Amir Gal-Oz

Secondary Prevention of Hyperkalemia With Sodium Polystyrene Sulfonate in Cardiac and Kidney Patients on Renin‐Angiotensin‐Aldosterone System Inhibition Therapy

Hyperkalemia, induced by renin‐angiotensin‐aldosterone system inhibition (RAAS‐I) in patients with chronic kidney disease (CKD), or cardiac disease often leads to withdrawal of RAAS‐I therapy. Sodium polystyrene sulfonate (SPS) is a potassium‐binding resin used for the treatment of hyperkalemia. Recently, concerns about the safety and efficacy of SPS were raised. We report here a follow‐up of 14 patients with CKD and heart disease on RAAS‐I treatment who were treated with low‐dose daily SPS to prevent recurrence of hyperkalemia.

Inflammatory Bowel Disease Is Not Associated With Increased Intimal Media Thickening

OBJECTIVES:Several studies have suggested that chronic inflammatory diseases might be associated with an acceleration of the atherosclerotic process. There is little information on the effect of chronic inflammation in patients with inflammatory bowel disease (IBD) on the presence of increased intimal media thickening (IMT), a surrogate marker for atherosclerotic diseases. In this work our aim was to determine whether IBD is a risk factor for increased IMT.METHODS:IMT was measured by ultrasound of the carotid arteries; a computer software program was used to analyze 80–100 independent IMT samples from each carotid artery segment in 61 patients with IBD (45 with Crohns disease and 16 with ulcerative colitis) and in 61 controls matched for age (±2 yr), sex, body mass index (BMI, ±2 kg/m2), and smoking status.RESULTS:Inflammatory markers (erythrocyte sedimentation rate, fibrinogen, high−sensitive C-reactive protein) were significantly (P < 0.001) elevated in IBD patients compared with controls. Even though there was a disease duration of 8.7 ± 8.5 yr, the mean IMT of IBD patients was similar to that of the control group (0.66 ± 0.09 vs 0.64 ± 0.07 mm; P > 0.05).CONCLUSIONS:Despite chronic inflammation, IBD patients had IMT values similar to those of the controls. Thus, unlike other inflammatory diseases, IBD appears not to be a risk factor for accelerated atherosclerosis.

Relation of time to coronary reperfusion and the development of acute kidney injury after ST-segment elevation myocardial infarction.

Time to coronary reperfusion and acute kidney injury (AKI) are powerful prognostic markers in patients with ST-segment elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI); however, no information to date is present regarding the association between time to reperfusion and AKI. We evaluated whether time to reperfusion predicts the risk of developing AKI in patients with STEMI who underwent primary PCI. Medical records of 417 patients admitted to our department from January 2008 to July 2013, for STEMI, and treated with primary PCI were reviewed. Patients were stratified by time to coronary reperfusion tertiles, and their records were assessed for the occurrence of AKI after PCI. Mean age was 61 ± 13 years, and 346 patients (83%) were men. The cut-off points for the time to reperfusion tertiles were <120, 120 to 300, and >300 minutes. Patients having longer time to reperfusion had significantly more AKI complicating the course of STEMI (3% vs 11% vs 13%, p = 0.007) and had significantly higher serum creatinine change throughout hospitalization (0.13 vs 0.18 vs 0.21 mg/dl, p = 0.003). In a multivariable regression model, time to coronary reperfusion emerged as an independent predictor of AKI and to the maximal change in serum creatinine. In conclusion, longer time to coronary reperfusion is an independent risk factor for the development of AKI in patients with STEMI who underwent primary PCI.

Usefulness of Urine Output Criteria for Early Detection of Acute Kidney Injury after Transcatheter Aortic Valve Implantation

Background: Previous studies demonstrated that acute kidney injury (AKI) following transcatheter aortic valve implantation (TAVI) is frequent and associated with adverse outcomes. However, these studies only applied the serum creatinine (sCr) criteria while ignoring the urine output criteria. We hypothesized that adding the urine output criteria might contribute to an earlier diagnosis of AKI. Methods: We included 143 patients with severe aortic stenosis who underwent transfemoral TAVI between December 2012 and April 2014. Urine output was assessed hourly for at least 24 h following TAVI, and sCr was assessed at least daily until discharge. Based on the Valve Academic Research Consortium-2 (VARC-2), AKI was determined using both sCr and urine output criteria. We compared the incidence of AKI and time to AKI diagnosis based on these two methods. Results: The mean age was 81 w 6 years (range 61-94) and 56% were male. AKI occurred in 27 (19%) patients, 13 (9%) of whom had AKI defined by sCr criteria. Twenty (14%) patients had AKI defined by urine output criteria, only 6 of whom had AKI also defined by sCr criteria. The use of urine output criteria resulted in earlier identification of AKI (18 w 4 vs. 64 w 57 h, p = 0.02) and was associated with lower sCr elevation in patients having AKI defined by only urine output criteria (0.03 w 0.12 vs. 0.37 w 0.06 mg/dl, p < 0.001). Conclusion: The use of the VARC-2 urine output criteria significantly increased the incidence of AKI and shortened the time to AKI diagnosis. i 2014 S. Karger AG, Basel

Admission Glucose Levels and the Risk of Acute Kidney Injury in Nondiabetic ST Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention

Background: Hyperglycemia upon admission is associated with an increased risk for acute kidney injury (AKI) in ST segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). However, the relation of this association to the absence of diabetes mellitus (DM) is less studied. We evaluated the effect of acute hyperglycemia levels on the risk of AKI among STEMI patients without DM who were all treated with primary PCI. Methods: We retrospectively studied 1,065 nondiabetic STEMI patients undergoing primary PCI. Patients were stratified according to admission glucose levels into normal (<140 mg/dl), mild (140-200 mg/dl), and severe (>200 mg/dl) hyperglycemia groups. Medical records were reviewed for the occurrence of AKI. Results: The mean age was 61 ± 13 years and 81% were males. Hyperglycemia upon hospital admission was present in 402 of 1,065 patients (38%). Patients with severe admission hyperglycemia had a significantly higher rate of AKI compared to patients with no or mild hyperglycemia (20 vs. 7 and 8%, respectively; p = 0.001) and had a significantly greater serum creatinine change throughout hospitalization (0.17 vs. 0.09 and 0.07 mg/dl, respectively; p = 0.04). In multivariate logistic regression, severe hyperglycemia emerged as an independent predictor of AKI (OR = 2.46, 95% CI 1.16-5.28; p = 0.018). Conclusion: Severe admission hyperglycemia is an independent risk factor for the development of AKI among nondiabetic STEMI patients undergoing primary PCI.

C-reactive protein and carotid and femoral intima media thickness: predicting inflammation.

BACKGROUND C-reactive protein (CRP) is a recognized marker of systemic inflammation. Its association with carotid and femoral intima media thickness (surrogate measures of atherosclerosis) may explain excess cardiovascular disease risk in hemodialysis patients. OBJECTIVES To estimate the association between CRP and both carotid and femoral IMT in hemodialysis (HD) patients; to predict CRP in these patients. METHODS The present cross-sectional study is nested in the Sevelamer hydrochloride and ultrasound-measured femoral and carotid intima media thickness progression in end-stage renal disease (SUMMER) clinical trial. Carotid (common, internal, and bifurcation) and femoral arteries were visualized in B-mode ultrasonography. CRP was measured in serum. RESULTS The study cohort included 144 HD patients (39.5% female, mean age 67.8 ± 11.5 years). All measures of both carotid and femoral IMT were significantly positively associated with CRP. Subjects with a history of smoking or coronary revascularization had significantly higher CRP levels, while subjects treated with sevelamer hydrochloride had significantly lower CRP. CRP was significantly positively associated with serum phosphorus, calcium, alkaline phosphatase, and PTH, and significantly inversely associated with HDL and albumin. CONCLUSIONS CRP is significantly positively associated with both femoral and carotid IMT. Treatment with sevelamer hydrochloride is associated with lower CRP in HD patients.

Comparative analysis of Bayer wide-range C-reactive protein (wr-CRP) and the Dade-Behring high sensitivity C-reactive protein (hs-CRP) in patients with inflammatory bowel disease

OBJECTIVE:  The recently introduced Bayer wide‐range C‐reactive protein (wr‐CRP) assay might be relevant for the real‐time low‐cost and online determination of inflammatory bowel disease (IBD) activity. Our aim was to examine whether wr‐CRP can substitute for the Dade Behring high sensitivity C‐reactive protein (hs‐CRP) assay in IBD patients.

Care of undocumented-uninsured immigrants in a large urban dialysis unit

BackgroundMedical, ethical and financial dilemmas may arise in treating undocumented-uninsured patients with end-stage renal disease (ESRD). Hereby we describe the 10-year experience of treating undocumented-uninsured ESRD patients in a large public dialysis-unit.MethodsWe evaluated the medical files of all the chronic dialysis patients treated at the Tel-Aviv Medical Center between the years 2000–2010. Data for all immigrant patients without documentation and medical insurance were obtained. Clinical data were compared with an age-matched cohort of 77 insured dialysis patients.ResultsFifteen undocumented-uninsured patients were treated with chronic scheduled dialysis therapy for a mean length of 2.3 years and a total of 4953 hemodialysis sessions, despite lack of reimbursement. All undocumented-uninsured patients presented initially with symptoms attributed to uremia and with stage 5 chronic kidney disease (CKD). In comparison, in the age-matched cohort, only 6 patients (8%) were initially evaluated by a nephrologist at stage 5 CKD. Levels of hemoglobin (8.5 ± 1.7 versus 10.8 ± 1.6 g/dL; p < 0.0001) and albumin (33.8 ± 4.8 versus 37.7 ± 3.9 g/L; p < 0.001) were lower in the undocumented-uninsured dialysis patients compared with the age-matched insured patients at initiation of hemodialysis therapy. These significant changes were persistent throughout the treatment period. Hemodialysis was performed in all the undocumented-uninsured patients via tunneled cuffed catheters (TCC) without higher rates of TCC-associated infections. The rate of skipped hemodialysis sessions was similar in the undocumented-uninsured and age-matched insured cohorts.ConclusionsUndocumented-uninsured dialysis patients presented initially in the advanced stages of CKD with lower levels of hemoglobin and worse nutritional status in comparison with age-matched insured patients. The type of vascular access for hemodialysis was less than optimal with regards to current guidelines. There is a need for the national and international nephrology communities to establish a policy concerning the treatment of undocumented-uninsured patients with CKD.

Prognostic Implications of Acute Renal Impairment among ST Elevation Myocardial Infarction Patients with Preserved Left Ventricular Function

Background: Only limited data is present regarding the incidence and prognostic implications of acute kidney injury (AKI) in ST elevation myocardial infarction (STEMI) patients with preserved left ventricular (LV) function in the primary percutaneous coronary intervention (PCI) era. Methods: We conducted a retrospective study of 842 consecutive STEMI patients with preserved LV function (ejection fraction ≥50%, assessed by echocardiography) who underwent primary PCI between January 2008 and January 2015. AKI was defined as an increase of ≥0.3 mg/dl in serum creatinine within 48 h following admission. Patients were assessed for all-cause mortality up to 5 years. Results: Fifty-two patients (6.2%) developed AKI. Patients with AKI were older, had impaired baseline renal function, and presented more often with heart failure throughout their hospitalization. Patients with AKI had a higher 5-year all-cause mortality (13.4 vs. 2.4%, p < 0.001). Compared to patients with no AKI, the adjusted hazard ratio for all-cause mortality was 2.64 (95% CI 1.25-5.56, p = 0.01). Conclusions: Among STEMI patients with preserved LV function undergoing primary PCI, AKI is associated with a higher long-term mortality.

Relation of in-hospital serum creatinine change patterns and outcomes among ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.

The worsening of serum creatinine (sCr) level is a frequent finding among ST‐segment elevation MI (STEMI) patients undergoing primary percutaneous coronary intervention (PCI), associated with adverse short‐term and long‐term outcomes. No information is present, however, regarding the incidence and prognostic implications associated with an improvement in sCr levels throughout hospitalization, as compared with admission levels.