Novel technique for resolving a stuck rotational atherectomy device in a peripheral artery: a case report.

BackgroundAcute kidney injury (AKI) requiring renal replacement therapy (RRT) is a serious complication in the ICU that results in increased mortality and risk of chronic kidney disease (CKD). Some studies suggest RRT modality may have an impact on long-term renal recovery after AKI. However, other predictive factors of severe long-term CKD in ICU patients with AKI requiring RRT are unknown.MethodsWe performed an ancillary study of the multicenter ELVIS trial in the population with AKI requiring RRT. Patients alive 3 months after RRT initiation were eligible. Serum creatinine levels available at 3, 6 and 12 months and 3 and 5 years were recorded. CKD stage was determined according to the glomerular filtration rate as estimated by the CKD-EPI formula. At each timepoint, two groups of patients were compared, a no/mild CKD group with normal or mildly to moderately decreased renal function (stages 1, 2 and 3 of the international classification) and a severe CKD group (stages 4 and 5). Our objective was to identify predictive factors of severe long-term CKD.ResultsOf the 287 eligible patients, 183 had follow-up at 3 months, 136 (74.3%) from the no/mild CKD group and 47 (25.7%) from the severe CKD group, and 122 patients at 5 years comprising 96 (78.7%) from the no/mild CKD group and 26 (21.3%) from the severe CKD group. Multivariate analysis showed that a long RRT period was associated with severe CKD up to 12 months (ORM12 = 1.03 95% CI [1.02–1.05] per day) and that a high SOFA score at the initiation of RRT was not associated with severe CKD up to 5 years (ORM60 = 0.85 95% CI [0.77–0.93] per point).ConclusionSevere long-term CKD was found in 21% of ICU survivors who underwent RRT for AKI. The duration of the RRT in AKI patients was identified as a new predictive factor for severe long-term CKD. This finding should be taken into consideration in future studies on the prognosis of ICU patients with AKI requiring RRT.Trial registration ELVIS trial was registered with ClinicalTrials.gov, number: NCT00875069 (June 16, 2014), and this ancillary study was registered with ClinicalTrials.gov, number: NCT03302624 (October 6, 2017).

Background: Disease-related malnutrition is highly prevalent, and has prognostic implications for patients with chronic kidney disease (CKD); however, few studies have investigated the impact of malnutrition, or protein-energy wasting (PEW), on healthcare utilization and medical expenditure among CKD patients.Methods: Using claim data from the National Health Insurance in Taiwan, this study identified patients with CKD between 2009–2013 and categorized them into those with mild, moderate, or severe CKD. Cases with PEW after CKD was diagnosed were propensity-score matched with controls in a 1:4 ratio. Healthcare resource utilization metrics were compared, including outpatient and emergency department visits, frequency and duration of hospitalization, and the cumulative costs associated with different CKD severity.Results: From among 347,501 CKD patients, eligible cohorts of 66,872 with mild CKD (49.2%), 27,122 with moderate CKD (19.9%), and 42,013 with severe CKD (30.9%) were selected. Malnourished CKD patients had significantly higher rates of hospitalization (p < .001 for all severities) and re-admission (p = .015 for mild CKD, p = .002 for severe CKD) than non-malnourished controls. Cumulative medical costs for outpatient and emergency visits, and hospitalization, were significantly higher among all malnourished CKD patients than non-malnourished ones (p < .001); total medical costs were also higher among malnourished patients with mild (62.9%), moderate (59.6%), or severe (43.6%) CKD compared to non-malnourished patients (p < .001).Conclusions: In a nationally-representative cohort, CKD patients with PEW had significantly more healthcare resource utilization and higher aggregate medical costs than those without, across the spectrum of CKD: preventing PEW in CKD patients should receive high priority if we would like to reduce medical costs.

The relationship between serum uric acid (SUA) and cardiovascular (CV) mortality in patients with chronic kidney disease (CKD) has been described as either a J- or U-shaped function. However, its effect in non-diabetic CKD (and varying severities of CKD) remains unclear. We analyzed the database of the National Health and Nutrition Examination Survey, USA, from the years 1999 to 2010. We then grouped the subjects into 4 categories according to their SUA levels: (a) < 5 mg/dl, (b) 5–7 mg/dl, (c) 7–9 mg/dl and (d) ≥ 9 mg/dl. For mortality comparison purposes (CV related, cancer related and all-cause mortality), we set the SUA group of 5–7 mg/dl as the reference. We also separated this population into moderate (stage 3) and severe (stages 4 and 5) CKD. A total of 1860 participants were included in this study. Results showed that the group with the lowest SUA levels (< 5 mg/dl), were the least male gender (19.25%), had the lowest body mass index (26.41(95% CI = 25.66–27.16) kg/m2), highest systolic blood pressure (139.02 (95% CI 135.72–142.32) mmHg), highest high-density cholesterol (59.55 (95% CI 57.37–61.74) mg/dl), lowest blood glucose (95.46 (95% CI 93.16–97.76) mg/dl), highest total cholesterol (210.31 (95% CI 203.36–217.25) mg/dl), lowest serum albumin (4.09 (95% CI 4.04–4.14) g/dl), highest estimated glomerular filtration rate (eGFR) (47.91 (95% CI 45.45–50.49) ml/min/1.732m2), least history of hypertension (54.4%), and least total energy intake (1643.7 (95% CI 1536.13–1751.27) kcal/day). In the group with SUA ≥ 9 mg/dl, patients had higher all-cause mortality (HR = 2.15) whatever their baseline CVD status. In non-DM CKD patients with a CVD history, the group with SUA ≥ 9 mg/dl had the highest all-cause mortality (HR = 5.39), CVD mortality (HR = 8.18) and CVD or cancer (HR = 8.25) related mortality. In non-DM patients with severe CKD (eGFR < 30 ml/min/1.732m2), the group with SUA < 5 had a significantly increased all-cause mortality. On the contrary, in non-DM patients with moderate CKD (eGFR = 30–60 ml/min/1.832m2), the group with SUA ≥ 9 had a significantly increased all-cause mortality. In moderate non-DM CKD, SUA ≥ 9 mg/dl is associated with higher all-cause mortality. However, once progressing to severe non-DM CKD, SUA < 5 mg/dl is associated with higher all-cause mortality (even though it has the least risk factors for metabolic syndrome).

The aim was to assess the incidence of hospital complications in patients with acute kidney injury (AKI) after coronary artery bypass grafting (CABG).Patients and Methods. The study included 77 patients with stable angina who underwent CABG, aged 65 (61-69) years, 77,9 % men. The number of patients with arterial hypertension was 96,1 %, with carbohydrate metabolism disorders 45,5 %, with chronic kidney disease (CKD) 22,1 %, and with myocardial infarction (MI) 57,1 %. CABG on the working heart was performed in 28,6 %, bimammary CABG in 49,4 %. The duration of artificial circulation was 64 (55-82) minutes; the number of shunts implanted was 2,7+0,7 units. CKD was diagnosed when the glomerular filtration rate was less than 60 ml/min. The development of AKI was assessed according to the KDIGO criteria (2012).Results. CABG related AKI was detected in 10 (13 %) patients, of which grade 1 in 9 (11,7 %), grade 2 in 1 (1,3 %). The indicators associated with AKI after CABG were more severe initial CKD (stages 3b and 4 CKD – 20 % vs 1,5 %, p=0,043), a higher incidence of acute heart failure (in terms of adrenaline requirement – 30 % vs 5,9 %, p=0,043), more occluded coronary arteries (in the groups with and without CABG: one occlusion 70 % and 52,2 %, two occlusions 0 % and 13,4 %, three occlusions 10 % and 0 %, respectively, p=0,028). More severe CKD (stages 3b and 4) statistically significantly increased the relative risk of AKI after CABG by an average of 2,9 times. Among patients with AKI compared to patients without AKI after CABG, there was a higher incidence of cardiac death (20 % vs 0 %, p=0,015), intraoperative MI (60 % vs 8,9 %, p=0,001), acute heart failure (30 % vs 5,9 %, p=0,043).Conclusion. The incidence of AKI following CABG was 13 %. The development of AKI was associated with more severe initial CKD. Patients with postoperative AKI had a poor hospital prognosis.

BackgroundGlucagon-like peptide-1 receptor agonists (GLP-1 RAs) have been shown to provide cardiovascular benefits in patients with type 2 diabetes mellitus (T2DM). However, their cardiovascular protective efficacy in high-risk T2DM patients, particularly those with a history of cardiovascular events or severe chronic kidney disease, remains uncertain.MethodsA comprehensive search was conducted in PubMed, Embase, Web of Science, and The Cochrane Library to identify randomized controlled trials (RCTs) that evaluated the effects of GLP-1 RAs on cardiovascular outcomes in high-risk patients with T2DM. A random-effects model was used to calculate pooled hazard ratios (HRs) for cardiovascular outcomes. Subgroup analyses and GRADE assessment were also performed.ResultsNine RCTs involving 63,613 patients were included. GLP-1 RAs significantly reduced the risk of the primary composite outcome (HR: 0.86, 95% CI: 0.80–0.92), cardiovascular death (HR: 0.85, 95% CI: 0.78–0.93), all-cause death (HR: 0.87, 95% CI: 0.82–0.93), myocardial infarction (HR: 0.90, 95% CI: 0.82–0.98), stroke (HR: 0.85, 95% CI: 0.77–0.95), and heart failure (HF) hospitalization (HR: 0.90, 95% CI: 0.83–0.97). No significant difference in unstable angina (UA) hospitalization was observed (HR: 1.04, 95% CI: 0.95–1.15). Subgroup analyses indicated greater benefits with combination therapy, particularly in patients with chronic kidney disease. The quality of evidence was rated as “High” for six outcomes and “Moderate” for UA hospitalization.ConclusionsGLP-1 RAs significantly reduce cardiovascular risk in high-risk T2DM patients, especially with combination therapy and in those with chronic kidney disease. However, further research is needed to confirm their long-term effects.

Rotational atherectomy in atherosclerotic rabbit iliac arteries

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Versus Without Chronic Kidney Disease

Chronic Kidney Disease Following Liver Transplantation: A South Australian Experience

Background and Aims The predictive value of hemoglobin A1c (HbA1c) in severe chronic kidney disease (CKD) remains uncertain. We examined the association between HbA1c and complications in individuals with diabetes and severe CKD. Method In a Danish nationwide registry-based cohort study, we included individuals ≥18 years with diabetes and an estimated glomerular filtration rate (eGFR) &amp;lt;30 mL/min/1.73 m2 (not on dialysis) between 2010 and 2022. Each individual with severe CKD was age- and sex-matched with three individuals with diabetes and no/mild CKD (eGFR ≥60 mL/min/1.73 m2) and three individuals with diabetes and moderate CKD (eGFR 30–59 mL/min/1.73 m2), respectively. Multiple Cox regressions were used to estimate the standardized 1-year risk of major adverse cardiovascular events (MACE), microvascular complications, and hospitalization due to hypoglycemia across strata of HbA1c levels. Results We included 27,113 individuals with severe CKD. The standardized 1-year risks of outcomes across strata of HbA1c levels for the three cohorts are presented in Fig. 1. For the individuals with severe CKD, the risk of MACE increased significantly at HbA1c levels &amp;lt;40 mmol/mol (5.8%) and ≥55 mmol/mol (7.2%), compared with an HbA1c level of 45–49 mmol/mol (6.3–6.6%). The risk of microvascular complications increased significantly at HbA1c levels ≥55 mmol/mol (7.2%), whereas there was no statistically significant difference between HbA1c levels of 30–54 mmol/mol (4.9–6.7%). Lastly, the risk of hospitalization due to hypoglycemia was lowest for those with an HbA1c level of 40–44 mmol/mol (5.8–6.2%), while the risk increased significantly with increasing levels of HbA1c ≥45 mmol/mol (6.3%). The patterns of association between HbA1c and outcomes were similar in the severe CKD cohort compared to the matched cohorts with no/mild CKD (n = 80,797) and moderate CKD (n = 80,131). Conclusion HbA1c remained an important predictor of complications in severe CKD. Our data suggest an HbA1c range of 50–54 mmol/mol (6.7–7.1%) to be most favorable with regards to long-term complications in this high-risk population.

Using transformations of existing quality-of-life data to estimate utilities has the potential to efficiently provide investigators with utility information. We used within-method and across-method comparisons and estimated disutilities associated with increasing chronic kidney disease (CKD) severity. In an observational cohort of veterans with diabetes (DM) and pre-existing SF-36/SF-12 responses, we used six transformation methods (SF-12 to EQ-5D, SF-36 to HUI2, SF-12 to SF-6D, SF-36 to SF-6D, SF-36 to SF-6D (Bayesian method), and SF-12 to VR-6D) to estimate unadjusted utilities. CKD severity was staged using glomerular filtration rate estimated from serum creatinines, with the modification of diet in renal disease formula. We then used multivariate regression to estimate disutilities specifically associated with CKD severity stage. Of 67,963 patients, 22,273 patients had recent-onset DM and 45,690 patients had prevalent DM. For the recent-onset group, the adjusted disutility associated with CKD derived from the six transformation methods ranged from 0.0029 to 0.0045 for stage 2; -0.004 to -0.0009 for early stage 3; -0.017 to -0.010 for late stage 3; -0.023 to -0.012 for stage 4; -0.078 to -0.033 for stage 5; and -0.012 to -0.001 for ESRD/dialysis. Disutility did not increase monotonically as CKD severity increased. Differences in disutilities estimated using the six different methods were found. Both findings have implications for using such estimates in economic analyses.

The aim of this study was to investigate the relations of left ventricular (LV) mass and geometry to LV function in patients with predialysis chronic kidney disease (CKD), by real-time 3-dimensional echocardiography (RT3-DE). Echocardiography was performed on 76 consecutively enrolled patients (51 men) with different stages of CKD, including 26 patients with mild CKD (CKD stages 1-2) and 50 patients with moderate-to-severe CKD (CKD stages 3-5). LV mass and LV end-diastolic volume were measured by RT3-DE. Greater prevalence of LV diastolic dysfunction and higher mitral E/myocardial velocities in early diastole (Em) values were noted in patients with moderate-to-severe CKD. In the moderate-to-severe CKD group, patients with increased LV mass had lower myocardial velocities in peak systole (Sm) and longer isovolumic relaxation time (IVRT). In the mild CKD group, patients with increased LV mass to volume ratios had lower Em. Moderate-to-severe CKD was associated with lower Sm and Em and higher mitral rapid filling to Em (E/Em) ratios by LV mass quartile stratification. Using LV mass/volume quartile stratification, moderate-to-severe CKD was associated with longer IVRT, lower Sm and higher mitral E/Em. Multivariable logistic regression analysis showed that CKD severity was the most independent predictor of elevated LV filling pressure (odds ratio = 2.96, p=0.019). Increased LV mass impaired LV contraction and relaxation in patients with moderate-to-severe CKD. Concentric remodeling impaired LV diastolic function in patients with mild CKD. CKD severity was positively associated with elevated LV filling pressure.

Introduction: Chronic kidney disease (CKD) and ischemic stroke are both associated with significant global disease burdens and share common risk factors. Understanding the impact of CKD on stroke incidence is essential for improving patient outcomes. Traditionally, CKD severity has been graded using the estimated glomerular filtration rate (eGFR). However, the Kidney Failure Risk Equation (KFRE), which incorporates age, sex, eGFR, and the urine albumin/creatinine ratio, has emerged as a more robust tool for predicting progression to end-stage kidney disease. This study aimed to investigate if CKD severity, as assessed by these parameters is associated with incident acute ischemic stroke. Methods: Consecutive CKD patients receiving care within the National University Health System from March 2022 to September 2023 were included for analyses. Patients with a previous history of ischemic stroke or transient ischemic attack were excluded. CKD severity was defined by eGFR calculated with the CKD-EPI equation and as per KDIGO guidelines. The 2-year and 5-year risk of kidney failure was estimated by the 4-variable KFRE. Cox proportional hazards model was used to study the relationship between CKD stage and KFRE scores with acute ischemic stroke. Results: A total of 14,794 consecutive CKD patients were included, of which 155 (1.05%) experienced an acute ischemic stroke. The median age was 73 years old (IQR = 14), with 6,251 females (42.3%) and the majority being Chinese (n = 10,759; 73.5%). The median days-to-stroke was 265 days (IQR 242 days). Older age (p&lt;0.001), ischemic heart disease (p&lt;0.001), advanced CKD Stage 4-5 (p=0.013) and KFRE strata (p=0.0018) were associated with ischemic stroke. The risk of ischemic stroke was higher with advanced CKD stage; CKD Stage 4-5 patients were more likely to develop an acute ischemic stroke event as compared to CKD Stage 1-3b patients (HR 1.70, 95%CI: 1.14-2.53). Moreover, a 10% increase in 2-year and 5-year kidney failure risks corresponded to significantly higher risks of ischemic stroke, with hazard ratios of 1.38 (95% CI: 1.17-1.63) and 1.20 (95% CI: 1.10-1.31), respectively. These associations remained significant after adjusting for age, gender, ethnicity, comorbidities, HbA1c and lipid parameters. Conclusion: CKD patients at elevated risk of kidney failure also face an increased risk of suffering an acute ischemic stroke. Implementing the KFRE in CKD management could prove valuable in assessing ischemic stroke risk.

Because current rat models used to study chronic kidney disease (CKD)-related vascular calcification show consistent but excessive vascular calcification and chaotic, immeasurable, bone mineralization due to excessive bone turnover, they are not suited to study the bone-vascular axis in one and the same animal. Because vascular calcification and bone mineralization are closely related to each other, an animal model in which both pathologies can be studied concomitantly is highly needed. CKD-related vascular calcification in rats was induced by a 0.25% adenine/low vitamin K diet. To follow vascular calcification and bone pathology over time, rats were killed at weeks 4, 8, 10, 11, and 12. Both static and dynamic bone parameters were measured. Vascular calcification was quantified by histomorphometry and measurement of the arterial calcium content. Stable, severe CKD was induced along with hyperphosphatemia, hypocalcemia as well as increased serum PTH and FGF23. Calcification in the aorta and peripheral arteries was present from week 8 of CKD onward. Four and 8 weeks after CKD, static and dynamic bone parameters were measurable in all animals, thereby presenting typical features of hyperparathyroid bone disease. Multiple regression analysis showed that the eroded perimeter and mineral apposition rate in the bone were strong predictors for aortic calcification. This rat model presents a stable CKD, moderate vascular calcification, and quantifiable bone pathology after 8 weeks of CKD and is the first model that lends itself to study these main complications simultaneously in CKD in mechanistic and intervention studies.

Use and Abuse of Atherectomy: Where Should it be Used?

Background: The influence of hemodialysis (HD) on limb salvage and survival in patients with peripheral artery disease (PAD) has been reported. However, whether severe chronic kidney disease (CKD) may increase the risk of outcomes in patients with PAD undergoing endovascular revascularization is unknown. In this present study, we evaluated the influence of CKD grade on outcomes, including amputation-free survival (AFS) and major adverse limb events (MALEs) + 30-day perioperative death (POD), after endovascular treatment (EVT) in patients with PAD. Methods: Only patients with primary intervention were included. The eGFR was calculated automatic for each patient and patients were then stratified into two groups for comparative analysis: those with severe CKD (classes 4 and 5; eGFR <30) vs. those with lesser degrees of low-grade CKD (eGFR ≥ 30). Results: Severe CKD was associated with a significantly higher proportion incidence of diabetes mellitus, HD, critical limb ischemia (CLI), and infrainguinal lesions. AFS and MALEs+POD were significantly better in low-grade CKD than in severe CKD. In multivariate analysis, showed that HD and CLI were found to negatively impact affects AFS. In multivariate analysis, only CLI was found to negatively affect MALEs+POD. Conclusions: The presence of severe CKD did not independently influence AFS and MALEs+POD. Appropriate revascularization should be considered in CKD patients before developing irreversible renal insufficiency.