Catheter-directed thrombolytic infusion for thrombosed arteriovenous fistulas with a large clot burden: A case series.

Arteriovenous fistula (AVF) thrombosis occurs less often when compared to arteriovenous grafts. Since the number of AVFs has increased in the United States, AVF thrombosis is seen more frequently today. AVF thrombectomy can be tedious, requires physician ingenuity, and many times results in failure. Substantial clot burden in megafistulas and aneurysms is considered a relative contraindication to endovascular thrombectomy. Usually, it results in surgical referral for open thrombectomy or, at times, abandonment of the fistula altogether. Herein, we describe the technique, results, and cautions of combining a continuous infusion of recombinant tissue plasminogen (rTPA) followed by angioplasty of the culprit stenotic lesion that was successful in opening five of six AVFs with a substantial clot burden.

Early cytomegalovirus DNAemia and antiviral dose adjustment in high vs intermediate risk kidney transplant recipients.

BACKGROUND: Cytomegalovirus (CMV) infection continues to negatively affect outcomes for solid organ transplant recipients, despite the advent of strategies for preemptive surveillance and prophylaxis. The impact is especially great for CMV seronegative recipients of donor seropositive organs, who typically lack the ability to control CMV infection at the time of transplantation. METHODS: We reviewed episodes of CMV DNAemia in a modern cohort of kidney transplant recipients over a 3-year period at a high-volume transplant center to investigate the frequency of DNAemia during antiviral prophylaxis. RESULTS: Despite receipt of antiviral prophylaxis per current guidelines, 75 cases of CMV DNAemia were observed in the first 100 days after transplantation. For high risk patients, median time to DNAemia was 75 days after transplantation, and the majority of patients had experienced dose-reduction of valganciclovir due to renal insufficiency. Review of CMV seropositive intermediate risk patients demonstrated DNAemia occurring earlier after transplantation compared with high risk patients with a median time of 64 days (P = .029). The impact of valganciclovir dose adjustment was less notable in the intermediate risk group. CONCLUSIONS: Guidelines recommend beginning routine surveillance for CMV after the completion of antiviral prophylaxis. Our findings suggest that closer monitoring may be beneficial, especially for high risk patients at risk for DNAemia. Patients requiring dose adjustment of valganciclovir due to renal insufficiency may be at increased risk for CMV DNAemia. Improved methods for CMV prophylaxis and evaluation of immunologic risk for CMV DNAemia and disease are needed to improve patient outcomes after kidney transplantation.

Are Salt Tablets Effective in the Treatment of Euvolemic Hyponatremia?

OBJECTIVES: There is limited evidence for the use of salt tablets in the treatment of hyponatremia. This retrospective study evaluated the effectiveness of salt tablet administration in euvolemic hyponatremia. METHODS: This was a single-center, retrospective cohort study. Information on patients' demographics, clinical characteristics, and laboratory data were collected for retrospective review. Treatment for hyponatremia, including the amount of salt tablets, fluid restriction, and diuretics was collected. We compared hyponatremic patients with those who received salt tablets versus those who did not receive salt tablets. The primary outcome of interest was the change in serum sodium at 48 hours between the two groups. RESULTS: A total of 1258 medical records were initially screened with inclusion and exclusion criteria. After screening, there were 83 patients included in the study. Forty-two patients received salt tablets and 41 patients were in the group that did not receive salt tablets. Patients treated with salt tablets were older, more often female, and had lower body weight and lower initial serum sodium. The change in serum sodium after 48 hours was higher in the salt tablet group (5.2 mEq/L) than the non-salt tablet group (3.1 mEq/L; P < 0.001). This difference in serum sodium between the two groups remained statistically significant when adjusted for age, sex, weight, and initial serum sodium. CONCLUSIONS: The use of salt tablets in the treatment of euvolemic hyponatremia is associated with a small but significant improvement in serum sodium compared with patients who did not receive such therapy, even after adjusting for age, sex, weight, and initial serum sodium. This study supports the effectiveness of salt tablets in the treatment of euvolemic hyponatremia in medical patients.

Modes of death and clinical outcomes in adult patients with hypertrophic cardiomyopathy in Thailand.

BACKGROUND: There are limited data about modes of death and major adverse cardiovascular events (MACEs) in patients with hypertrophic cardiomyopathy (HCM) in South East Asian population. The aim of the study was to examine modes of death and clinical outcomes in Thai patients with HCM. METHODS: Between January 1, 2009 and December 31, 2013, 166 consecutive patients with HCM diagnosed in our institution were evaluated. Five patients were excluded because of non-Thai ethnic groups (n = 3) and diagnosis of myocardial infarction at initial presentation documented by coronary angiography (n = 2). The final study population consisted of 161 patients with HCM. HCM-related deaths included: (1) sudden cardiac death (SCD) - death due to sudden cardiac arrest or unexpected sudden death; (2) heart failure - death due to refractory heart failure; or (3) stroke - death due to embolic stroke associated with atrial fibrillation. MACEs included: (1) SCD, sudden unexpected aborted cardiac arrest, fatal, or nonfatal ventricular arrhythmia (ventricular fibrillation or sustained ventricular tachycardia); (2) heart failure (fatal or non-fatal), or heart transplantation; or (3) stroke - fatal or non-fatal embolic stroke associated with atrial fibrillation. RESULTS: One hundred and sixty-one Thai patients with HCM (age 66 ± 16 years, 58% female) were enrolled. Forty-two patients (26%) died over a median follow-up period of 6.8 years including 25 patients (16%) with HCM-related deaths (2%/year). The HCM-related deaths included: heart failure (52% of HCM-related deaths; n = 13), SCD (44% of HCM-related deaths; n = 11), and stroke (4% of HCM-related deaths, n = 1). The SCDs occurred in 6.8% of patients (1%/year). Eighty-four major MACEs occurred in 65 patients (41, 5%/year). The MACEs included: 40 heart failures in which 2 patients underwent heart transplants; 22 SCDs and nonfatal ventricular arrhythmias; and 22 fatal or nonfatal strokes. CONCLUSIONS: The most common mode of death in adult patients with HCM in Thailand was heart failure followed by SCD. About one-third of the patients experiencing heart failure died during the 6.8 years of follow-up. SCDs occurred in 7% of patients (1%/year), predominantly in the fourth decade or later.

Ruptured Gastric Aneurysm in α-1 Antitrypsin Deficiency.

We present a unique vascular complication of α-1 antitrypsin deficiency (AATD) in a patient with an acute onset of epigastric pain and hemodynamic instability. Abdominal computed tomography angiography detected hemoperitoneum and hematoma within the gastrohepatic ligament with active extravasation. Abdominal angiography revealed left gastric aneurysms. An association between AATD and vascular aneurysms has been suggested to be secondary to unopposed proteolytic activity against arterial structural proteins. The aneurysm formation in aortic, superior mesenteric, inferior mesenteric, and splenic arteries has been reported. We report the first case with ruptured gastric artery aneurysm as a complication of AATD.

Cerebral Venous Air Embolism Secondary to Mesenteric Infarction.

Cerebral air embolism is a rare, yet potentially fatal condition. We present a case of retrograde cerebral venous air emboli arising from the hepatic portal venous system, secondary to a mesenteric infarction. A 69-year-old man with a history of gastrointestinal amyloidosis presented with fever and lethargy. Computed tomography of the brain detected multiple foci of air in the right frontal, fronto-parietal, and left lateral frontal sulci consistent with cerebral venous air emboli. Computed tomography of the abdomen and pelvis revealed moderate thickening and dilatation of the small bowel with diffuse scattered intestinal pneumatosis suggestive of mesenteric infarction with resultant extensive intrahepatic portal venous air. The patient was deemed a poor candidate for surgical intervention and died as a result of septic shock. We believe the cerebral venous air emboli was a result of retrograde flow of air arising from the hepatic venous air ascending via the inferior and superior vena cava to the cerebral venous system. To our knowledge, there have been no reported cases of retrograde cerebral venous air embolism arising from hepatic portal venous system secondary to mesenteric infarction. The clinical significance and prognosis in this setting requires further investigation.

An Unusual Cause of Altered Mental Status in Multiple Myeloma: An Extraosseous Manifestation.

Multiple myeloma typically presents as lytic bony lesions, hypercalcemia, anemia, and renal failure. Extraosseous manifestations are rare. We report on a patient who was recently diagnosed with multiple myeloma and completed the first cycle of bortezomib, dexamethasone, and palliative radiation therapy with good response. Two weeks after discharge, she became confused and was re-admitted. Despite treatment with lactulose and rifaximin, altered mental status worsened. Computer tomographic scan of abdomen showed hepatomegaly and numerous ill-defined small hyperdense nodules scattered throughout the liver. Liver biopsy demonstrated aggregation of plasma cell myeloma. Magnetic resonance imaging of brain revealed dural thickening. Patient's altered mental status was likely from leptomeningeal myelomatosis and hyperammonemic encephalopathy. Although extraosseous manifestations in multiple myeloma including liver and leptomeningeal involvement are rare, its incidence has increased. This condition portends a poor prognosis. The non-specific manifestations of extraosseous myeloma can be confused with complications of multiple sclerosis and lead to incorrect management, thus clinicians should be aware of these pathologies and perform proper diagnostic tests including imaging and tissue pathology. The most effective treatment is unknown, however bortezomib and thalidomide show promise.

Comparison of renal outcomes in off-pump versus on-pump coronary artery bypass grafting: A systematic review and meta-analysis of randomized controlled trials.

AIM: The objective of this meta-analysis was to compare the effects of off-pump and on-pump coronary artery bypass grafting (CABG) on acute kidney injury (AKI) and the need of dialysis after surgery. METHODS: Comprehensive literature searches for randomized controlled trials (RCTs) of CABG with on-pump and off-pump was performed using MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials Systematic Reviews and clinicaltrials.gov from inception through September 2014. Primary outcomes were the incidence of AKI and the need of dialysis. Mortality was assessed among the studies that reported renal outcomes. Pooled risk ratios (RRs) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method. RESULTS: Thirty-three RCTs with 17 322 patients were enrolled in our study. Patients in the off-pump CABG group had overall lower incidence of AKI (19.1%) compared with the on-pump CABG group (22.2%). There was a protective effect of off-pump CABG on the incidence of AKI compared with the on-pump CABG group (RR: 0.87; 95% CI: 0.77-0.98). However, there was no significant difference in the need for dialysis in the off-pump group compared with the on-pump group (RR: 0.84; 95% CI 0.63-1.13). Within the selected trials, post hoc analysis assessing the mortality outcome demonstrated a pooled RR of 0.97 (95% CI, 0.77-1.23) in off-pump versus on-pump CABGs. CONCLUSIONS: Our study demonstrates a beneficial effect of off-pump CABG on the incidence of AKI. However, our meta-analysis does not show benefits of the need of dialysis or survival among patients undergoing off-pump CABG.

Coronary artery disease in primary biliary cirrhosis: A systematic review and meta-analysis of observational studies.

AIM: To investigate the association between primary biliary cirrhosis (PBC) and risk of coronary artery disease (CAD). METHODS: We conducted a systematic review and meta-analysis of published observational studies that reported relative risks, odd ratios, hazard ratios or standardized incidence ratios with 95% confidence intervals (CI) comparing CAD risk in patients with PBC versus non-PBC controls. Pooled risk ratios and 95% confidence intervals were combined using a random-effect model and generic inverse variance of DerSimonian and Laird methods. RESULT: Four studies with 3362 patients with PBC were identified and included in our data analysis. The pooled risk ratio of CAD in patients with PBC was 1.57 (95% CI, 1.21-2.06). The statistical heterogeneity was low with an I(2) of 38%. CONCLUSION: Our study demonstrated a statistically significant increased risk of CAD among patients with PBC.

Granulomatosis with Polyangiitis: A Case of Nasal Mass, Necrotic Lung, and Normal Kidneys.

A diagnosis of granulomatosis with polyangiitis (GPA) can be challenging given various clinical manifestations. We report an incident case of GPA presenting with chronic sinusitis and mimicking an early lung abscess without renal involvement. A 51 year-old woman with chronic obstructive sinusitis presented with subacute dyspnea, pleuritic chest pain and fever. Physical examination revealed a right nasal mass without discharge or bleeding. Decreased to absent breath sounds and dullness to percussion were noted at the left lung base. Laboratory findings were significant for leukocytosis but normal renal function. The chest CT demonstrated dense consolidation with hypo-enhancement of the lingula. The sinus CT revealed an enhancing mass in the right nasal cavity and anterior ethmoid sinuses with associated bony destruction. Patient did not improve with empiric antibiotics for lung abscess. Aspiration of the lingular fluid showed purulent material, however, microbes did not grow in culture. A positive C-ANCA screen was confirmed. A right nasal biopsy was performed which revealed granulomatous inflammation with focal necrosis and vasculitis. The final diagnosis was GPA. Given various clinical manifestations, the diagnosis of GPA can be difficult to distinguish from infectious etiologies. This can delay the treatment, which may be life-saving and organ sparing. We emphasize that an initial screening ANCA serology test is recommended in patients with suggestive clinical findings of GPA. Biopsy of an affected organ is paramount for the definitive diagnosis.

Idiopathic retroperitoneal fibrosis: a challenging case in a rare disease.

CONTEXT: Retroperitoneal fibrosis is a rare but severe disease. The diagnosis is usually late when a patient is evaluated for renal insufficiency. Untreated cases may develop serious complications or advance to end-stage renal disease. CASE REPORT: We report a 66-year-old man who presented with worsening kidney function. He was successfully given the diagnosis of idiopathic retroperitoneal fibrosis. Prednisone (1 mg/kg per day) was initiated. The patient's symptoms continued to improve at 1 month with stable kidney function. CONCLUSION: Clinicians should have high index of suspicion for retroperitoneal fibrosis when patients present with an elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) and renal insufficiency from obstructive uropathy. The diagnosis of retroperitoneal fibrosis is primarily made from imaging by computed tomography (CT) scan. Biopsy should be performed in patients who do not have typical findings on CT scan and to exclude the possibility of immunoglobulin G4 (IgG4)-related disease.

Risk of coronary artery disease in patients with idiopathic inflammatory myopathies: a systematic review and meta-analysis of observational studies.

OBJECTIVES: To investigate the risk of coronary artery disease in patients with idiopathic inflammatory myopathies (IIM). METHODS: We conducted a systematic review and meta-analysis of observational studies that reported odds ratios, relative risks, hazard ratios, or standardized incidence ratios comparing the risk of coronary artery disease in patients with IIM versus non-IIM participants. We searched published studies indexed in MEDLINE, EMBASE, and the Cochrane database from inception to December 2013 using the terms "coronary artery disease" OR "coronary heart disease" OR "myocardial infarction" OR "atherosclerosis" combined with the terms "dermatomyositis" OR "polymyositis" OR "Idiopathic inflammatory myopathy." Pooled risk ratio and 95% confidence interval were calculated using a random-effect, generic inverse variance method. RESULT: Overall, four studies were identified and included for data analysis. The pooled risk ratio of CAD in patients with IIM was 2.24 (95% CI: 1.02-4.92). The statistical heterogeneity of this meta-analysis was high with an I(2) of 97%. CONCLUSION: Our study demonstrated a statistically significant increased risk of CAD among patients with IIM.

Risk of venous thromboembolism in patients with rheumatoid arthritis: a systematic review and meta-analysis.

We performed this meta-analysis to assess venous thromboembolism risk in patients with rheumatoid arthritis. A comprehensive search was performed in MEDLINE, EMBASE, and the Cochrane databases. Nine observational studies met our inclusion criteria and were included in the data analysis. The pooled risk ratios of deep venous thrombosis, pulmonary embolism, and venous thromboembolism in patients with rheumatoid arthritis (RA) compared with non-RA participants were 2.08 (95% CI 1.75-2.47), 2.17 (95% CI 2.05-2.31), and 1.96 (95% CI 1.81-2.11), respectively. Subgroup analysis demonstrated a consistent increased risk in every study design (cohort, case-control, and cross-sectional). Our results indicate a significant increased risk of venous thromboembolism among patients with rheumatoid arthritis.