Echocardiographic parameters and renal outcomes in patients with preserved renal function, and mild- moderate CKD

Abstract Background Echocardiographic characteristics across the spectrum of chronic kidney disease (CKD) have not been well described. We assessed the echocardiographic characteristics of patients with preserved renal function and mild or moderate CKD referred for echocardiography and determined whether echocardiographic parameters of left ventricular (LV) and right ventricular (RV) structure and function were associated with changes in renal function and mortality. Methods This retrospective cohort study enrolled all adult patients who had at least one trans-thoracic echocardiography between 2004 and 2014 in our institution. The composite outcome of doubling of serum creatinine or initiation of maintenance dialysis or kidney transplantation was the primary outcome. Mortality was the secondary outcome. Results 29,219 patients were included. Patients with worse renal function had higher prevalence of structural and functional LV and RV abnormalities. Higher estimated glomerular filtration rate (eGFR) was independently associated with preserved LV ejection fraction, preserved RV systolic function, and lower LV mass, left atrial diameter, pulmonary artery pressure, and right atrial pressure, as well as normal RV structure. 1041 composite renal events were observed. 8780 patients died during the follow-up. Pulmonary artery pressure and the RV, but not the LV, echocardiographic parameters were independently associated with the composite renal outcome. In contrast, RV systolic function, RV dilation or hypertrophy, LV ejection fraction group, LV diameter quartile, and pulmonary artery pressure quartile were independently associated with all-cause mortality. Conclusions Echocardiographic abnormalities are frequent even in early CKD. Echocardiographic assessment particularly of the RV may provide useful information for the care of patients with CKD.https://deepblue.lib.umich.edu/bitstream/2027.42/144773/1/12882_2018_Article_975.pd

Echocardiographic parameters and renal outcomes in patients with preserved renal function, and mild- moderate CKD

Abstract Background Echocardiographic characteristics across the spectrum of chronic kidney disease (CKD) have not been well described. We assessed the echocardiographic characteristics of patients with preserved renal function and mild or moderate CKD referred for echocardiography and determined whether echocardiographic parameters of left ventricular (LV) and right ventricular (RV) structure and function were associated with changes in renal function and mortality. Methods This retrospective cohort study enrolled all adult patients who had at least one trans-thoracic echocardiography between 2004 and 2014 in our institution. The composite outcome of doubling of serum creatinine or initiation of maintenance dialysis or kidney transplantation was the primary outcome. Mortality was the secondary outcome. Results 29,219 patients were included. Patients with worse renal function had higher prevalence of structural and functional LV and RV abnormalities. Higher estimated glomerular filtration rate (eGFR) was independently associated with preserved LV ejection fraction, preserved RV systolic function, and lower LV mass, left atrial diameter, pulmonary artery pressure, and right atrial pressure, as well as normal RV structure. 1041 composite renal events were observed. 8780 patients died during the follow-up. Pulmonary artery pressure and the RV, but not the LV, echocardiographic parameters were independently associated with the composite renal outcome. In contrast, RV systolic function, RV dilation or hypertrophy, LV ejection fraction group, LV diameter quartile, and pulmonary artery pressure quartile were independently associated with all-cause mortality. Conclusions Echocardiographic abnormalities are frequent even in early CKD. Echocardiographic assessment particularly of the RV may provide useful information for the care of patients with CKD.https://deepblue.lib.umich.edu/bitstream/2027.42/144773/1/12882_2018_Article_975.pd

Results and safety profile of trainee cataract surgeons in a community setting in East Africa

Purpose: To evaluate the results and safety profile of assistant medical officer ophthalmologists (AMO-O) performing cataract surgery in the last stage of their surgical training, before their appointment to local communities. Methods: We retrospectively analyzed the records of patients who underwent cataract surgery by AMO-Os at Dar es Salaam, Comprehensive Community Based Rehabilitation for Tanzania Disability Hospital between September 2008 and June 2011. Surgical options were either extracapsular cataract extraction (ECCE) or manual small incision cataract surgery (MSICS), both with polymethylmethacrylate intraocular lens implantation. Results: Four hundred and fourteen patients were included in the study. Two hundred and twenty-five (54%) underwent ECCE and 189 had MSICS. Mean logarithm of the minimum angle of resolution (logMAR) uncorrected visual acuity (UCVA) improved from 2.4 ± 0.6 preoperatively to 1.3 ± 0.8 1 week postoperatively (t-test, P < 0.001) and to 1.1 ± 0.7 3 months postoperatively (t-test, P < 0.001). Mean logMAR best-corrected visual acuity (BCVA) was 0.7 ± 0.5 1 week postoperatively and 0.6 ± 0.5 3 months postoperatively. There was no significant difference in mean logMAR UCVA (P = 0.7) and BCVA (P = 0.7) postoperatively between ECCE and MSICS. 89.5% achieved BCVA better than 6/60 and 57.3% better than 6/18 with a follow-up of 3 months. Posterior capsule rupture and/or vitreous loss occurred in 34/414 patients (8.2%) and was more frequent (P = 0.047) in patients undergoing ECCE (10.2%) compared with MSICS (5.3%). Conclusion: AMO-O cataract surgeons at the end of their training offer significant improvement in the visual acuity of their patients. Continuous monitoring of outcomes will guide further improvements in surgical skills and minimize complications. In the era of phacoemulsification for cataract surgery, extracapsular cataract extraction (ECCE) and manual small incision cataract surgery (MSICS) are still widely held to be the techniques of choice for the developing world.[1],[2],[3],[4],[5] Both MSICS and ECCE are affordable[6] and are considered safe and effective for the treatment of cataract patients in community eye care settings. MSICS appears to provide better postoperative uncorrected visual acuity (UCVA)[1] and faster rehabilitation[7] compared with ECCE although the technique is more challenging. In Tanzania, in addition to medical doctors, there is a special cadre of health professionals, created to care for the large population, called assistant medical officers (AMOs). AMOs can specialize in ophthalmology for 2 years and become AMO ophthalmologists (AMO-O) who perform cataract surgery. AMO-O's are a subtype of nonphysician cataract surgeons previously described by Lewallen et al.[8] AMO-Os deliver high-volume cataract surgery in community eye care settings and are essential in reducing the backlog of cataract-related visual disability. AMO-Os are more likely to set up their practice and stay in rural areas than ophthalmologists tied to larger centers and in addition, their training is shorter and less expensive compared to ophthalmologists.[8],[9] Ensuring sufficient training of AMO-Os in cataract surgery is necessary to achieve good visual outcomes and maintain low rates of complications. This is particularly important in an African community setting, where follow-up may not be optimal and management of complications more challenging. In this study, we evaluate the results and safety profile of AMO-O cataract surgeons. The surgeries were supervised by trainers and performed entirely by the AMO-O in the last stage of their surgical training (6-9 months), before operating independently in their local communities. Patients with diabetes were excluded from the surgical cohort for AMO-Os

A Systematic Review of the Incidence of Arrhythmias in Hemodialysis Patients Undergoing Long-Term Monitoring With Implantable Loop Recorders

Funding Funders who supported this work. Boston Scientific Corporation MedtronicPeer reviewedPublisher PD

Effect of Eplerenone, a Selective Aldosterone Blocker, on the Development of Diabetic Nephropathy in Type 2 Diabetic Rats

Background: Aldosterone antagonists are reported to have beneficial effects on diabetic nephropathy by effective blocking of the renin-angiotensin-aldosterone system. We investigated the renoprotective effect of the selective aldosterone receptor blocker eplerenone, the angiotensin converting enzyme inhibitor lisinopril, and combined eplerenone and lisinopril treatment in type 2 diabetic rats. Methods: Animals were divided into six groups as follows: Otsuka Long-Evans Tokushima Fatty (OLETF) rat control, OLETF rats treated with a low dose of eplerenone (50 mg/kg/day), OLETF rats treated with a high dose of eplerenone (200 mg/kg/day), OLETF rats treated with lisinopril (10 mg/kg/day), OLETF rats treated with a combination of both drugs (eplerenone 200 mg/kg/ day and lisinopril 10 mg/kg/day), and obese non-diabetic Long-Evans Tokushima Otsuka rats for 26 weeks. Results: Urinary albumin excretion was significantly lower in the lisinopril group, but not in the eplerenone group. Urinary albumin excretion was decreased in the combination group than in the lisinopril group. Glomerulosclerosis and renal expression of type I and type IV collagen, plasminogen activator inhibitor-1, transforming growth factor-β1, connective tissue growth factor, and fibronectin mRNA were markedly decreased in the lisinopril, eplerenone, and combination groups. Conclusion: Eplerenone and lisinopril combination showed additional benefits on type 2 diabetic nephropathy compared to monotherapy of each drug

Lower Renal Function Is Associated With Derangement of 11- Hydroxysteroid Dehydrogenase in Type 2 Diabetes

Context: Derangement of 11-β hydroxysteroid dehydrogenase type 1 and type 2 (11β-HSD1 and 11β-HSD2), which regulate intracellular cortisol production, has been suggested in both type 2 diabetes (T2D) and chronic kidney disease (CKD). However, activity of 11β-HSD enzymes in patients with T2D and CKD has never been assessed. Objectives: To compare 11β-HSD activities between patients with T2D and healthy controls, and assess whether in T2D, renal function is associated with 11β-HSD activities. Design: Cross-sectional analysis in the Diabetes and Lifestyle Cohort Twente (DIALECT-1). Setting: Referral center for T2D. Patients: Patient with T2D [n = 373, age 64 ± 9 years, 58% men, 26% of patients estimated glomerular filtration rate (eGFR) <60 mL/min·1.73 m2] and healthy controls (n = 275, age 53 ± 11 years, 48% men). Mean Outcome Measure: We measured cortisol, cortisone, and metabolites [tetrahydrocortisol (THF), allo-THF (aTHF), and tetrahydrocortisone (THE)] in 24-hour urine samples. Whole body 11β-HSD and 11β-HSD2 activities were calculated as the urinary (THF + aTHF)/THE and cortisol/cortisone ratios, respectively. Results: Patients with T2D had a higher (THF + aTHF)/THE ratio [1.02 (0.84 to 1.27) vs 0.94 (0.79 to 1.0), P < 0.001] and cortisol/cortisone ratio [0.70 (0.58 to 0.83) vs 0.63 (0.54 to 0.74), P < 0.001] than healthy controls. In T2D, lower eGFR was associated with a higher (THF + aTHF)/THE ratio (β = -0.35, P < 0.001), and a higher cortisol/cortisone ratio (β = -0.16, P = 0.001). Conclusions: In this real-life secondary care setting of patients with T2D, 11β-HSD enzymes activities were shifted to higher intracellular cortisol production in T2D, which was further aggravated in patients with CKD. Prospective analyses are warranted to investigate causality of these associations

Optimizing the medical management of patients with chronic kidney disease and end-stage renal disease

Chronic kidney disease (CKD) prevalence is high and constantly increasing over the last years across the world. CKD is associated with higher incidence of cardiovascular disease, as well as premature mortality. There is an urgent unmet need for more data on novel treatment strategies that may prevent further renal function decline and appropriately treat cardiovascular complications in patients with CKD. Cardiac and renal interactions remain complex and poorly understood. As we show in the first publication, there is significant overlap between acute kidney injury or acutely decompensated heart failure and progression of chronic kidney disease or congestive heart failure. Involvement of both organs portends worse clinical outcomes. In the ESRD population, hemodialysis itself probably exerts detrimental effects on heart function through worsening myocardial perfusion that seems to be caused by excessive ultrafiltration rates, as we show in the second publication. The third article summarizes available clinical evidence and suggests beneficial effects of mineralocorticoid receptor antagonists, spironolactone or eplerenone, when added to an angiotensin converting enzyme inhibitor or an angiotensin receptor blocker in patients with diabetic nephropathy. Although albuminuria that was examined in this study is a surrogate marker for hard renal outcomes, further blockade of renin-angiotensin-aldosterone system looks promising, at least in patients with diabetes mellitus. Atrial fibrillation is a common problem in CKD and is associated with significant morbidity. It has recently been shown that vitamin K antagonists may not be as effective in this population and there is increasing interest on direct oral anticoagulants in CKD. The fourth article examines the pharmacokinetics of apixaban in patients on hemodialysis. This article demonstrates that steady state levels are far higher than levels obtained after a single dose of the drug and may be supratherapeutic with the full dose (5 mg twice daily). Furthermore, it shows that apixaban is not removed by hemodialysis. The fifth article examines platelet reactivity in stable outpatients with cardiovascular disease and CKD. In contrast to what has been shown in patients undergoing percutaneous coronary intervention, CKD is not associated with higher platelet reactivity or lower antiplatelet drug responsiveness in stable outpatients. Furthermore, there is no interaction between CKD status and high platelet reactivity for major adverse cardiovascular events in this population

Mesure de la facilité d'évacuation de l'humeur aqueuse après la création d'une fistule intrasclérale par injection de l'acide hyaluronique stabilisé dans les yeux de porc

Le but de traitement du glaucome est de maintenir la morphologie de la papille et de préserver la fonction visuelle du patient et la qualité de vie qui lui est liée. Nous présentons ici une nouvelle technique, d'application simple pour créer une microfistule intrasclérale afin de diminuer la pression intraoculaire. Nous créons pour cela un canal intrascléral en injectant une forme d'acide hyaluronique cohésive, qui est perméable à l'humeur aqueuse (NASHA), pour créer un nouveau passage entre la chambre antérieure de l'oeil et l'espace sous-conjonctival. Notre hypothèse est que l'acide hyaluronique cohésive restera pour plusieurs mois dans le canal intrascléral et ceci permettra aux cellules endothéliales de migrer et couvrir ce nouveau canal

Traitements anticoagulants: inconvénients des régimes actuels et promesses pour le futur

La maladie thromboembolique veineuse constitue une cause majeure de morbidité et de mortalité et le traitement anticoagulant est la pierre angulaire de sa prévention et de sa prise en charge. Les anticoagulants actuellement utilisés ont fait preuve d'une incontestable efficacité mais présentent également certains inconvénients. L'héparine non fractionnée, les héparines de bas poids moléculaire et le fondaparinux doivent être administrés en parentéral ce qui rend leur utilisation problématique au long cours. Les anti-vitamines K ont un début d'action lent et nécessitent un traitement initial par un agent parentéral. Etant donné leur effet anticoagulant variable, un monitoring fréquent est nécessaire dans le but d'ajuster la posologie. A la recherche d'un anticoagulant idéal qui ne présenterait pas ces inconvénients, plusieurs molécules ont été développées. Celles qui sont actuellement à un stade avancé de développement sont les trois inhibiteurs directs oraux du facteur Xa, le rivaroxaban, l'apixaban et l'edoxaban, et un inhibiteur direct de la thrombine, le dabigatran. Ces dernières années, de nombreuses études ont évalué leur place dans la prévention et le traitement de la maladie thromboembolique veineuse ou la fibrillation auriculaire avec des résultats prometteurs. Leurs propriétés pharmacologiques se rapprochent du profil de l'anticoagulant idéal : administration orale, pas de monitoring, dosage unique, interactions médicamenteuses limitées. Leur emploi permettra de simplifier la prise en charge de la maladie thromboembolique veineuse et de la fibrillation auriculaire