Outcomes of peritoneal dialysis in cirrhosis: A systematic review and meta-analysis.

BACKGROUND: Cirrhosis and end-stage kidney disease (ESKD) are significant global health concerns, contributing to high mortality and morbidity. Haemodialysis (HD) is frequently used to treat ESKD in patients with cirrhosis. However, it often presents challenges such as haemodynamic instability during dialysis sessions, leading to less than optimal outcomes. Peritoneal dialysis (PD), while less commonly used in cirrhotic patients, raises concerns about the risks of peritonitis and mortality. Our systematic review and meta-analysis aimed to assess outcomes in PD patients with cirrhosis. METHODS: We executed a comprehensive search in Ovid MEDLINE, EMBASE and Cochrane databases up to 25 September 2023. The search focused on identifying studies examining mortality and other clinical outcomes in ESKD patients with cirrhosis receiving PD or HD. In addition, we sought studies comparing PD outcomes in cirrhosis patients to those without cirrhosis. Data from each study were aggregated using a random-effects model and the inverse-variance method. RESULTS: Our meta-analysis included a total of 13 studies with 15,089 patients. Seven studies compared ESKD patients on PD with liver cirrhosis (2753 patients) against non-cirrhosis patients (9579 patients). The other six studies provided data on PD (824 patients) versus HD (1943 patients) in patients with cirrhosis and ESKD. The analysis revealed no significant difference in mortality between PD and HD in ESKD patients with cirrhosis (pooled odds ratio (OR) of 0.77; 95% confidence interval (CI), 0.53-1.14). In PD patients with cirrhosis, the pooled OR for peritonitis compared to non-cirrhosis patients was 1.10 (95% CI: 1.03-1.18). The pooled ORs for hernia and chronic hypotension in cirrhosis patients compared to non-cirrhosis controls were 2.48 (95% CI: 0.08-73.04) and 17.50 (95% CI: 1.90-161.11), respectively. The pooled OR for transitioning from PD to HD among cirrhotic patients was 1.71 (95% CI: 0.76-3.85). Mortality in cirrhosis patients on PD was comparable to non-cirrhosis controls, with a pooled OR of 1.05 (95% CI: 0.53-2.10). CONCLUSIONS: Our meta-analysis demonstrates that PD provides comparable mortality outcomes to HD in ESKD patients with cirrhosis. In addition, the presence of cirrhosis does not significantly elevate the risk of mortality among patients undergoing PD. While there is a higher incidence of chronic hypotension and a slightly increased risk of peritonitis in cirrhosis patients on PD compared to those without cirrhosis, the risks of hernia and the need to transition from PD to HD are comparable between both groups. These findings suggest PD as a viable and effective treatment option for ESKD patients with cirrhosis.

A case of acquired thrombotic thrombocytopenic purpura following near-drowning.

A 19-year-old woman with a history of asthma presented with acute confusion following a near-drowning event 2 weeks prior to admission. She was found to have severe thrombocytopenia and microangiopathic hemolytic anemia (MAHA). The treatment for thrombotic thrombocytopenic purpura (TTP) was started on the day of admission due to high clinical suspicion. Subsequent workup confirmed a diagnosis of TTP with no clear etiology except the near-drowning incident. TTP following a near-drowning event has never been reported in the literature. Furthermore, she developed refractory TTP that required reinitiation of therapeutic plasma exchange and rituximab. After discharge, the patient had been doing well over a year of follow-up without remission.

The Association and Utility of Left Ventricular End-Diastolic Pressure in Predicting the Development of and in Managing Contrast-Induced Nephropathy in Patients Undergoing Coronary Angiography.

Contrast-induced nephropathy (CIN) is a significant complication in patients undergoing coronary angiography, and its development is associated with increased morbidity and mortality. Left ventricular end-diastolic pressure (LVEDP) provides one index of left heart filling status. An elevated LVEDP can reflect volume overload or abnormal diastolic function and indicates a cardiac disorder. Data on the association between an elevated LVEDP and CIN are limited and have had conflicting results. We systematically searched the databases PubMed, Embase, and Scopus for full-text articles from database inception to May 2022. Studies were included if they evaluated the association between a high LVEDP and the incidence of CIN in patients undergoing coronary angiography. The study was registered in the PROSPERO CRD42022334070. A second search in PubMed identified randomized controlled trials using LVEDP to guide fluid administration during coronary procedures. Four studies were identified that used LVEDP to classify patients into groups to determine the association between the level and the development of CIN. In these studies, 240 patients of 2441 patients (9.8%) developed CIN. One study found no association between LVEDP levels and the development of CIN. Two studies found an increased frequency of CIN in patients with elevated levels using 2 cutoff points for LVEDP, ≥20 mm Hg and >30 mm Hg. One study found that lower LVEDP levels (5-14 mm Hg) were associated with the development of CIN. Three randomized control trials used LVDEP levels to manage fluid administration in patients undergoing coronary procedures; only one study found that the use of these levels to guide fluid administration resulted in better outcomes. In patients undergoing coronary angiography, an elevated LVEDP was not consistently associated with increased risk of CIN, and using LVEDP levels to guide fluid administration during these procedures did not always improve outcomes in comparison to other protocols. The use of LVEDP levels can help classify patients with cardiac disorders but does not necessarily provide an adequate description of the hemodynamic patterns in these patients to predict or prevent CIN in patients undergoing angiography.

Periodontal disease and risk of atrial fibrillation or atrial flutter: A systematic review and meta-analysis.

Background: We conducted a study to evaluate the risk of atrial fibrillation (AF) and atrial flutter (AFL) in periodontal disease (PD) patients. Methods: Cohort studies that evaluate the risk of AF or AFL in PD patients were included. The risk was expressed in the pooled odd ratio (OR) with 95% confidence interval (CI). Results: A total of four cohort studies were included. We found that patients with PD have a significantly higher risk of AF/AFL compared to those without PD with the pooled OR of 1.33 (95% CI 1.29-1.38; p = 0.357, I 2 = 3.0%). Conclusions: PD increases the risk of AF and AFL.

Eosinophilia with Lung Involvement in an Elderly Patient with a History of Chronic Obstructive Pulmonary Disease.

Eosinophilia with pulmonary involvement is characterized by the presence of peripheral blood eosinophilia, typically >500 cells/mm3, nonspecific pulmonary symptoms, and radiographic evidence of pulmonary disease. Clinical, laboratory, and radiologic features can be overlapping in these diseases, thus, it is wise to approach eosinophilia with pulmonary involvement systematically to determine the diagnosis and provide definitive treatment for a better outcome. The authors present a case of idiopathic chronic eosinophilic pneumonia in a patient with a long history of chronic obstructive pulmonary disease (COPD) which was resolved by corticosteroid.

Pre-bariatric surgery acute kidney injury: Can this be prevented?

Key Clinical Message: Pre-bariatric surgery dietary recommendations should take into account daily protein intake and other risk factors for kidney injury. This is important because a high protein intake can potentially lead to kidney injury. Abstract: Bariatric surgery has been shown to be a highly effective intervention for achieving weight loss and reducing obesity related-comorbidities. Acute kidney injury (AKI) is considered one of the common complications in perioperative and post-bariatric surgery. However, pre-bariatric surgery AKI has never been reported. Several studies demonstrated that pre-bariatric surgery weight loss improved surgical outcomes and decrease postoperative complications. Some diet regimens have been introduced including low-caloric diet (LCD), very-low caloric diet (VLCD), and very-low caloric ketogenic diet (VLCKD). We present a patient who develops AKI after 10 days of having a high-protein diet from a pre-bariatric weight loss strategy.

Rumpel-Leede Phenomenon Following Radial Artery Catheterisation.

Rumpel-Leede phenomenon is a rarely diagnosed entity that can be seen in patients following the application of tourniquet-like forces to the extremities. This phenomenon describes petechiae and purpura secondary to venous compression and congestion, with its underlying aetiology involving the fragility of capillary vessels within the dermis. This condition is associated with chronic medical conditions such as diabetes mellitus, hypertension, dyslipidemia, peripheral vascular disease and systemic inflammatory diseases, including infections. In addition, patients with coagulopathy including thrombocytopenia or platelet dysfunction from antiplatelet use, or those with thrombotic thrombocytopenic purpura and idiopathic thrombocytopenic purpura, are predisposed to capillary haemorrhage and petechiae formation. In this report, we present a case of a patient who developed Rumpel-Leede phenomenon following catheterisation of the right radial artery with spontaneous resolution - where only five cases have been reported to date - with the aim to make clinicians aware of this condition and to avoid unnecessary interventions. LEARNING POINTS: Rumpel-Leede phenomenon is a benign condition that can be seen after tourniquet-like compression of a limb in those with capillary fragility.Dermatologists and other practitioners should remain aware of the phenomenon, helping to avoid unnecessary investigation.Rumpel-Leede phenomenon self-resolves, with only supportive treatment required with no reported lingering effects to date.

Ivabradine effects on COVID-19-associated postural orthostatic tachycardia syndrome: a single center prospective study.

BACKGROUND: A wide range of cardiac arrhythmias were reported in the setting of active infection or as a complication of COVID-19. The main pathophysiology can be attributed to dysautonomia or autonomic nervous system dysfunction. Postural orthostatic tachycardia syndrome (POTS) is a complex, multisystemic disorder affecting usually younger age with tachycardia at rest or with minimal effort being the main symptom. Data regarding the safety and efficacy of ivabradine in POTS treatment is limited to small studies and case reports. METHODS: This prospective observational study included a total of 55 COVID-19-associated POTS patients after the exclusion of other causes of tachycardia. Ivabradine 5 mg twice daily was initiated. Re-assessment of patients' symptoms, heart rate, and heart rate variability (HRV) parameters' changes after 3 days of ivabradine therapy was done. RESULTS: The mean age of the included patients was 30.5±6.9 years with 32 patients being males (58.2%). 43 of 55 (78%) of the included patients reported significant improvement of the symptoms within 7 days of ivabradine therapy. 24-hour heart rate (minimum, average, and maximum) was significantly lower (p-value < 0.0001*, = 0.001*, < 0.0001* consecutively) with a significant difference in HRV time-domain parameters (SDNN, rMSSD) (p-value < 0.0001*) after ivabradine therapy. CONCLUSION: In a prospective study that evaluated the effects of ivabradine in post-COVID-19 POTS, patients treated with ivabradine reported improvement of their symptoms within 7 days of ivabradine treatment with a significant reduction of 24-hour average, minimum, and maximum heart rate, and improvement of HRV time domains parameters. Ivabradine might be a useful option to relieve symptoms of tachycardia in COVID-19 POTS. Further research is required to confirm the safety and efficacy of ivabradine in POTS treatment.

High-risk phenotypes of arrhythmic mitral valve prolapse: a systematic review and meta-analysis.

BACKGROUND: Mitral valve prolapse (MVP) is associated with aggravated risk of ventricular tachycardia (VT), ventricular fibrillation (VF) and sudden cardiac death (SCD). There is a lack of specific guideline recommendation regarding risk stratification and management, despite multiple proposed high-risk phenotypes. We performed systematic review and meta-analysis to evaluate high-risk phenotypes for malignant arrhythmias in patients with MVP. METHODS: We comprehensively searched the databases of MEDLINE, SCOPUS, and EMBASE from inception to April 2023. Included studies were cohort and case-control comparing between MVP patients with and without VT, VF, cardiac arrest, ICD placement, or SCD. Data from each study were combined using the random-effects. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: Nine studies from 1985 to 2023 were included involving 2,279 patients with MVP. We found that T-wave inversion (OR 2.52; 95% CI: 1.90-3.33; p < 0.001), bileaflet involvement (OR 2.28; 95% CI: 1.69-3.09; p < 0.001), late gadolinium enhancement (OR 17.05; 95% CI: 3.41-85.22; p < 0.001), mitral annular disjunction (OR 3.71; 95% CI: 1.63-8.41; p < 0.002), and history of syncope (OR 6.96; 95% CI: 1.05-46.01; p = 0.044), but not female (OR 0.96; 95% CI: 0.46-2.01; p = 0.911), redundant leaflets (OR 4.30; 95% CI: 0.81-22.84; p = 0.087), or moderate-to-severe mitral regurgitation (OR 1.24; 95% CI: 0.65-2.37; p = 0.505), were associated with those events. CONCLUSION: Bileaflet prolapse, T-wave inversion, mitral annular disjunction, late gadolinium enhancement, and history of syncope are high-risk phenotypes among population with MVP. Further research is needed to validate the risk stratification model and justify the role of primary prophylaxis against malignant arrhythmias.

Association between elevated CHA2DS2-VASC score and contrast-induced nephropathy among patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis.

BACKGROUND: Promising results with the CHA2DS2-VASc risk score (CVRS) have been reported for the prediction of contrast-induced nephropathy (CIN). The aim of this study is to consolidate all the data available and examine the association between elevated CVRS and the incidence of CIN in patients undergoing percutaneous coronary intervention (PCI). METHODS: We systematically searched PubMed, Embase, and Scopus for abstracts and full-text articles from inception to May 2022. Studies were included if they evaluated the association between a high CVRS and the incidence of CIN in patients undergoing PCI. Data were integrated using the random-effects, generic inverse variance method of DerSimonian and Laird. Prospero registration: CRD42022334065. RESULTS: Seven studies from 2016 to 2021 with a total of 7,401 patients were included. In patients undergoing PCI, a high CVRS (≥2: Odds ratio [OR]:2.98, 95% confidence interval [95% CI] 2.25-3.94, p < .01, I2 = 1%, ≥3: OR 4.46, 95% CI 2.27-8.78, p < .01, I2=56% and ≥4: OR:2.75, 95% CI 1.76-4.30, p < .01, I2 = 11%) was significantly associated with an increase incidence for CIN. Subgroup analyses were done in patients with acute coronary syndrome, and association with CIN remained statistically significant (≥2: OR 2.93, 95% CI 2.11-4.07, p < .01, I2=22%and ≥4: OR:2.24, 95% CI 1.36-3.69, p < .01, I2 = 0%,). CONCLUSION: In patients undergoing PCI, an elevated CVRS is associated with an increased risk for CIN. More rigorous studies are needed to clarify this association and to identify strategies to reduce CIN.

Reactivation of Parvovirus B19 Infection: An Uncommon Trigger of Macrophage Activation Syndrome in Adult-Onset Still's Disease.

A 40-year-old woman presented with four weeks of intermittent high-grade fever, cough, and joint pain, and two weeks of a generalized rash. She was found to have adult-onset Still's disease (AOSD) and rapidly developed macrophage activation syndrome (MAS) on the second day of admission. Among infectious etiologies, Epstein-Barr virus and members of the herpes virus family are common triggers of MAS. However, our patient was found to have reactivation/recurrence of parvovirus B19 infection as the cause; this is an uncommon trigger reported infrequently in the medical literature. Despite intensive treatment, the patient passed away.

A Systematic Review and Meta-Analysis of Posttransplant Anemia With Overall Mortality and Cardiovascular Outcomes Among Kidney Transplant Recipients.

Introduction: Posttransplant anemia is a common finding after kidney transplantation. A previous meta-analysis reported an association between anemia and graft loss. However, data on cardiovascular outcomes have not yet been reported. Objective: We conducted an updated meta-analysis to examine the association between posttransplant anemia and outcomes after transplantation including cardiovascular mortality in adult kidney transplant recipients. Methods: We comprehensively searched the databases of MEDLINE and EMBASE from inception to November 2021. Data from each study were combined using the random-effects model. Generic inverse variance method of DerSimonian and Laird was employed to calculate the risk ratios and 95% CIs. Results: Seventeen studies from August 2006 to April 2019 were included (16 463 kidney transplantation recipients). Posttransplant anemia was associated with overall mortality (pooled risk ratio = 1.72 [1.39, 2.13], I2 = 56%), graft loss (pooled risk ratio = 2.28 [1.77, 2.93], I2 = 94%), cardiovascular death (pooled risk ratio = 2.06 [1.35, 3.16], I2 = 0%), and cardiovascular events (pooled risk ratio = 1.33 [1.10, 1.61], I2 = 0%). Early anemia (≤6 months), compared with late anemia (>6 months), has higher risk of overall mortality and graft loss with a pooled risk ratio of 2.63 (95% CI 1.79-3.86; I2 = 0%) and 2.96 (95% CI 2.29-3.82; I2 = 0%), respectively. Discussion: In addition to increased risk of graft loss, our updated meta-analysis demonstrated that posttransplant anemia was significantly associated with poor outcomes after kidney transplantation including overall mortality, graft loss, cardiovascular death, and cardiovascular events. Future studies are required to assess the effects of treatment strategies for posttransplant anemia on posttransplant outcomes including cardiovascular mortality.

Daptomycin-induced rhabdomyolysis complicated with acute gouty arthritis.

Rhabdomyolysis is a well-documented side effect of daptomycin and is associated with hyperuricemia. However, the occurrence of acute gouty arthritis secondary to rhabdomyolysis-induced hyperuricemia has not been reported. We report a case of a patient who presented with daptomycin-induced rhabdomyolysis prior to the usual 7-10-day administration period. This case was complicated with acute gouty arthritis after 7 days from the onset of rhabdomyolysis symptoms. Treatment consisted of fluid management with the addition of prednisone for gouty arthritis treatment given his poor kidney function. This report indicates the importance of early monitoring of creatine kinase levels in patients on daptomycin to prevent complications from rhabdomyolysis.

Transient diabetes insipidus after vasopressin discontinuation in cystic fibrosis with septic shock.

Central diabetes insipidus (DI) is an uncommon condition caused by reduced or lack of vasopressin secretion from the posterior pituitary gland, typically caused by gland destruction. Several other causes for central DI have also been proposed. Here we present a case of transient central DI after discontinuation of vasopressin used for septic shock without evidence of overt pituitary damage in a cystic fibrosis patient. The serum sodium concentration peaked at 137 mmol/L in the setting of polyuria within 3 days of vasopressin discontinuation without other identified alternative etiologies. Sodium levels and urine output trended down dramatically with desmopressin administration.

Transient Leukopenia Induced by Combination Therapy for Severe SARS-CoV-2 Pneumonia.

Treatment strategies for patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continue to be heavily researched and ever-changing. Recent data has suggested that combination therapy with dexamethasone, remdesivir and baricitinib could decrease the severity and length of illness in patients with severe SARS-CoV-2. However; the data regarding the safety and side effects related to this combination therapy are limited to case reports. The purpose of this case report is to highlight a potentially life-threatening side effect of one or all medications mentioned above. LEARNING POINTS: Current National Institutes of Health treatment guidelines recommend remdesivir for patients with a high risk of progression. In patients requiring minimal supplemental oxygen, remdesivir or dexamethasone monotherapy is recommended, while in patients requiring high-flow oxygen or non-invasive ventilation, dexamethasone monotherapy or dexamethasone plus remdesivir is recommended. Baricitinib or tocilizumab can be added in patients requiring oxygen supplementation.Clinicians should be aware of transient leukocytopenia that can be induced with combination therapy of dexamethasone, remdesivir and baricitinib during the early phase of treatment of SARS-CoV-2 patients.The evaluation approach for leukopenia should consider autoimmune disorders, inflammatory diseases, infections, malignancy, and medication and toxin exposure.

Melatonin: Translation of Ongoing Studies Into Possible Therapeutic Applications Outside Sleep Disorders.

PURPOSE: Melatonin, a natural hormone mainly synthesized by the pineal gland, is regulated by circadian rhythm. Synthetic melatonin is not approved by the US Food and Drug Administration for any indication. However, melatonin receptor agonists such as ramelteon and tasimelteon are US Food and Drug Administration approved and are considered by the American Academy of Family Physicians for the treatment of insomnia. Due to the availability of over-the-counter products in some countries and the increasing use of melatonin, it is interesting to highlight knowledge regarding the potential benefits of melatonin outside sleep disorders. METHODS: This narrative review included published reports in EMBASE and MEDLINE databases between 1975 and 2021 relating to the therapeutic applications of melatonin. FINDINGS: Based on the quality of the evidence published to date, the most promising non-insomnia indications are for treating ischemia/reperfusion injury, primary headache disorders, fibromyalgia, glucose control, and blood pressure control. IMPLICATIONS: Most of the studies were preclinical and in in vivo and in vitro phases. More clinical trials are needed before recommending melatonin as a treatment in clinical practice.

Empyema necessitans as a rare manifestation of Aspergillus fumigatus infection.

Fungal empyema is an uncommon condition associated with high morbidity and mortality. Aspergillus empyema thoracis is rare and is usually associated with preexisting chronic empyema, pulmonary tuberculosis, or rupture of aspergilloma cavity. This case describes a healthy 20-year-old man presenting with chronic intractable back pain and constitutional symptoms for 6 months who was eventually diagnosed with Aspergillus empyema thoracis, complicated by empyema necessitans extending into multiple ribs and paravertebral areas. He was treated with surgical decortication, chest tube drainage, and systemic antifungal agents. The diagnostic difficulties of fungal empyema thoracis are highlighted.

Idiopathic spontaneous pneumoperitoneum.

Spontaneous pneumoperitoneum is the presence of free air in the peritoneum without evidence of any perforation of hollow viscera. The usual presentation includes acute abdominal pain with leukocytosis and elevated inflammatory markers. Here we present a case of spontaneous pneumoperitoneum occurring recurrently in a 58-year-old man with inclusion body myositis and hypertension who presented with cellulitis of both legs. Abdominal computed tomography demonstrated retroperitoneal free air; however, colonoscopy, esophagogastroduodenoscopy, and a prior laparoscopy did not demonstrate any perforation of hollow viscera. Conservative management with antibiotics and symptom control with antiemetics and pain medicines led to clinical improvement, and the patient was discharged home in stable condition.