Acute Renal Failure in Hospitalized Patients in China: A Prospective Study

Acute renal failure (ARF) is a common complication in hospitalized patients, but little is known about the epidemiology of ARF in China. In this study, we performed a prospective examination of the cause, prognosis, and risk factors associated with ARF at a hospital in Shanghai, China. We considered all ARF patients who were admitted to our hospital from December 2003 to December 2006. Among the 320 ARF patients, 135 (42.2%) were over the age of 60. Sepsis, heart failure, and nephrotoxic drug use were the leading causes of ARF. The overall mortality rate was 31.9%, and mortality rate was significantly higher among the elderly. Logistic regression indicated that heart failure, respiratory failure, and malignant cancer were risk factors independently associated with poor prognosis. In this Shanghai hospital, there was a high incidence and mortality rate of patients hospitalized with ARF. The prognosis of patients who underwent renal replacement therapy was better than those who were treated more conservatively.     

Predictors of Mortality in Acute Renal Failure in a Developing Country: A Prospective Study

Acute renal failure (ARF) occurs in wide range of conditions, making the evaluation of its prognosis a difficult task. Data regarding prognostic factors in ARF in a general population in developing countries are scarce. The objective of the study was to describe predictors of mortality in ARF that are relevant in the developing world. This prospective study was carried out over a one-year period; all hospitalized adults with ARF were included in the study. Predictors of mortality studied included causes of ARF, pre-existing diseases, and severity as well as complications of ARF. Of 33,301 patients admitted during the study period, 294 (0.88%) were either admitted with or developed ARF after hospitalization. Mean age was 43.9 ± 16.9 (18–86 yrs). Sepsis was the most common cause (63.26%). Pre-existing diseases like cardiovascular disease (CVSD), respiratory system disease (RSD), central nervous system disease (CNSD), hypertension, diabetet mellitus (DM), and malignancy were significantly higher in elderly as compared to younger patients. On univariate analysis sepsis, hypoperfusion as a cause of ARF and hospital-acquired ARF were associated with higher mortality. Pre-existing diseases viz. RSD, CVSD, CNSD, and DM had higher mortality. Among the severity and complications of ARF, oliguria, bleeding and infection during the course of ARF and critical illness were predictors of poor outcome. Age >60 yrs was associated with significantly higher mortality. However, on multivariate analysis, only critical illness (odds ratio 37.3), age > 60 years (odds ratio of 5.6), and sepsis as cause of ARF (odds ratio of 2.6) were found to be independent predictors of mortality.     

Comparison of Intravenous versus Topical Tranexamic Acid in Total Knee Arthroplasty: A Prospective Randomized Study

The purpose of this study was to compare the efficacy of topical Tranexamic Acid (TXA) versus Intravenous (IV) Tranexamic Acid for reduction of blood loss following primary total knee arthroplasty (TKA). This prospective randomized study involved 89 patients comparing topical administration of 2.0 g TXA, versus IV administration of 10 mg/kg. There were no differences between the two groups with regard to patient demographics or perioperative function. The primary outcome measure, perioperative change in hemoglobin level, showed a decrease of 3.06 ± 1.02 in the IV group and 3.42 ± 1.07 in the topical group (P = 0.108). There were no statistical differences between the groups in preoperative hemoglobin level, lowest postoperative hemoglobin level, or total drain output. One patient in the topical group required blood transfusion (P = 0.342). Based on our study, topical Tranexamic Acid has similar efficacy to IV Tranexamic Acid for TKA patients.     

舒芬太尼复合曲马多用于老年髋部手术患者术后静脉自控镇痛的研究

目的探讨舒芬太尼复合曲马多用于老年髋部手术后患者自控静脉镇痛（patient-controlled intravenous analgesia,PCIA）的效果与不良反应。方法40例择期在腰麻联合硬膜外麻醉下行髋部手术的老年患者,按随机数字表随机分为单纯舒芬太尼组（S组）和舒芬太尼复合曲马多组（T组）,每组各20例。术毕缓慢经静脉注射欧贝8mg,连接电子镇痛泵。镇痛药物：S组为舒芬太尼100μg＋0.9%NaCl100ml,T组为舒芬太尼50μg＋曲马多400mg＋0.9%NaCl100ml,负荷剂量1ml,持续输注速率1.5ml/h,病人自控镇痛（patient-controlled analgesia,PCA）剂量0.5ml,锁定时间15min。分别于术后4、20、24、48h随访病人并记录静息时和运动时的视觉模拟评分（visual analogue score,VAS）,各时点的呼吸频率（respiration rate,RR）,心率（heart rate,HR）,平均动脉压（mean arterial pressure,MAP）,脉搏血氧饱和度（peripheral oxygen saturation,SPO2）,镇静评分（sedation scale,SS）,记录使用镇痛泵48h内恶心呕吐的发生率。结果术后48h内,2组患者静态和动态VAS评分的差异均无统计学意义（P〉0.05）,除术后4h2组患者的动态VAS评分〉3以外,其余各时点2组患者静态和动态VAS均小于3。2组患者HR、SPO2和MAP在各时点组内的差异均无统计学意义（P〉0.05）。术后4、20h,S组患者的RR较T组明显降低（P〈0.01）。术后4、20h,S组SS评分显著高于T组（P〈0.01）。2组恶心、呕吐发生率的差异无统计学意义（10%vs30%,P=0.235;5%vs25%,P=0.182）。结论舒芬太尼复合曲马多可以有效用于老年髋部手术后PCIA,与单用舒芬太尼相比,镇痛效果确切,不良反应减少。     

Oral vs Intravenous vs Topical Tranexamic Acid in Primary Hip Arthroplasty: A Prospective,Randomized, Double-Blind,Controlled Study

Background

Tranexamic acid (TXA) has demonstrated efficacy in reducing blood loss, reduction in hemoglobin, and blood transfusion requirements in primary total hip arthroplasty (THA). The optimal mode of TXA administration for patients undergoing primary THA is unclear. The purpose of this randomized controlled trial is to determine whether oral administration of TXA was superior to intravenous or topical routes in these patients.

The safety of gadolinium in patients with stage 3 and 4 renal failure.

BACKGROUND: Although there is a well-documented risk of acute renal failure (ARF) with the iodinated contrast agents, intravenous gadolinium-based contrast agents are considered non-nephrotoxic and have been widely used for magnetic resonance imaging (MRI). However, debate continues regarding the safety issue of gadolinium, especially in patients with kidney failure. Therefore, we aimed to evaluate the safety of gadolinium in patients with stage 3 and 4 renal failure as well as risk factors for nephrotoxicity. METHOD: We retrospectively analysed 473 patients with chronic renal failure who underwent angiographic MRI procedures in our centre from February 1999 to March 2005 in whom gadolinium was used as the sole contrast agent at a dose of 0.2 ml/kg. Among them, 91 patients with stage 3 or 4 renal failure according to K/DOQI definition, who had available data in their files, were enrolled in the study. The ARF was defined as an increase of at least 0.5 mg/dl in serum creatinine level over baseline after using gadolinium. RESULTS: Eleven of 91 (52 males, 39 females; median age 59 years; median estimated glomerular filtration rate (eGFR) 33 ml/min/1.73 m2) patients developed ARF (12.1%). The median eGFR was lower in patients with ARF than in those who did not develop ARF. The risk factors for ARF were baseline eGFR, older age, diabetic nephropathy and low baseline haemoglobin and albumin levels. Baseline eGFR and diabetic nephropathy were determined as the independent risk factors in regression analysis. CONCLUSIONS: An ARF can occur after gadolinium-based contrast agents in patients with moderate to severe chronic renal failure. Risk factors for ARF after gadolinium toxicity include diabetic nephropathy and low GFR.     

多层螺旋CT尿路造影与逆行肾盂造影在诊断输尿管梗阻性疾病中的价值对比

目的：探讨多层螺旋CT尿路造影（CTU）和逆行肾盂造影（RP）在诊断输尿管梗阻性疾病中的准确性和应用价值。方法：对40例输尿管梗阻性病变患者均先后行CTU和RP,以输尿管镜或开放手术或（和）病理检杏结果为标准,两者进行对照分析。结果：40例输尿管梗阻性疾病患者中。肿瘤6例,先天性狭窄9例,结石8例,良性狭窄17例。CTU和RP诊断准确率均为92．5％（37／40）（P〉0．05）,病因诊断符合率分别为90％（36／40）和57．5％（23／40）（P〈0．05）。结论：CTU对输尿管梗阻性病变诊断的准确率和病因符合率高,较RP有更好的病因诊断价值,可作为IVU显影不良者的首选补充检查方法,但仍存在一定局限性,需选择性应用。     

Effect of Hemodialysis on Cognitive Function in ESRD Patients

Background. Uremia is associated with impairment of different cognitive functions. However the pathogenesis of this cognitive dysfunction is unknown. Objective. In this study, long-latency event related potentials (ERPs) were used to assess changes in cortical function due to hemodialysis treatment. Methods. In this cross-sectional study, we measured event related potentials in 15 end stage renal disease (ESRD) patients maintained on hemodialysis, two hours before and two hours after they underwent hemodialysis and compared their data with a strictly age and sex matched healthy control group. The P3 was elicited by using standard auditory “odd-ball” paradigm and the data obtained was statistically analyzed (Wilcoxon signed ranks, Mann Whitney). Results. Before hemodialysis, the patients' P3 latency (347.73 ± 39.47 ms) was significantly increased as compared with that of healthy control group (308.4 ± 13.73 ms) (p = 0.001). After hemodialysis, P3 latency of the patients showed a significant decrease (347.73 ± 39.47 ms to 325.20 ± 37.15 ms, p = 0.001). P3 latency after dialysis was not significantly different from controls. No significant correlation was noted between various biochemical parameters (hemoglobin, blood urea, creatinine, uric acid and calcium) and P3 latency or amplitude. Conclusions. Removal of uremic toxins by hemodialysis leads to an improvement in cognitive processing.     

糖尿病患者行冠状动脉旁路移植术中应用腔镜采集大隐静脉的临床研究

目的探讨腔镜大隐静脉采集法(endoscopic vein harvesting,EVH)对糖尿病患者行冠状动脉旁路移植术(CABG)后恢复和桥血管再狭窄的影响。方法采用非随机临床对照研究的方法,纳入2010年12月至2012年2月华西医院行冠状动脉旁路移植术合并2型糖尿病的患者,按所采用的静脉桥血管采集方式,将患者分为腔镜大隐静脉采集法(EVH)组和开放大隐静脉采集法(CVH)组,评价两组患者围手术期并发症情况。随访期间采用介入或CT冠状动脉造影评价桥血管再狭窄情况。结果共纳入51例患者,其中EVH组24例,CVH组27例。两组患者年龄、体重、基础病变程度差异均无统计学意义。两组术中体外循环时间和主动脉阻断时间差异均无统计学意义[(67.2±9.8)min vs.(68.3±14.5)min,P>0.05;(62.4±11.3)min vs.(65.2±10.3)min,P>0.05]。两组患者术后主要并发症发生率差异无统计学意义。与CVH比较,EVH能显著缩短桥血管采集时间[(35.6±6.4)minvs.(45.2±11.4)min,P<0.05],降低腿部切口延迟愈合发生率[0.0%(0/24)vs.18.5%(5/27),P<0.05]。CVH组随访9.1个月,EVH组随访9.4个月。随访期间两组并发症(胸痛、大隐静脉再狭窄)发生率差异无统计学意义(P>0.05)。结论对于合并糖尿病行CABG的患者,EVH是一种安全有效、微创快速的桥血管采集方法。     

Pharmacokinetics and Pharmacodynamics of Thiopental in Patients Undergoing Renal Transplantation

The effects and pharmacokinetics of thiopental were studied in eight patients undergoing renal transplantation. The results were compared with findings in a group of patients with normal renal function. No differences were observed in induction doses or between arterial or venous sleep concentrations. The average V₃ in the renal failure group was 1441 or 2.5 times the value of the control group ( P <0.01). The apparent differences indicating longer elimination half-lives and higher serum clearances in the renal patients were not significant. The average binding of thiopental to serum protein shortly after the induction was 83.9 % (78.2–88.1) in the renal patients and 89.0% (85.2–91.6) in the control patients ( P <0.05). The difference in V₃ could be explained by the differences in protein binding and when the serum clearance was calculated by using the unbound fraction, this "intrinsic clearance" was significantly lower in the renal failure group ( P <0.05). Haemodynamic parameters were determined during the initial 5 min. No significant difference was observed between the thiopental-induced changes in stroke volume. Cardiac output was unchanged in both patient groups.     

Prospective Study on Late Consequences of Subclinical Non-Compliance with Immunosuppressive Therapy in Renal Transplant Patients

In this prospective study we compared the incidence of late acute rejections (LAR) and changes in serum-creatinine over time between compliers and noncompliers with immunosuppressive therapy more than 1 year post transplantation and explored the relative contribution of non-compliance and other risk factors in the occurrence of LAR. One hundred and forty-six adult renal transplant recipients were followed during a 5-year period. Patients were interviewed at the beginning of the study and categorized as non-compliers if they admitted to have skipped immunosuppressive medication on a regular basis during the previous 12 months. The occurrence of LAR during the follow-up period was recorded. We identified 22.6% non-compliers of which 21.2% experienced a late acute rejection compared with 8% in the group of compliers at 5 years postinclusion (p < 0.05). Kaplan-Meier survival analysis showed a decreased rejection free time in non-compliers compared with compliers (p = 0.03). Non-compliant patients had a 3.2 higher risk of LAR (Cox regression analysis, p = 0.005). Non-compliers experienced a higher increase in serum-creatinine over time (Linear Mixed Models, p < 0.001). Non-compliance in renal transplant patients more than 1-year post transplantation is associated with an increased risk for LAR and a higher increase in serum-creatinine during the following 5 years.     

A Multi-Center Evaluation of Early Acute Kidney Injury in Critically Ill Trauma Patients

Rationale. Few studies have evaluated the epidemiology of acute kidney injury (AKI) in trauma. Objective. To evaluate the incidence, risk factors, and outcomes associated with early AKI (evident within 24 hours of admission) in critically ill trauma patients. Methods. A retrospective interrogation of prospectively collected data from the Australian New Zealand Intensive Care Society Adult Patient Database. A total of 9,449 trauma patients were admitted for ≥24 hours to 57 intensive care units across Australia from January 1^st, 2000, to December 31^st, 2005. Main Findings. The crude incidence of AKI was 18.1% (n = 1,711). Older age, female sex (OR 1.60, 95% CI, 1.43–1.78, p < 0.0001), and the presence of co-morbid illness (OR 2.70, 95% CI 2.3–3.2, p < 0.0001) were associated with higher odds of AKI. Those with trauma not associated with brain injury (OR 2.40, 95% CI, 2.1–2.7, p < 0.0001) and a higher illness severity (OR 1.12, 95% CI, 1.11–1.12, p < 0.001) also had higher likelihood of AKI. Overall, AKI was associated with a higher crude mortality (16.7% vs. 7.8%, OR 2.36, 95% CI, 2.0–2.7, p < 0.001). Each RIFLE category of AKI was independently associated with hospital mortality in multi-variable analysis (risk: OR 1.69; injury OR 1.88; failure 2.29). Conclusions. Trauma admissions to ICU are frequently complicated by early AKI. Those at high risk for AKI appear to be older, female, with co-morbid illnesses, and present with greater illness severity. Early AKI in trauma is also independently associated with higher mortality. These data indicate a higher burden of AKI than previously described.     

Comparison of 3 Routes of Administration of Tranexamic Acid on Primary Unilateral Total Knee Arthroplasty: A Prospective,Randomized, Controlled Study

Background

The mode of administration for tranexamic acid (TXA) to significantly reduce the decrease in hemoglobin (Hb), number of transfusions, relevant costs, and side effects in patients undergoing primary unilateral total knee arthroplasty (TKA) has not been resolved.