The prognostic and diagnostic implications of surveillance serial myocardial perfusion imaging in asymptomatic renal transplant candidates.

BACKGROUND: The utility of serial SPECT myocardial perfusion imaging (MPI) for CAD surveillance in asymptomatic ESRD patients awaiting kidney transplantation (KT) is uncertain. METHODS AND RESULTS: We retrospectively investigated 700 asymptomatic KT candidates with ≥ 2 pre-transplant SPECT-MPIs (mean interval, 20 ± 13 months). Worsening MPI was defined as total perfusion deficit increase (ΔTPD) > 5%. High clinical risk was defined as ≥ 3 AHA/ACC KT risk factors. The primary outcome was major adverse cardiac events (MACE) of cardiac death or myocardial infarction. The initial MPI was normal in 462 (66%) subjects. On repeat MPI, ΔTPD > 5% was observed in 82 (12%) subjects, and the incidence increased with increasing time gap between MPIs (P = .006). During a mean follow-up of 16 ± 8 months, there were 119 (17%) MACEs. In the entire cohort, ΔTPD > 5% was not significantly associated with MACE (HR = 1.38; P = .210). ΔTPD > 5% was associated with increased MACE rate among patients with normal initial MPI (HR = 2.30; P = .005), but not among those with abnormal initial MPI (P = .260). There was a significant interaction between ΔTPD > 5% and initial MPI normalcy status in predicting MACE (interaction P = .018), such that the predictive value of ΔTPD is dependent on the initial MPI normalcy. Among subjects with normal initial MPI, ΔTPD > 5% was significantly associated with MACE only if the sum of KT risk factors was ≥ 3 (HR = 2.26; P = .016). Among 123 patients who underwent coronary angiography, ΔTPD > 5% was associated with a higher prevalence of obstructive CAD when the initial MPI was normal and the sum of KT risk factors was ≥ 3. CONCLUSION: Among patients with ESRD waitlisted for KT, new/worsening MPI abnormalities are expected. On serial surveillance, ΔTPD > 5% is associated with MACE and obstructive CAD among those with a normal initial MPI and ≥ 3 AHA/ACC KT risk factors.

Intensity-Dependent Benefit of Statins in Survival Among Prospective Kidney Transplant Patients.

Statin use in patients listed for in kidney transplant is believed to be beneficial. However, the optimum statin dose for improved survival in this high-risk population is unknown. Our study aimed to determine the impact of prekidney transplant statin dosage on survival postkidney transplant. In this retrospective cohort study, we enrolled patients who underwent kidney transplant from January 2005 to September 2015 at Rush University Medical. Data on the statin use and intensity used before kidney transplant were obtained. The patient population was stratified into 2 groups based on prekidney transplant use of statins. Patients using any form of statin, without regard to the type and dose, were placed in the statin groups, whereas the rest were categorized as the no statin group. The statin group was further classified into low-intensity, moderate-intensity, and high-intensity statin subgroups based on the present atherosclerotic cardiovascular disease definition of statin intensity. The primary outcome was patient survival after kidney transplant. A total of 687 patients had data on statin use before kidney transplant were followed. Median follow-up time was 3.4 years (interquartile range 1.2 to 5.6 years). Multivariate analysis showed that the use of statins prekidney transplant was associated with improved survival postkidney transplant compared with prestatin group (Hazard ratio 0.56, confidence intervals 0.32 to 1.00, p = 0.05). When patients on statins were stratified by statin intensity, Kaplan-Meier survival analysis revealed a significant dose-dependent improvement in survival. Multivariate analysis showed that the relation between statin intensity and survival was maintained even after adjusting for confounder (hazard ratio 0.30, confidence intervals 0.18 to 0.51, p <0.001). In conclusion, our data indicate statistically significant survival benefit in patients receiving high-intensity statin before kidney transplant.

An easy miss: aortic dissection in a 'healthy' male.

Aortic dissection is an uncommon cause of chest discomfort that can be rapidly fatal without early diagnosis and prompt treatment. In this report, we present a man with no risk factors who presented with chest discomfort not typical of a dissection, absent pulse and blood pressure differential and a normal chest radiograph. He eventually was diagnosed with an extensive Type-A aortic dissection. We discuss diagnostic clues, classification of aortic dissection and possible treatment options.

Cutaneous Drug Reactions in a tertiary government hospital in the Philippines 2009-2011

OBJECTIVES: To determine the frequency of cutaneous drug reactions (CDRs), thier associated drugs, and morphological presentation min the Philippine General Hospital (PGH) from 2009 to 2011 and to identify new or uncommon drugs causing CDRs. METHODS: This is a 3-year retrospective record review. The Naranjo algorithm was used to score drug causality. RESULTS: One hundred and forty-three (143) patient records were retrieved, with 218 associated drugs identified. The most common drug classes were antibiotics (29%), anti-tuberculosis medications (17%), and NSAIDs (9%). The most common drugs were isoniazid, rifampicin, pyrazinamide, ethambutol (HRZE) combination drug (9%); amoxicillin (6%); and cotrimoxazole (5%). A morbiliform reaction (49%) was the most common morphological presentation. There were several identified drugs, including anti-fungals and beta-blockers, which caused a single drug reaction but had a sufficient Naranjo score to warrant inclusion. CONCLUSION: The most common drug classes, drugs, and cutaneous morphological presentation found in this study are similar to those seen in existing literature. However, there were several drugs identified causing single drug reactions. This may reflect the need for improved documentation, diagnosis, and follow-up of CDR cases in the PGH.