8 research outputs found
Associations between depressive symptoms and disease progression in older patients with chronic kidney disease: results of the EQUAL study
Background Depressive symptoms are associated with adverse clinical outcomes in patients with end-stage kidney disease; however, few small studies have examined this association in patients with earlier phases of chronic kidney disease (CKD). We studied associations between baseline depressive symptoms and clinical outcomes in older patients with advanced CKD and examined whether these associations differed depending on sex. Methods CKD patients (>= 65 years; estimated glomerular filtration rate <= 20 mL/min/1.73 m(2)) were included from a European multicentre prospective cohort between 2012 and 2019. Depressive symptoms were measured by the five-item Mental Health Inventory (cut-off <= 70; 0-100 scale). Cox proportional hazard analysis was used to study associations between depressive symptoms and time to dialysis initiation, all-cause mortality and these outcomes combined. A joint model was used to study the association between depressive symptoms and kidney function over time. Analyses were adjusted for potential baseline confounders. Results Overall kidney function decline in 1326 patients was -0.12 mL/min/1.73 m(2)/month. A total of 515 patients showed depressive symptoms. No significant association was found between depressive symptoms and kidney function over time (P = 0.08). Unlike women, men with depressive symptoms had an increased mortality rate compared with those without symptoms [adjusted hazard ratio 1.41 (95% confidence interval 1.03-1.93)]. Depressive symptoms were not significantly associated with a higher hazard of dialysis initiation, or with the combined outcome (i.e. dialysis initiation and all-cause mortality). Conclusions There was no significant association between depressive symptoms at baseline and decline in kidney function over time in older patients with advanced CKD. Depressive symptoms at baseline were associated with a higher mortality rate in men
Tecniche anestesiologiche nel trattamento endovascolare dello stroke ischemico
Durante il trattamento endovascolare dello stroke ischemico, in aggiunta a fattori prognostici, quali la gravitĂ dello stroke e lâefficacia dellâintervento, giocano un ruolo fondamentale il tipo di anestesia, la saturazione di ossigeno e la pressione sanguigna.
Il nostro studio retrospettivo confronta la sicurezza e i risultati di due tecniche anestesiologiche: lâanestesia generale (AG) e la sedazione cosciente (SC).
Lo studio include 32 pazienti con stroke ischemico trattati dal 2009 al 2013. I pz sono stati divisi in due gruppi: nel gruppo AG (14pz) lâanestesia Ăš stata indotta con propofol (2mg/kg), fentanyl (2-3Îł/kg) e Cisatracurio (0,15mg/kg) ed Ăš stata mantenuta mediante TIVA. Nel gruppo SC (18pz) la neuroleptoanalgesia Ăš stata realizzata con fentanyl (1-1,5Îł/Kg), droperidolo (0,06mg/Kg) e midazolam (0,03mg/kg).
Lâanestesia generale ha determinato una maggiore stabilitĂ emodinamica (PAM 90±14mmHg in AG vs 108±25 mmHg in SC [P=0,022]) e una miglior ventilazione polmonare (PaO2 150±10 mmHg in AG vs 100±10 mmHg in SC [P<0,001] e PaCO2 34±1 in AG vs 38±1 in SC [P<0,001)] rispetto alla sedazione cosciente.
I risultati del NIHSS a 7 giorni erano sovrapponibili.
Questo studio sembra essere in contrasto con i piĂč recenti che identificano lâanestesia generale come un fattore prognostico negativo.
Nella nostra esperienza lâanestesia generale ha consentito di mantenere unâemodinamica ottimale con un minor rischio di complicanze dovute ai movimenti del paziente
Monitoraggio neurofisiologico intraoperatorio. Influenza degli anestetici inalotori ed endovenosi sui potenziali evocati somatosensoriali (PESS). Nostra esperienza clinica.
Obiettivo: i potenziali evocati somatosensoriali (PESS) sono
utilizzati durante la chirurgia per identificare e controllare
strutture nervose difficilmente riconoscibili su basi puramente
anatomiche. Una volta identificate tali strutture Ăš possibile
valutarne lâintegritĂ funzionale durante tutto il corso dellâintervento.
1 Il monitoraggio neurofisiologico intraoperatorio Ăš
influenzato dal tipo di agente anestetico utilizzato.2 Obiettivo
del nostro lavoro Ăš stato quello di confrontare lâeffetto degli
anestetici inalatori e dellâanestesia completamente endovenosa
(TIVA) sulla morfologia dei PESS e sulla velocitĂ di registrazione
dei potenziali.
Materiali e metodi: da Gennaio 2010 ad Aprile 2013 sono
stati divisi in 2 gruppi in modalitĂ random 79 pazienti da sottoporre
ad interventi di neurochirurgia spinale. Lâanestesia Ăš
stata indotta con propofol (1,5-2 mg/kg), fentanyl (3-4
mcg/kg) e cisatracurio (0,15 mg/kg). Nel gruppo TIVA lâanestesia
Ăš stata mantenuta mediante lâinfusione continua di propofol
5-7 mg/kg/h e remifentanil a 0,3-0,6 mcg/kg/min. Nel
gruppo sevo-remi lâanestesia Ăš stata mantenuta mediante il
sevoflurane a MAC 1-1,3 e remifentanil a 0,2-0,5 mcg/kg/
min. Nella chirurgia cervicale i potenziali evocati somatosensoriali
intraoperatori sono stati registrati dal nervo mediano,nella chirurgia lombare dal nervo tibiale posteriore. Infine per
la parte dorsale della colonna i PESS sono stati registrati sia
dal nervo mediano sia dal nervo tibiale posteriore. Durante la
procedura il neurofisiologo non era a conoscenza della tecnica
anestesiologica utilizzata. Ulteriori fattori che potessero
influenzare la registrazione del monitoraggio sono stati adeguatamente
controllati.
Risultati: tutti i pazienti hanno completato la procedura chirurgica.
Durante lâintervento si Ăš sempre garantito un adeguato
monitoraggio e un controllo della funzionalitĂ delle strutture
nervose interessate. Potenziali evocati somatosensoriali
soddisfacenti sono stati registrati in tutti i pazienti senza
variazioni significative nella registrazione della latenza (velocitĂ )
e ampiezza (morfologia) dei PESS.
Conclusioni: possiamo concludere che sia il propofol associato
al remifentanil in infusione continua endovenosa (TIVA),
sia il sevoflurane associato al remifentanil in unâanestesia
bilanciata, garantiscono un adeguato monitoraggio intraoperatorio
dei potenziali evocati somatosensoriali in neurochirurgia
spinale. Lâalterazione dei PESS risulta infatti essere minima
e non significativa per tutte e due le tecniche anestesiologiche
usate garantendo la possibilitĂ di scelta del tipo di anestesia
da utilizzare
Kidney Failure Prediction Models: A Comprehensive External Validation Study in Patients with Advanced CKD
Background: Various prediction models have been developed to predict the risk of kidney failure in patients with CKD. However, guideline-recommended models have yet to be compared head to head, their validation in patients with advanced CKD is lacking, and most do not account for competing risks.Methods: To externally validate 11 existing models of kidney failure, taking the competing risk of death into account, we included patients with advanced CKD from two large cohorts: the European Quality Study (EQUAL), an ongoing European prospective, multicenter cohort study of older patients with advanced CKD, and the Swedish Renal Registry (SRR), an ongoing registry of nephrology-referred patients with CKD in Sweden. The outcome of the models was kidney failure (defined as RRT-treated ESKD). We assessed model performance with discrimination and calibration.Results: The study included 1580 patients from EQUAL and 13,489 patients from SRR. The average c statistic over the 11 validated models was 0.74 in EQUAL and 0.80 in SRR, compared with 0.89 in previous validations. Most models with longer prediction horizons overestimated the risk of kidney failure considerably. The 5-year Kidney Failure Risk Equation (KFRE) overpredicted risk by 10%-18%. The four- and eight-variable 2-year KFRE and the 4-year Grams model showed excellent calibration and good discrimination in both cohorts.Conclusions: Some existing models can accurately predict kidney failure in patients with advanced CKD. KFRE performed well for a shorter time frame (2 years), despite not accounting for competing events. Models predicting over a longer time frame (5 years) overestimated risk because of the competing risk of death. The Grams model, which accounts for the latter, is suitable for longer-term predictions (4 years)
Predicting Kidney Failure, Cardiovascular Disease and Death in Advanced CKD Patients
Introduction: Predicting the timing and occurrence of kidney replacement therapy (KRT), cardiovascular events, and death among patients with advanced chronic kidney disease (CKD) is clinically useful and relevant. We aimed to externally validate a recently developed CKD G4+ risk calculator for these outcomes and to assess its potential clinical impact in guiding vascular access placement. Methods: We included 1517 patients from the European Quality (EQUAL) study, a European multicentre prospective cohort study of nephrology-referred advanced CKD patients aged â„65 years. Model performance was assessed based on discrimination and calibration. Potential clinical utility for timing of referral for vascular access placement was studied with diagnostic measures and decision curve analysis (DCA). Results: The model showed a good discrimination for KRT and âdeath after KRT,â with 2-year concordance (C) statistics of 0.74 and 0.76, respectively. Discrimination for cardiovascular events (2-year C-statistic: 0.70) and overall death (2-year C-statistic: 0.61) was poorer. Calibration was fairly accurate. Decision curves illustrated that using the model to guide vascular access referral would generally lead to less unused arteriovenous fistulas (AVFs) than following estimated glomerular filtration rate (eGFR) thresholds. Conclusion: This study shows moderate to good predictive performance of the model in an older cohort of nephrology-referred patients with advanced CKD. Using the model to guide referral for vascular access placement has potential in combating unnecessary vascular surgeries
The association between TMAO, CMPF and clinical outcomes in advanced CKD; results from the EQUAL study
Background Trimethylamine N-oxide (TMAO), a metabolite from red meat and fish consumption, plays a role in promoting cardiovascular events. However, data regarding TMAO and its impact on clinical outcomes are inconclusive, possibly due to its undetermined dietary source. Objectives We hypothesized that circulating TMAO derived from fish intake might cause less harm compared with red meat sources by examining the concomitant level of 3-carboxy-4-methyl-5-propyl-2-furanpropionate (CMPF), a known biomarker of fish intake, and investigated the association between TMAO, CMPF, and outcomes. Methods Patients were recruited from the European QUALity (EQUAL) Study on treatment in advanced chronic kidney disease among individuals aged >= 65 y whose estimated glomerular filtration rate (eGFR) had dropped for the first time to <= 20 mL/min per 1.73 m(2) during the last 6 mo. The association between TMAO, CMPF, and outcomes including all-cause mortality and kidney replacement therapy (KRT) was assessed among 737 patients. Patients were further stratified by median cutoffs of TMAO and CMPF, suggesting high/low red meat and fish intake. Results During a median of 39 mo of follow-up, 232 patients died. Higher TMAO was independently associated with an increased risk of all-cause mortality (multivariable HR: 1.46; 95% CI: 1.17, 1.83). Higher CMPF was associated with a reduced risk of both all-cause mortality (HR: 0.79; 95% CI: 0.71, 0.89) and KRT (HR: 0.80; 95% CI: 0.71, 0.90), independently of TMAO and other clinically relevant confounders. In comparison to patients with low TMAO and CMPF, patients with low TMAO and high CMPF had reduced risk of all-cause mortality (adjusted HR: 0.49; 95% CI: 0.31, 0.73), whereas those with high TMAO and high CMPF showed no association across adjusted models. Conclusions High CMPF conferred an independent role in health benefits and might even counteract the unfavorable association between TMAO and outcomes. Whether higher circulating CMPF concentrations are due to fish consumption, and/or if CMPF is a protective factor, remains to be verified
Symptom Burden before and after Dialysis Initiation in Older Patients
For older patients with kidney failure, lowering symptom burden may be more important than prolonging life. Dialysis initiation may affect individual kidney failure-related symptoms differently, but the change in symptoms before and after start of dialysis has not been studied. Therefore, we investigated the course of total and individual symptom number and burden before and after starting dialysis in older patients