James Paparello

Association of C-Reactive Protein and Microalbuminuria (from the National Health and Nutrition Examination Surveys, 1999 to 2004)

Chronic kidney disease and cardiovascular disease share many risk factors. Injury to the vascular endothelium, measured by elevated levels of serum C-reactive protein (CRP), may play a role in kidney and cardiovascular disease. We therefore examined the association of CRP with microalbuminuria, a marker of early kidney injury. We conducted a cross-sectional analysis of a nationally representative, population-based survey. Weighted multiple logistic regression was used to study the association between CRP and microalbuminuria, adjusting for well-known risk factors. CRP was analyzed by a continuous variable and two categorized variables using quartiles and clinically recommended cutpoints. CRP concentration was positively associated with microalbuminuria. In the multivariate model, a one unit (in milligrams per liter) increase in CRP concentration was associated with a 2% increased odds of microalbuminuria (odds ratio 1.02, 95% confidence interval [CI] 1.01 to 1.02, p=0.0003). When CRP concentrations were stratified by clinically recommended cutpoints, compared with persons with CRP concentrations<1 mg/dl, persons with CRP concentrations between 1 and 3 mg/L and >3 mg/L were 1.15 times (95% CI 0.94 to 1.42) and 1.33 times (95% CI 1.08 to 1.65) more likely to have microalbuminuria, respectively. In subgroup analyses, the strength of association was comparable or stronger. In conclusion, elevated CRP levels were associated with microalbuminuria in a large, nationally representative data set. Vascular inflammation, as measured by CRP, may be a common contributor to early heart and kidney disease.

Distortion Product Otoacoustic Emission Test of Sensorineural Hearing Loss: Performance Regarding Sensitivity, Specificity and Receiver Operating Characteristics

The performance of distortion product otoacoustic emissions (DPOEs) as a frequency-specific test of sensorineural hearing loss was evaluated in 142 ears of human adults with normal middle-ear function. The DPOE was measured with the stimulus levels of the two tones equal to 65 dB SPL (re 20 mu Pa) and the ratio between the two frequencies 1.2. In the DPOE test, the cochlear function of an ear at a test frequency was predicted to be normal or abnormal depending upon whether the DPOE level with the geometric mean of the two stimulus frequencies at the test frequency was greater or less than a criterion. The DPOE test outcomes were evaluated against the pure-tone hearing threshold as the standard. We found the sensitivity, specificity and predictive efficiency of the test to be 85-89% at 6000 and 4000 Hz, 82-83% at 2000 Hz and 78-79% at 1000 Hz, respectively. The performance was also evaluated using decision theory in terms of the area under the receiver operating characteristics. The latter was found to range from 0.90 (for 1000 Hz) to 0.94 (for 6000 Hz). These findings support the conclusion that the DPOEs can form a useful frequency-specific objective test of cochlear function.

Thrombocytopenia associated with dialysis treatments

We present a case of a 51‐year‐old woman who developed thrombocytopenia associated with dialysis treatments. Laboratory values revealed a platelet count of 50,000 or less postdialysis, with recovery of platelet count during her interdialytic period. An extensive work up including infectious serology and heparin‐induced thrombocytopenia test was negative. Based on the pattern of thrombocytopenia and negative work‐up, it is concluded that her thrombocytopenia was due to her dialysis treatments. We discuss the literature on thrombocytopenia and hemodialysis and postulate that our patient had a reaction to her dialyzer membrane or to the electron beam radiation method used to sterilize her dialyzer.

Preoperative Nuclear Renal Scan Underestimates Renal Function After Radical Nephrectomy

OBJECTIVE To compare expected and actual renal function after nephrectomy. Nuclear renal scan estimates differential kidney function and is commonly used to calculate expected postoperative renal function after radical nephrectomy. However, the observed postoperative renal function is often different from the expected. METHODS A retrospective review was performed on 136 patients who underwent radical nephrectomy or nephroureterectomy and had a preoperative renal scan with calculated differential function. RESULTS Glomerular filtration rate (GFR) values, preoperative and postoperative, were calculated with the Modification of Diet in Renal Disease (MDRD) equation. The expected postoperative GFR based on renal scan was compared with the actual postoperative GFR. The average age of patients undergoing surgery was 58.6 years, and the indication for surgery was for benign causes in 59 (44%) patients and cancer in 76 (56%) patients. The average preoperative creatinine and estimated GFR were 1.0 mg/dL and 69.9 mL/min/1.73 m(2). At a median follow-up of 3.3 months, the actual postoperative GFR exceeded the expected GFR by an average of 12.1% (interquartile range, 2.6%-25.2%). When stratified by preoperative GFR >90, 60-90, and <60 mL/min/1.73 m(2), respectively, the observed GFR exceeded the expected GFR by 4.3%, 12.6%, and 14.9%, respectively (P = .16). This trend was maintained when GFR was plotted over time. CONCLUSION After nephrectomy, the remaining kidney exceeded the expected postoperative GFR by 12% in this cohort of patients with preoperative renal scans. Patients with existing renal insufficiency had the greatest compensatory response, and this was durable over time.

Appropriate diuretic dosing: Closed loop communication

Injectable furosemide was first approved for use by the US Food and Drug Administration in 1968. For more than 40 years, loop diuretics have been the mainstay of therapy for relief of congestion and fluid removal in patients admitted with acute decompensated heart failure (ADHF). Despite the widespread use of loop diuretics in clinical practice, robust data supporting their role is scarce. Furthermore, the optimal approach to the management of the patient with acute volume overload has not been well defined.

Osmotic shifts, cerebral edema, and neurologic deterioration in severe hepatic encephalopathy

Objectives: We sought to determine the effect of acute electrolyte and osmolar shifts on brain volume and neurologic function in patients with liver failure and severe hepatic encephalopathy. Design: Retrospective analysis of brain CT scans and clinical data. Setting: Tertiary care hospital ICUs. Patients: Patients with acute or acute-on-chronic liver failure and severe hepatic encephalopathy. Interventions: Clinically indicated CT scans and serum laboratory studies. Measurements and Main Results: Change in intracranial cerebrospinal fluid volume between sequential CT scans was measured as a biomarker of acute brain volume change. Corresponding changes in serum osmolality, chemistry measurements, and Glasgow Coma Scale were determined. Associations with cerebrospinal fluid volume change and Glasgow Coma Scale change for initial volume change assessments were identified by Spearman’s correlations (rs) and regression models. Consistency of associations with repeated assessments was evaluated using generalized estimating equations. Forty patients were included. Median baseline osmolality was elevated (310 mOsm/Kg [296–321 mOsm/Kg]) whereas sodium was normal (137 mEq/L [134–142 mEq/L]). Median initial osmolality change was 9 mOsm/kg (5–17 mOsm/kg). Neuroimaging consistent with increased brain volume occurred in 27 initial assessments (68%). Cerebrospinal fluid volume change was more strongly correlated with osmolality (r = 0.70; p = 4 × 10–7) than sodium (r = 0.28; p = 0.08) change. Osmolality change was independently associated with Glasgow Coma Scale change (p = 1 × 10–5) and cerebrospinal fluid volume change (p = 2.7 × 10–5) in initial assessments and in generalized estimating equations using all 103 available assessments. Conclusions: Acute decline in osmolality was associated with brain swelling and neurologic deterioration in severe hepatic encephalopathy. Minimizing osmolality decline may avoid neurologic deterioration.