Patients at elevated risk of major adverse events following endarterectomy for asymptomatic carotid stenosis

Background

Carotid endarterectomy (CEA) as treatment in patients with asymptomatic carotid stenosis is the subject of much debate.

Methods

The National Surgical Quality Improvement Program database from 2005 to 2012 was queried. Patients undergoing CEA for asymptomatic carotid stenosis were identified. Preoperative risk factors and patient demographics were compared using chi-square analysis and logistic regression to determine their relation with stroke and death.

Results

During an 8-year period, 24,211 CEAs performed for asymptomatic carotid stenosis were identified. Patients with dependent functional status (12.5%), recent myocardial infarction (6.3%), chronic heart failure (5.0%), hypoalbuminemia (4.8%), angina (4.1%), dialysis dependence (3.4%), steroid dependence (3.4%), chronic obstructive pulmonary disease (3.3%), and American Society of Anesthesiologists > 3 (3.2%) had a clinically significant increase in risk of stroke and death. Patients with none of the above risk factors had a stroke and death rate of 1.08%, which was significantly less than the overall stroke and death rate (P < .001).

Conclusions

A high-risk subset of patients undergoing CEA for asymptomatic carotid stenosis can be identified. If patient selection is optimized and perioperative morbidity and mortality are minimized, CEA will continue to play an important role in stroke prevention for those with significant asymptomatic carotid stenosis.     

Fibrillary glomerulonephritis: An apparent familial form?

Fibrillary glomerulonephritis is a rare cause of glomerulonephritis characterized by non‐amyloid fibrillary deposits of unknown aetiology. It is generally considered idiopathic but may be associated with secondary causes such as monoclonal gammopathy, hepatitis B and C infections, autoimmune diseases and malignancies. We report two Australian families with apparent familial fibrillary glomerulonephritis inherited in an autosomal dominant pattern, and postulate the existence of a primary familial entity. Family 1 consists of an affected father and daughter; the daughter progressed to end‐stage renal failure within 18 months of diagnosis, despite immunosuppressive therapy. The father, however, remains stable at 10 months follow up. Family 2 comprises an affected mother and son; the mother commenced haemodialysis 5 years after diagnosis and subsequently underwent successful renal transplantation. The son is presently stable at last follow‐up after 5 years. A further review of the second family history reveals a third family member (maternal father) dying of ‘Bright's disease’. We describe their histopathology, clinical progression and treatment outcomes, and provide a review of the current understanding of this heterogeneous condition that is associated with poor renal outcomes.     

Predictors of Treatment Outcomes in ANCA-Associated Vasculitis with Severe Kidney Failure

Background and objectives

In ANCA-associated GN, severe renal dysfunction portends a poor prognosis for renal recovery and patient survival. This study evaluated the prognostic factors affecting renal and patient outcomes in patients presenting with severe kidney failure to guide immunosuppressive therapy.

Design, setting, participants, & measurements

This study retrospectively evaluated clinical and histopathologic characteristics of 155 patients who underwent biopsy between October 1985 and February 2011 (median eGFR at presentation, 7.1 ml/min per 1.73 m²; 87% required hemodialysis), all treated with immunosuppressive medications. Three outcomes of interest were measured: patient survival, renal survival, and treatment response (defined as dialysis-free survival without active vasculitis by 4 months after biopsy). Competing risk, Cox, and logistic regression analyses were conducted for each outcome measure.

Results

Within 4 months after biopsy, treatment response was attained in 51% of patients, 35% remained on dialysis, and 14% died. In a competing risk analysis, estimated cumulative incidence rates of ESRD and disease-related mortality were 26% and 17% at 1 year and 32% and 28% at 5 years, respectively. Cyclophosphamide therapy and treatment response by 4 months were independently associated with patient and renal survival, adjusting for the percentage of normal glomeruli, histopathologic chronicity index score, and baseline clinical characteristics. Only 5% of patients still dialysis dependent at 4 months subsequently recovered renal function. Low chronicity index score (odds ratio [OR], 1.16; 95% confidence interval [95% CI], 1.04 to 1.30, per unit decrease) and baseline eGFR>10 ml/min per 1.73 m² (OR, 2.77; 95% CI, 1.09 to 7.01) were significantly associated with treatment response by 4 months. Among cyclophosphamide-treated patients, the likelihood of treatment response was >14% even with highest chronicity index score and eGFR<10 ml/min per 1.73 m².

Conclusions

Although low baseline renal function and severe renal scarring are associated with lower treatment response rate, no “futility” threshold could be identified. Conversely, continued immunosuppressive therapy beyond 4 months is unlikely to benefit patients who remain dialysis dependent.     

Asymptomatic pancreatic lesions: New insights and clinical implications

Despite great efforts in experimental and clinical research, the prognosis of pancreatic cancer (PC) has not changed significantly for decades. Detection of pre-invasive lesions or early-stage PC with small resectable cancers in asymptomatic individuals remains one of the most promising approaches to substantially improve the overall outcome of PC. Therefore, screening programs have been proposed to identify curable lesions especially in individuals with a familial or genetic predisposition for PC. In this regard, Canto et al recently contributed an important article comparing computed tomography, magnetic resonance imaging, and endoscopic ultrasound for the screening of 216 asymptomatic high-risk individuals (HRI). Pancreatic lesions were detected in 92 of 216 asymptomatic HRI (42.6%). The high diagnostic yield in this study raises several questions that need to be answered of which two will be discussed in detail in this commentary: First: which imaging test should be performed? Second and most importantly: what are we doing with incidentally detected pancreatic lesions? Which ones can be observed and which ones need to be resected?     

Pulmonary Renal Syndrome Due to Anti-GBM and IgM C-ANCA Disease Requiring the Use of Novel Therapeutic Agents

There are several known causes for the clinical syndrome of pulmonary hemorrhage and acute renal failure. Here, we report a unique case of a 50-year-old man presenting in this manner. The initial diagnosis was one of antiglomerular basement membrane (anti-GBM) disease that responded well to steroids, cyclophosphamide, and plasma exchange (PE). The pulmonary hemorrhage resolved, but he remained dialysis dependent. However, despite falling anti-GBM titers, the symptoms relapsed and standard therapy was reinitiated with limited success. The anti-GBM antibody titer fell to zero despite clinical deterioration, prompting a search for an alternative diagnosis. He was found to be IgM anti-proteinase-3 antineutrophil cytoplasmic antibody (C-ANCA) positive. The pulmonary hemorrhage responded successfully to the use of intravenous immunoglobulin and the antilymphocyte monoclonal antibody CD52. To our knowledge, this is the first known case of IgM C-ANCA in association with anti-GBM disease. As such, it highlights the predominance of pulmonary hemorrhage in this condition, as well as the need to consider alternative therapies in refractory cases.