Fluid accumulation and major adverse kidney events in sepsis: a multicenter observational study.

BACKGROUND: Whether early fluid accumulation is a risk factor for adverse renal outcomes in septic intensive care unit (ICU) patients remains uncertain. We assessed the association between cumulative fluid balance and major adverse kidney events within 30 days (MAKE30), a composite of death, dialysis, or sustained renal dysfunction, in such patients. METHODS: We performed a multicenter, retrospective observational study in 1834 septic patients admitted to five ICUs in three hospitals in Stockholm, Sweden. We used logistic regression analysis to assess the association between cumulative fluid balance during the first two days in ICU and subsequent risk of MAKE30, adjusted for demographic factors, comorbidities, baseline creatinine, illness severity variables, haemodynamic characteristics, chloride exposure and nephrotoxic drug exposure. We assessed the strength of significant exposure variables using a relative importance analysis. RESULTS: Overall, 519 (28.3%) patients developed MAKE30. Median (IQR) cumulative fluid balance was 5.3 (2.8-8.1) l in the MAKE30 group and 4.1 (1.9-6.8) l in the no MAKE30 group, with non-resuscitation fluids contributing to approximately half of total fluid input in each group. The adjusted odds ratio for MAKE30 was 1.05 (95% CI 1.02-1.09) per litre cumulative fluid balance. On relative importance analysis, the strongest factors regarding MAKE30 were, in decreasing order, baseline creatinine, cumulative fluid balance, and age. In the secondary outcome analysis, the adjusted odds ratio for dialysis or sustained renal dysfunction was 1.06 (95% CI 1.01-1.11) per litre cumulative fluid balance. On separate sensitivity analyses, lower urine output and early acute kidney injury, respectively, were independently associated with MAKE30, whereas higher fluid input was not. CONCLUSIONS: In ICU patients with sepsis, a higher cumulative fluid balance after 2 days in ICU was associated with subsequent development of major adverse kidney events within 30 days, including death, renal replacement requirement, or persistent renal dysfunction.

Conduction disorders after tricuspid annuloplasty with mitral valve surgery: Implications for earlier tricuspid intervention.

OBJECTIVE: Tricuspid valve repair has been recently advocated in patients undergoing mitral valve surgery who have mild to moderate secondary tricuspid regurgitation. However, the incidence of heart conduction disorders after combined mitral valve and tricuspid valve interventions has not been evaluated. We sought to analyze the incidence of permanent pacemaker implantations and heart conduction disorders in patients undergoing mitral valve surgery with and without tricuspid valve annuloplasty. METHODS: In 2011 and 2012, among 201 consecutive patients referred to the Hôpital Européen Georges Pompidou for isolated nonischemic mitral valve disease, 113 underwent an isolated mitral valve procedure (group 1) and 88 had a concomitant tricuspid valve ring annuloplasty (group 2). RESULTS: Patients' mean age was 59.7 ± 16.5 years in group 1 and 60.7 ± 14.9 years in group 2 (P = .5). Mean crossclamp time and bypass time were 78 ± 35 minutes and 105 ± 47 minutes in group 1 and 92 ± 36 minutes and 128 ± 50 minutes in group 2, respectively (P = .001 and .005, respectively). Operative mortality was 3% (2.7% in group 1 and 3.2% in group 2, P = .4). Incidence of high-grade heart conduction disorders lasting more than 3 days postoperatively was 14.5% in group 1 and 41.2% in group 2 (P = .001). At 3 years, freedom from permanent pacemaker implantation was 99% ± 2% in group 1 and 94.1% ± 5% in group 2 (P = .02). For the entire cohort, longer crossclamp time (P = .02) and tricuspid ring annuloplasty (hazard ratio, 3.8; P = .001) were independent predictors of heart conduction disorders. CONCLUSIONS: The need for permanent pacemaker implantation is increased after concomitant tricuspid ring annuloplasty in the setting of mitral valve surgery. A clinical period of observation up to 14 days after postoperative heart conduction disorders should be observed before recommending permanent pacemaker placement.

Massive spontaneous choroidal hemorrhage in a patient with chronic renal failure and coronary artery disease treated with Plavix.

PURPOSE: To report a case of massive spontaneous choroidal hemorrhage in a patient with chronic renal failure and coronary artery disease treated with clopidogrel bisulfate (Plavix). METHODS: Case report. RESULTS: A 75-year-old man presented with pain and loss of vision in the left eye for 1 week. His medical history was remarkable for systemic hypertension, chronic renal failure, and artery coronary disease. For 6 months, he had been taking 75 mg/day of Plavix after coronary angioplasty. Ocular examination revealed the patient to be in angle closure. Ultrasonography and computed tomography scan revealed a massive choroidal hemorrhage pushing the iris-lens diaphragm forward. Pain and intraocular pressure were treated successfully with evacuative sclerotomies, but the final exitus after 6 months was bulbar phthisis. CONCLUSIONS: Massive spontaneous choroidal hemorrhage is an extremely rare event that usually has been described in older patients (65-87 years old) receiving anticoagulants or thrombolytic agents. Systemic hypertension, generalized atherosclerosis, and age-related macular degeneration are additional risk factors. In the present case, massive choroidal hemorrhage was associated with use of clopidogrel bisulfate (Plavix) in a patient with chronic renal failure. Our report indicates that Plavix should be administered with caution in patients with chronic renal failure owing to the risk of serious choroidal bleeding. Chronic renal failure should be also included in the list of risk factors for massive spontaneous choroidal hemorrhage. Evacuative sclerotomies may have value in the relief of pain and elevated intraocular pressure but has not been shown to be beneficial in visual and anatomic outcomes.