disease (CVD) leads to increased mortality rates among renal transplant recipients; however, its effect on allograft survival has not been well studied. The records from the United States Renal Data System and the United Network for Organ Sharing from January 1, 1995, through December 31, 2002, were examined in this retrospective study. The outcome variables were allograft survival time and recipient survival time. The primary variable of interest was CVD, defined as the presence of at least one of the following: cardiac arrest, myocardial infarction, dysrhythmia, congestive heart failure, ischemic heart disease, peripheral vascular disease, and unstable angina. The Cox models were adjusted for potential confounding factors. Of the 105,181 patients in the data set, 20,371 had a diagnosis of CVD. The presence of CVD had an adverse effect on allograft survival time (HR 1.12, p < 0.001) and recipient survival time (HR 1.41, p < 0.001). Among the subcategories, congestive heart failure (HR 1.14, p < 0.005) and dysrhythmia (HR 1.26, p < 0.05) had adverse effects on allograft survival time. In addition to increasing mortality rates, CVD at the time of end-stage renal disease onset is also a significant risk factor for renal allograft failure. Further research is needed to evaluate the role of specific forms of CVD in allograft and recipient outcome.     

One-year outcomes with the Taxus Liberté stent in the real world: the Taxus Olympia registry (phase I)

Background: The TAXUS OLYMPIA registry is a prospective, postapproval registry collecting clinical outcomes data on patients receiving the TAXUS Liberté paclitaxel‐eluting stent during routine interventional cardiology practice. Methods: Between February and July 2005, 529 patients receiving the TAXUS Liberté stent at 16 centers in the Middle East, South/Central America, and Asia/Pacific regions were enrolled in Phase I of OLYMPIA. The primary end‐point was TAXUS Liberté stent‐related cardiac events (cardiac death, MI, and revascularization) at 30 days postimplant. Additional clinical assessment was conducted at 6 and 12 months. OLYMPIA phases II and III are in clinical follow‐up and will be reported separately. Results: One‐year clinical follow‐up is available for 98% of patients. Complex patients and lesions were prevalent, including: 50% diabetes mellitus, 49% multivessel disease, 30% multiple stenting, 48% AHA/ACC type B2/C lesions, 19% long lesions (>26 mm), and 40% small vessels (≤2.75 mm). At 1 year, the cardiac event rate was 4.1%, including 1.5% cardiac death, 1.5% MI, and 2.3% target vessel revascularization (TVR). The TAXUS Liberté stent‐related cardiac event rate was 3.7% at 1 year. Stent thrombosis (ST) occurred in 1.7% of patients, with three cases occurring >30 days postprocedure. One‐year cardiac event rates among complex subpopulations (diabetics 5.0%, multiple stents 3.8%, long lesions 3.1%, and small vessels 2.9%) were comparable to the overall study population. Conclusions: In conclusion, this first report of real‐world experience with the TAXUS Liberté stent demonstrates the safety and clinical utility of this stent in the broader spectrum of coronary disease treated in everyday practice.     

Susceptibility of TNF-α-deficient mice to Trypanosoma congolense is not due to a defective antibody response

C57BL/6 mice deficient in one or two copies of the gene for tumor necrosis factor alpha (TNF-α) were more susceptible to Trypanosoma congolense infection than their resistant, wild-type counterparts. The number of TNF-α genes was correlated with the capacity to control parasitaemia and with survival time. Absence of TNF-α resulted in a diminished capacity to form germinal centres in lymph nodes and spleen. Since germinal centres are involved in antibody production and affinity maturation, the susceptibility of the TNF-α-deficient mice could have been due to this secondary defect. Despite the lack of the germinal centres, the antibody responses to internal and exposed trypanosome antigens and to non-trypanosome antigens were not significantly different. Also the relative avidities measured in infected sera did not significantly differ between the two mouse strains. These data suggest that the role of TNF-α in control of T. congolense was not due to its role in the development of an antibody response.     

Review of cytomegalovirus infection findings with mammalian target of rapamycin inhibitor-based immunosuppressive therapy in de novo renal transplant recipients

Cytomegalovirus (CMV) infection and disease are major complications in the renal transplant recipient. The occurrence of CMV is associated with acute rejection, allograft dysfunction, significant end-organ disease, and mortality. Several clinical studies have indicated that the use of certain immunosuppressive drugs can delay the reconstitution of CMV-specific cell-mediated immune responses, thereby leading to uncontrolled CMV replication. Accumulating evidence indicates, however, that the use of the mammalian target of rapamycin (mTOR) inhibitors, sirolimus, and everolimus, may decrease the incidence and severity of CMV infection in renal transplant recipients. The purpose of this article is to review CMV infection data from randomized clinical trials that investigated the use of sirolimus- and everolimus-based treatment regimens in de novo renal transplantation. The mTOR inhibitor clinical trials included were primarily identified using biomedical literature database searches, with additional studies added at the authors' discretion. This review will summarize these studies to discuss whether mTOR inhibitor-based immunosuppressive therapy can reduce the magnitude of CMV-related complications in the de novo renal transplantation setting.