Hasan Bazari

Are Patients With Renal Failure Good Candidates for Percutaneous Coronary Revascularization in the New Device Era

Background—Patients with end-stage renal disease undergoing conventional balloon angioplasty have reduced procedural success and increased complication rates. This study was designed to determine the immediate and long-term outcomes of patients with varying degrees of renal failure undergoing percutaneous coronary intervention in the current device era. Methods and Results—We compared the immediate and long-term outcomes of 362 renal failure patients (creatinine >1.5 mg/dL) with those of 2972 patients with normal renal function who underwent percutaneous coronary intervention between 1994 and 1997. Patients with renal failure were older and had more associated comorbidities. They had reduced procedural success (89.5% versus 92.9%, P =0.007) and greater in-hospital combined major event (death, Q-wave myocardial infarction, emergent CABG; 10.8% versus 1.8%;P <0.0001) rates. Renal failure was an independent predictor of major adverse cardiac events (MACEs) (OR, 3.41; 95% CI, 1.84 to 6.22;P <0.00001). Logistic regression analysis identified shock, peripheral vascular disease, balloon angioplasty strategy, and unstable angina as independent predictors of in-hospital MACEs in the renal group. Compared with 362 age- and sex-matched patients selected from the control group, patients with renal failure had a lower survival rate (27.7% versus 6.1%, P <0.0001) and a greater MACE rate (51% versus 33%, P <0.001) at long-term follow-up. Cox regression analysis identified age and PTCA strategy as independent predictors of long-term MACEs in the renal group. Finally, within the renal failure population, the dialysis and nondialysis patients experienced remarkably similar immediate and long-term outcomes. Conclusions—Although patients with renal failure can be treated with a high procedural success rate in the new device era, they have an increased rate of major events both in hospital and at long-term follow-up. Nevertheless, utilization of stenting and debulking techniques improves immediate and long-term outcomes.

Atheroembolic renal failure after invasive procedures. Natural history based on 52 histologically proven cases

Atheromatous plaque material containing cholesterol crystals may dislodge and cause distal ischemia. To characterize atheroembolic renal failure, we retrospectively evaluated all patients at the Massachusetts General Hospital from 1981 to 1990 with both renal failure and histologically proven atheroembolism after angiography or cardiovascular surgery. Over the 10-year period, 52 patients were identified. They tended to be elderly men with a history of hypertension (81%), coronary artery disease (73%), peripheral vascular disease (69%), and current smoking (50%). Within 30 days of their procedure, only 50% of patients had cutaneous signs of atheroembolism, and 14% had documented blood eosinophilia. Urinalysis was often abnormal. Hemodynamically unstable patients died shortly after their procedure, yet renal function in the remainder continued to decline over 3 to 8 weeks. Patients who received dialysis had a higher baseline serum creatinine than those who did not (168 +/- 44 mumol/L versus 133 +/- 18 mumol/L, p = 0.02), with dialysis starting a median of 29 days after the procedure. Patients with renal failure due to atheroembolism alone, as opposed to multiple renal insults, were more likely to recover renal function (24% versus 3%, p = 0.03) and had a lower risk of death during the 6 months after their procedure (log-rank p = 0.002). Renal failure due to procedure-induced AE is characterized by a decline in renal function over 3 to 8 weeks. This time course is not consistent with most other iatrogenic causes of renal failure, such as radiocontrast or nephrotoxic medications, which present earlier and often resolve within 2 to 3 weeks after appropriate intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

Prophylaxis of contrast-induced nephropathy in patients undergoing coronary angiography.

Contrast‐induced nephropathy (CIN) is a common complication of cardiac catheterization, reported to result in a 15% incidence of acute renal failure. Convincing evidence supports the prophylactic use of prehydration and low volumes of contrast medium. Recently, the antioxidant acetylcysteine has been shown to have a potential preventive role. The aim of this study was to examine the hypothesis that acetylcysteine prevents CIN. Patients undergoing cardiac catheterization with a serum creatinine ≥ 1.5 mg/dl were prospectively randomized to receive acetylcysteine or placebo. A total of five doses of acetylcysteine 600 mg b.i.d. or placebo was administered, commencing on the day of the procedure. All patients were prehydrated with 0.45% saline and during the catheterization a nonionic low‐osmolality contrast medium was used. Serum creatinine and urea were measured at 24, 48, and 72 hr postprocedure. A total of 43 patients were studied. There was no significant difference between the groups in terms of baseline characteristics, including baseline renal function. No adverse events were experienced with acetylcysteine treatment. Serum creatinine levels at 48 and 72 hr remained largely unchanged in the acetylcysteine group but continued to rise at 48 and 72 hr in the placebo group. By 72 hr, the incidence of CIN, defined as a 25% increase in baseline creatinine, was significantly lower in the acetylcysteine arm compared to placebo (5% for acetylcysteine vs. 32% for placebo; P = 0.046). In patients with mild to moderate renal impairment undergoing cardiac catheterization, prophylactic treatment with oral acetylcysteine reduces the incidence of contrast‐induced nephropathy. Catheter Cardiovasc Interv 2003;60:458–461.

Renal artery reconstruction for the preservation of renal function

PURPOSE We reviewed a 13-year experience with an emphasis on long-term survival and renal function response when renal artery reconstruction (RAR) was performed primarily for the preservation or restoration of renal function in patients who had atherosclerotic renovascular disease. METHODS From January 1, 1980, to June 30, 1993, 139 patients underwent RAR for renal function salvage and were retrospectively reviewed. Inclusion criteria were either preoperative serum creatinine level > 2.0 mg/dl (67% of patients) or RAR to the entire functioning renal mass irrespective of baseline renal function. Patient survival was calculated by life-table methods. Cox regression analysis was used to determine relative risk (RR) estimates for the late outcomes of continued deterioration of renal function and late survival after RAR. A logistic regression model was used to evaluate variables associated with perioperative complications. RESULTS Clinical characteristics of the cohort were notable for advanced cardiac (history of congestive heart failure, 27%; angina, 22%; previous myocardial infarction, 19%) and renal disease (serum creatinine level < 2.0 mg/dl, 33%; 2.0 mg/dl to 3.0 mg/dl, 40%, > 3.0 mg/dl, 27%). Cardiac disease was the principle cause of early (6 of 11 operative deaths) and late death. Operative management consisted of aortorenal bypass in 47%, extraanatomic bypass in 45%, and endarterectomy in 8%; 45% of patients required combined aortic and RAR. The operative mortality rate was 8%; significant perioperative renal dysfunction occurred in 10%. Major operative morbidity was associated with increasing azotemia (RR = 2.1; p = 0.001; 95% confidence interval [CI], 1.3 to 4.7 for each 1.0 mg/dl increase in baseline creatinine level). Of those patients who had a baseline creatinine level > or = 2.0 mg/dl, 54% had > or = 20% reduction in creatinine level after RAR. Late follow-up data were available for 87% of operative survivors at a mean duration of 4 years (range, 6 weeks to 12.6 years). Actuarial survival at 5 years was 52% +/- 5%. Continued deterioration in renal function occurred in 24% of patients who survived operation, and eventual dialysis was required in 15%. Deterioration of renal function after RAR was associated with increasing levels of preoperative creatinine (RR = 1.6; 95% CI, 1.2 to 1.8; p = 0.001 for each 1.0 mg/dl increment in baseline creatinine level), and inversely related to early postoperative improvement in creatinine level (RR = 0.41; 95% CI, 0.2 to 0.9; p = 0.04). CONCLUSIONS Intervention before major deterioration in renal function and an aggressive posture toward the frequently associated coronary artery disease are necessary to improve long-term results when RAR is performed for renal function salvage.

Effectiveness of and Adverse Events After Percutaneous Coronary Intervention in Patients With Mild Versus Severe Renal Failure

Patients with renal failure undergoing percutaneous coronary intervention (PCI) experience reduced procedural success rates and increased in-hospital and long-term follow-up major adverse cardiac events. This study was designed to determine whether the severity of preprocedural renal failure influences the outcomes of patients with renal failure undergoing PCI. We compared the immediate and long-term outcomes of 192 patients with mild renal failure (creatinine 1.6 to 2.0 mg/dl, mean 1.76) with those of 131 patients with severe renal failure (creatinine >2.0 mg/dl, mean 2.90), selected from 3,334 consecutive patients undergoing PCI between 1994 and 1997. Although the overall population with renal failure represents a high-risk group, the severe renal failure cohort had a higher incidence of hypertension, multivessel disease, prior coronary bypass surgery, vascular disease, and congestive heart failure (all p values <0.05), yet had similar angiographic characteristics. Procedural success was higher in the group with severe renal failure (93.7% vs 87.7%, p = 0.04). There were no statistically significant differences in in-hospital mortality (11.5% vs 9.9%, p = 0.7), Q-wave myocardial infarction (0.5% vs 0%, p = 0.4), emergent bypass surgery (0% vs 0%, p = 1.0), and in-hospital major adverse cardiac events (11.5% vs 9.9%, p = 0.7) between the mild and severe renal groups, respectively. Kaplan-Meier analyses showed no statistically significant difference in long-term survival (log rank test, p = 0.1) or event-free survival (log rank test, p = 0.3) between the 2 groups. Finally, creatinine was not identified as an independent predictor of in-hospital or long-term follow-up major adverse cardiac events. In our high-risk population, patients with mild renal insufficiency undergoing PCI experience major adverse outcomes in the hospital and at long-term follow-up similar to those of patients with severe renal failure.

The Incidence and Predictors of Job Burnout in First-Year Internal Medicine Residents: A Five-Institution Study

Purpose Job burnout is prevalent among U.S. internal medicine (IM) residents and may lead to depression, suboptimal patient care, and medical errors. This study sought to identify factors predicting new burnout to better identify at-risk residents. Method The authors administered surveys to first-year IM residents at five institutions twice between June 2008 and June 2009, linking individual pre- and postresponses. Surveys measured job burnout, sleepiness, personality traits, and other characteristics. Burnout was defined using the most commonly identified definition and another stricter definition. Results Of 263 eligible residents, 185 (70%) completed both surveys. Among 114 residents who began free of burnout and completed both surveys, 86 (75%) developed burnout, with no differences across institutions. They were significantly more likely to report a disorganized personality style (9 versus 0; 11% versus 0%; P = .019) and less likely to report receiving regular performance feedback (34 versus 13; 63% versus 87%; P = .057). Using a stricter definition, 50% (78/156) of residents developed burnout. They were less likely to plan to pursue subspecialty training (49 versus 63; 78% versus 93%; P = .016) or have a calm personality style (59 versus 70; 77% versus 90%; P = .029). There were no significant associations between burnout incidence and duty hours, clinical rotation, demographics, social supports, loan debt, or psychiatric history. Conclusions This study identified a high burnout incidence. The associations observed between burnout incidence and personality style, lack of feedback, and career choice uncertainty may inform interventions to prevent burnout and associated hazards.

The Internal Medicine Reporting Milestones and the Next Accreditation System

The Accreditation Council for Graduate Medical Education (ACGME) developed the Milestones Project to facilitate more synthetic and narrative-based assessments of educational outcomes. This commenta...

Case records of the Massachusetts General Hospital. Case 6-2008. A 46-year-old woman with renal failure and stiffness of the joints and skin.

Dr. Nancy Cibotti-Granof (Medicine): A 46-year-old woman with end-stage renal disease was seen by a rheumatology consultant because of stiffness of her joints and skin. The patient had been well except for mild asthma until 7 years earlier, when group A streptococcal pneumonia developed, complicated by septic shock, with acute respiratory distress syndrome; septic emboli to the lungs, brain, and kidney; renal failure requiring dialysis; f laccid quadriplegia; and coma. On the 25th day after initial admission to another hospital, she was transferred to this hospital while she was receiving mechanical ventilation. As part of the evaluation during admission, computed tomography (CT) of the thorax, abdomen, and pelvis with intravenous contrast revealed cavitary lesions in the right lower lobe of the lung, with diffuse bilateral ground-glass opacities, small bilateral pleural effusions, and multiple prominent mediastinal lymph nodes. CT of the head revealed regions of cortical mineralization in the left posterior frontal lobe and the right parietal lobe, with surrounding hypodensity consistent with edema and minimal enhancement consistent with cerebritis. Magnetic resonance imaging (MRI) of the brain with gadolinium revealed regions of cortical enhancement with surrounding edema in the left posterior frontal lobe and right parietal lobe consistent with cerebritis and vasculitis, as well as a small infarct in the right corona radiata (Fig. 1A). Follow-up CT scans with contrast enhancement and MRI studies with gadolinium enhancement revealed regions of cerebritis and small infarcts, with no drainable abscesses. Transthoracic and transesophageal echocardiography showed a patent foramen ovale, normal left ventricular function, and no valvular vegetations. A filter was placed in the inferior vena cava. During the hospital stay, the blood pressure stabilized; the patient regained consciousness and recovered speech and motor strength, with residual right-sided weakness. Kidney function improved, and hemodialysis was discontinued. Weakness, sensory loss, and pain in both feet persisted, and treatment with gabapentin (300 mg twice daily) was begun. The patient was discharged on the 53rd hospital day, first to a rehabilitation facility for 2 months, and then to home. Follow-up MRI Case 6-2008: A 46-Year-Old Woman with Renal Failure and Stiffness of the Joints and Skin

Case 6-2008

Dr. Nancy Cibotti-Granof (Medicine): A 46-year-old woman with end-stage renal disease was seen by a rheumatology consultant because of stiffness of her joints and skin. The patient had been well except for mild asthma until 7 years earlier, when group A streptococcal pneumonia developed, complicated by septic shock, with acute respiratory distress syndrome; septic emboli to the lungs, brain, and kidney; renal failure requiring dialysis; f laccid quadriplegia; and coma. On the 25th day after initial admission to another hospital, she was transferred to this hospital while she was receiving mechanical ventilation. As part of the evaluation during admission, computed tomography (CT) of the thorax, abdomen, and pelvis with intravenous contrast revealed cavitary lesions in the right lower lobe of the lung, with diffuse bilateral ground-glass opacities, small bilateral pleural effusions, and multiple prominent mediastinal lymph nodes. CT of the head revealed regions of cortical mineralization in the left posterior frontal lobe and the right parietal lobe, with surrounding hypodensity consistent with edema and minimal enhancement consistent with cerebritis. Magnetic resonance imaging (MRI) of the brain with gadolinium revealed regions of cortical enhancement with surrounding edema in the left posterior frontal lobe and right parietal lobe consistent with cerebritis and vasculitis, as well as a small infarct in the right corona radiata (Fig. 1A). Follow-up CT scans with contrast enhancement and MRI studies with gadolinium enhancement revealed regions of cerebritis and small infarcts, with no drainable abscesses. Transthoracic and transesophageal echocardiography showed a patent foramen ovale, normal left ventricular function, and no valvular vegetations. A filter was placed in the inferior vena cava. During the hospital stay, the blood pressure stabilized; the patient regained consciousness and recovered speech and motor strength, with residual right-sided weakness. Kidney function improved, and hemodialysis was discontinued. Weakness, sensory loss, and pain in both feet persisted, and treatment with gabapentin (300 mg twice daily) was begun. The patient was discharged on the 53rd hospital day, first to a rehabilitation facility for 2 months, and then to home. Follow-up MRI Case 6-2008: A 46-Year-Old Woman with Renal Failure and Stiffness of the Joints and Skin

Time of flight renal MR angiography: Utility in patients with renal insufficiency

We studied the renal arteries prospectively in 16 patients with renal insufficiency using a combination of two-dimensional and three-dimensional time of flight magnetic resonance angiography (MRA). Results were compared with conventional angiography. All renal arteries were identified by MRA. Accuracy for classifying renal arteries into patent, moderately (30-70%) stenotic, severely (> 70%) stenotic, or occluded was 91%. With regard to the presence or absence of severe occlusive disease (> 70% stenosis or occlusion) the sensitivity was 100%, with a specificity of 93%.