Recurrent nephrolithiasis and loss of kidney function: a cohort study.

PURPOSE: To evaluate whether symptomatic recurrent nephrolithiasis leads to loss of kidney function. METHODS: Adults who presented to the Emergency Department at least twice with symptomatic and radiologically confirmed nephrolithiasis were retrospectively recruited. Primary endpoint was the change in glomerular filtration rate (GFR) between baseline and at the time of data collection. Secondary endpoints include GFR slope defined as the mean rate of change in GFR from baseline to the end of the study period. RESULTS: 240 patients had recurrent symptomatic nephrolithiasis. Median follow-up was 5.4 years. The median age of first acute presentation was 51.6 years and the median baseline serum creatinine (bsCr) was 85.5 umol/l. 17.5% (n = 42) had worsening GFR, with the average change in GFR of - 8.64 ml/min/1.73 m2 per year. Four patients progressed to ESKD requiring haemodialysis. 14.5% (n = 35) had calcium oxalate stones. Univariate analysis showed older patients (p < 0.001), more symptomatic stone episodes (p < 0.001) and non-calcium-containing stones (p < 0.001) were strongly associated with deteriorating kidney function. Age (p = 0.002) and number of acute stone episodes (p = 0.011) were significant predictive factors when unadjusted to co-morbidities. Age (p = 0.018) was the only predictive factor of worsening GFR when adjusted for co-morbidities. Average mean GFR slope was - 2.83/min/1.73 m2 per year. CONCLUSIONS: Recurrent symptomatic nephrolithiasis is associated with loss of kidney function, in older patients, increased episodes of symptomatic nephrolithiasis and non-calcium-containing stones. Age is the only predictive factor for progression to chronic kidney disease in this subgroup.

Heterotopic caval valve implantation in severe tricuspid regurgitation.

Severe symptomatic tricuspid regurgitation (TR) with right heart failure is associated with significant morbidity and mortality. Medical therapy is often ineffective and surgical correction is not feasible due to prohibitive perioperative risk. Transcatheter caval valve implantation (CAVI) is an evolving therapeutic option for this condition. It refers to the heterotopic placement of a valve into the inferior vena cava alone or with a second valve in the superior vena cava to restrict the backflow from the failing tricuspid valve. We hereby describe a patient with previous mitral valve surgery with chronic severe TR who underwent successful CAVI at our institute.

Combined off pump coronary artery bypass graft and liver transplant.

Background: Prospective recipients of liver transplant (LT) have a high prevalence rate of coronary artery disease (CAD) requiring revascularization. In patients of Child Turcot Pugh Class B and C performing LT prior to cardiac revascularization on cardiopulmonary bypass leads to a high risk of major adverse cardiovascular events (MACE). Whereas, isolated cardiac surgery prior to LT has perioperative risk of coagulopathy, sepsis, and hepatic decompensation. We present four cases of end stage liver disease who underwent concomitant living donor liver transplant (LDLT) with off pump coronary artery bypass graft (OPCAB) in an effort to decrease the morbidity and mortality. Methods: The cases were performed in a tertiary care centre over two years. Four patients scheduled for LDLT, who were diagnosed with significant CAD, underwent single sitting OPCAB and LDLT. Cardiac surgery was performed first and once patient was stable, it was followed by LDLT. The morbidity parameters in terms of duration of intubation, blood transfusion, hospital stay, ICU stay, requirement of dialysis, atrial fibrillation and sepsis was compared with similar studies. Results: The blood transfusion requirement (median 8 units PRBC), incidence of atrial fibrillation (25%), sepsis (25%), and renal dysfunction (0%) was less than the combined surgery conducted on cardiopulmonary bypass. The rate of median intubation time, length of ICU stay, hospital stay, and one year mortality rate was comparable with other studies. Conclusions: Morbidity with combined OPCAB and LDLT is less than combined on pump coronary artery bypass surgery with LDLT. Combined CABG with LDLT may be performed with acceptable outcomes in CTP class B and C cirrhosis.

Baseline characteristics of patients with atypical haemolytic uraemic syndrome (aHUS): The Australian cohort in a global aHUS registry.

AIMS: To describe the baseline characteristics and treatment of Australian patients diagnosed with atypical haemolytic uraemic syndrome (aHUS) reported to the Global aHUS Registry. METHODS: Descriptive analysis of the Australian cohort with aHUS (n = 106) was undertaken for demographics, disease characteristics and prior treatment with eculizumab; comparing with the global cohort (n = 1688) for certain pre-specified disease characteristics. RESULTS: In Australia, almost two-thirds of patients diagnosed with aHUS were female and over 80% of patients were Caucasians, with similar proportions reported in the global cohort. Less than 6% of patients in the Australia and global cohorts were reported to have a history of autoimmune disease (4% vs 2%, respectively; P = .21) or cancer (5% vs 5%, respectively; P = .93), conditions that have been associated with secondary HUS. In the Australian cohort, 26% had received a kidney transplant and 68% of patients had received eculizumab. Kidneys were the most common organ involvement, followed by gastrointestinal tract (26%) and cardiovascular system (19%), with 35% of patients reported to have had at least two organs involved within 6 months prior to baseline visit or entry into the registry. Complement factor H was the most common pathogenic complement gene variant in the Australian patients. CONCLUSION: Data from the aHUS registry confirms and defines region-specific disease characteristics among a selected group of Australian children and adults with aHUS reported to the registry. Ongoing and more inclusive data will provide further information about temporal trends and treatment outcomes, representing a unique opportunity for clinicians and researchers to further develop knowledge surrounding this rare disease.

APRT deficiency: the need for early diagnosis.

Adenine phosphoribosyltransferase (APRT) deficiency is a rare autosomal recessive disorder which leads to accumulation of poorly soluble 2,8-dihydroxyadenine in kidneys resulting in nephrolithiasis as well as chronic kidney disease from crystal nephropathy. This report describes a 55-year-old previously fit man who presented with shortness of breath and the investigative pathway that eventually led to a diagnosis of APRT deficiency. Early diagnosis has aided in timely institution of allopurinol, thereby improving his renal function and possibility of weaning off renal replacement therapy. Genetic testing has enabled early identification of other family members at risk and prevention of renal failure by commencing xanthine oxidoreductase (XOR) inhibitors. The issues surrounding kidney donation by a member of this family are also discussed. This case represents the importance of awareness and recognition of the signs and symptoms of this rare condition, complications of which can be easily prevented by early institution of XOR inhibitor therapy.

Nonanalgesic benefits of combined thoracic epidural analgesia with general anesthesia in high risk elderly off pump coronary artery bypass patients.

OBJECTIVE: Epidural anesthesia is a central neuraxial block technique with many applications. It is a versatile anesthetic technique, with applications in surgery, obstetrics and pain control. Its versatility means it can be used as an anesthetic, as an analgesic adjuvant to general anesthesia, and for postoperative analgesia. Off pump coronary artery bypass (OPCAB) surgery triggers a systemic stress response as seen in coronary artery bypass grafting (CABG). Thoracic epidural anesthesia (TEA), combined with general anesthesia (GA) attenuates the stress response to CABG. There is Reduction in levels of Plasma epinephrine, Cortisol and catecholamine surge, tumor necrosis factor-Alpha( TNF ά), interleukin-6 and leucocyte count. DESIGN: A prospective randomised non blind study. SETTING: A clinical study in a multi specialty hospital. PARTICIPANTS: Eighty six patients. Material and Methods/intervention: The study was approved by hospital research ethics committee and written informed consent was obtained from all patients. Patients were randomised to receive either GA plus epidural (study group) or GA only (control group). Inclusion Criteria (for participants) were -Age ≥ 70 years, Patient posted for OPCAB surgery, and patient with comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, cerebrovascular disease, peripheral vascular disease, renal dysfunction). Serum concentration of Interlukin: - 6, TNF ά, cortisol, Troponin - I, CK-MB, and HsCRP (highly sensitive C reactive protein), was compared for both the group and venous blood samples were collected and compared just after induction, at day 2, and day 5 postoperatively. Time to mobilization, extubation, total intensive care unit stay and hospital stay were noted and compared. Independent t test was used for statistical analysis. PRIMARY OUTCOMES: Postoperative complications, total intensive care unit stay and hospital stay. Secondary Outcome: Stress response. RESULT: Study group showed decreased Interlukin - 6 at day 2, TNF ά at day 2 and 5,troponin I at day 5, and decreased total hospital stay ( p < 0.05). CONCLUSION: Thoracic epidural anesthesia decreases stress and inflammatory response to surgery and decreases hospital stay. However a large multicentre study may be needed to confirm it.

Bilateral renal inflammatory pseudotumour effectively treated with corticosteroid.

Inflammatory pseudotumour (IPT) is a rare disease of unknown cause that most commonly involves the lung but can occur in almost any site in the body. Occurrence in the kidneys is very rare and bilateral renal involvement even rarer. There are 34 previously reported cases in the English-language medical literature between 1966 and 2008. Herein we report a case of IPT infiltrating both kidneys. We have also reviewed the clinical features, radiological findings, treatment and outcome of renal IPT. Clinical features at presentation are commonly non-specific. Features on imaging are inadequate to make a diagnosis of IPT or to clearly distinguish it from malignancy. Consequently diagnosis has frequently been made after nephrectomy and on a few occasions with the aid of percutaneous or open biopsies. The majority of renal IPT (83%) have been treated with nephrectomy and those cases with bilateral IPT have received corticosteroids.

Mortality associated with aprotinin during 5 years following coronary artery bypass graft surgery.

CONTEXT: Acute safety concerns have been raised recently regarding certain hemorrhage-sparing medications commonly used in cardiac surgery. However, no comprehensive data exist regarding their associations with long-term mortality. OBJECTIVE: To contrast long-term all-cause mortality in patients undergoing coronary artery bypass graft (CABG) surgery according to use of 2 lysine analog antifibrinolytics (aminocaproic acid and tranexamic acid), the serine protease inhibitor aprotinin, or no antibleeding agent. DESIGN, SETTING, AND PARTICIPANTS: Observational study of mortality conducted between November 11, 1996, and December 7, 2006. Following index hospitalization (4374 patients; 69 medical centers), survival was prospectively assessed at 6 weeks, 6 months, and annually for 5 years after CABG surgery among 3876 patients enrolled in a 62-center international cohort study. The associations of survival with hemorrhage-sparing medications were compared using multivariable analyses including propensity adjustments. MAIN OUTCOME MEASURE: Death (all-cause) over 5 years. RESULTS: Aprotinin treatment (223 deaths among 1072 patients [20.8% 5-year mortality]) was associated with significantly increased mortality compared with control (128 deaths among 1009 patients [12.7%]; covariate adjusted hazard ratio for death, 1.48; 95% confidence interval, 1.19-1.85), whereas neither aminocaproic acid (132 deaths among 834 patients [15.8%]; adjusted hazard ratio for death, 1.03; 95% confidence interval, 0.80-1.33) nor tranexamic acid (65 deaths among 442 patients [14.7%]; adjusted hazard ratio for death, 1.07; 95% confidence interval, 0.80-1.45) was associated with increased mortality. In multivariable logistic regression, either with propensity adjustment or without, aprotinin was independently predictive of 5-year mortality (adjusted odds ratio with propensity adjustment, 1.48; 95% confidence interval, 1.13-1.93; P = .005) among patients with diverse risk profiles, as well as among those surviving their index hospitalization. Neither aminocaproic nor tranexamic acid was associated with increased risk of death. CONCLUSIONS: These findings indicate that in addition to the previously reported acute renal and vascular safety concerns, aprotinin use is associated with an increased risk of long-term mortality following CABG surgery. Use of aprotinin among patients undergoing CABG surgery does not appear prudent because safer and less expensive alternatives (ie, aminocaproic acid and tranexamic acid) are available.

Spinal (subarachnoid) morphine for off-pump coronary artery bypass surgery.

OBJECTIVE: To study the effects of 8 microg/kg preoperatively administered intrathecal morphine sulfate on extubation time, postoperative pulmonary function, and postoperative analgesia after off-pump coronary artery bypass grafting (OPCAB). DESIGN: A prospective, randomized, double-blind, placebo controlled study. PARTICIPANTS: One hundred adult patients scheduled for elective primary OPCAB. INTERVENTIONS: Patients were randomized to preoperative administration of 8 microg/kg intrathecal morphine sulfate (group 1) with a 25-gauge spinal needle or to receive sterile normal saline placebo subcutaneously (group 2). Anesthetic induction and maintenance were standardized to allow planning for facilitating early tracheal extubation. Multivessel OPCAB was performed with an Octopus stabilizer. Patients were extubated in the intensive care unit by a blinded observer using predefined extubation criteria. MEASUREMENTS AND MAIN RESULTS: Postoperative times to extubation were 9.47 +/- 3.83 hours in group 1 versus 11.25 +/- 3.94 hours in group 2 (P = .025). Postextubation bedside spirometric lung volumes in percentage of preoperative lung volume showed significant differences in group 1 versus group 2 in forced vital capacity, 39.66% +/- 15.42% versus 31.85% +/- 11.65% (P = .016); forced expiratory volume in the first second, 44.8% +/- 16.18% versus 35.97% +/- 13.32% (P = .013); maximum voluntary ventilation, 39.40% +/- 13.57% versus 33.11% +/- 14.80% (P = .056); and expiratory flow rate, 47.76% +/- 24.61% versus 37.37% +/- 4.33% (P = .031). The visual analog pain scores at rest and during coughing at time intervals of 6, 12, 24, and 36 hours postoperatively showed significantly better results in group 1 compared with group 2. The total dose of fentanyl citrate required intraoperatively was significantly less in group 1 (P = .00). One patient in group 1 had a low respiratory rate, which responded to injection naloxone. There was no mortality or neurological complication in either group. CONCLUSION: Intrathecal morphine provided superior quality of analgesia that translated into better maintenance of postoperative lung volume determined by spirometry. This analgesic method also facilitated earlier tracheal extubation without any major respiratory or neurologic complications.

Perioperative management of a renal transplanted patient for coronary artery bypass grafting.

Following renal transplantation, patients for coronary artery bypass grafting are subjected to high morbidity and mortality during the perioperative period because of the risk of major infections, renal impairment or rejection, and myocardial infarction. We describe the perioperative management of one such high-risk patient.

Comparison of trough, 2-hour, and limited AUC blood sampling for monitoring cyclosporin (Neoral) at day 7 post-renal transplantation and incidence of rejection in the first month.

The use of alternative strategies to the traditional pre-dose/trough (C0) blood sampling for cyclosporine (CsA) therapeutic drug monitoring has the potential to revolutionize analytical practices which have, in many centers, been established for some 20 years. While the C0 sample has previously been recommended, current attitudes are increasingly proposing alternatives for assessing CsA exposure, including various limited sampling strategies of the AUC (lssAUC) in the early postdose period, or alternative single-point nontrough samples, such as a 2-hour postdose sample (C2). The present study has reviewed a series of consecutive renal transplant recipients over 18 months where CsA was the primary immunosuppressant. The lssAUC performed at around day 7 posttransplantation included drawing blood at 0, 2, and 4 hours postdose, giving AUC(0-4). The aim of this study was to review the occurrence of acute biopsy-proven rejection in the first month and consider which of (simultaneously measured) C0, C2 or AUC(0-4) was a better early indicator of this adverse outcome. The result was best described by comparing the data from rejectors (n = 13) and nonrejectors (n = 42) for these 3 indices of CsA exposure (i.e., C0, C2 or AUC(0-4)). There was no evidence that C0 predicted the likelihood of such adverse clinical outcomes. In contrast, rejectors tended to have lower mean C2 CsA concentrations, and the incidence of rejection was 0.0 when C2 exceeded 1200 microg/L (n = 10). While the data are limited in the higher C2 CsA concentration range, it is nevertheless consistent with more recent recommendations suggesting that the CsA at C2 should target 1700 microg/L in this first month posttransplantation. As 64% of the patients were also receiving a CsA-sparing agent (diltiazem [DTZ]), the relationships were also investigated to determine whether any affect of concomitant DTZ therapy could be demonstrated. However, in this small sample, no significant affect of DTZ was seen.

Comparison of continuous, stat, and intermittent cardiac output measurements in patients undergoing minimally invasive direct coronary artery bypass surgery.

OBJECTIVE: To compare intermittent cardiac output (ICO) with continuous cardiac output (CCO) and stat cardiac output (SCO) measurements in patients undergoing minimally invasive direct coronary artery bypass (MIDCAB) surgery. DESIGN: Prospective, clinical study. SETTING: Single, tertiary referral center. PARTICIPANTS: Twenty adult patients undergoing off-pump MIDCAB surgery from January through June 2000. INTERVENTIONS: Each patient had a 7.5F 5-lumen pulmonary artery thermodilution catheter (CCO catheter, Baxter Healthcare Corporation, Irvine, CA) inserted for measurement of cardiac output (CO). ICO, CCO, and SCO were compared at 10 predefined time points. RESULTS: A total of 400 data pairs for CO were obtained. ICO values ranged from 1.8 to 8.4 L/min; CCO, 1.9 to 7.5 L/min; and SCO, 2.25 to 6.35 L/min. Correlation between ICO and CCO was significant (correlation coefficient, r = 0.78, p < 0.001), accompanied by a bias of -0.095 L/min and precision of 0.729 L/min. Similarly, the correlation between ICO and SCO was significant (r = 0.79, p < 0.001), accompanied by good accuracy (bias, 0.084 L/min) and precision (0.843 L/min). There were statistically significant decreases in mean arterial pressure, CO, cardiac index, stroke volume, stroke volume index, and left and right ventricular stroke work indices during anastomosis of the left internal mammary artery to left anterior descending artery. These parameters returned to baseline preinduction values 1 minute after completion of the anastomosis. CONCLUSION: Excellent correlation, accuracy, and precision were found among the 3 methods of measuring CO in patients undergoing MIDCAB surgery. Further studies are needed to assess their accuracy in multivessel off-pump coronary artery bypass graft surgery and in patients with poor left ventricular function.

Off-pump coronary artery bypass grafting: new developments but a better outcome?

Off-pump coronary artery surgery is now performed safely and effectively without cardiopulmonary bypass. This review includes indications, approaches, anaesthetic and haemodynamic management, and compares the occurrence of postoperative complications and multiorgan dysfunction with conventional cardiac surgery.