The independent association of renal dysfunction and arrhythmias in critically ill patients

Study objectives: The purpose of this study was to quantify the impact of baseline renal dysfunction on incidence and occurrence of cardiac arrhythmias in the coronary ICU. Background: Renal dysfunction is an established predictor of all-cause mortality in the ICU setting. We set out to evaluate the independent contributory effect of renal dysfunction to arrhythmias and mortality in this population. Design and setting: We analyzed a prospective coronary care unit registry of 12, 648 admissions by 9, 557 patients over 8 years at a single, tertiary center. An admission serum creatinine level was available for 9, 544 patients. Those patients not receiving long-term dialysis were classified into quartiles of corrected creatinine clearance with cutpoints of 46.2 mL/min/72 kg (group 1), 63.1 mL/min/72 kg, and 81.5 mL/min/72 kg. Dialysis patients (n = 527) were considered as a fifth comparison group (group 5). Measurements and results: Baseline characteristics including older age, African-American race, diabetes, hypertension, history of previous coronary disease, and heart failure were incrementally more common with increasing renal dysfunction strata. There were graded, independent increased risks for accelerated idioventricular rhythm (relative risk [RR], 2.43; 95% confidence interval [CI], 1.40 to 4.20; p = 0.002), sustained ventricular tachycardia (RR, 2.07; 95% CI, 1.02 to 4.22; p = 0.04), ventricular fibrillation (RR, 2.42; 95% CI, 1.13 to 5.15; p = 0.02), and complete heart block (RR, 3.64; 95% CI, 1.77 to 7.48; p = 0.0004, group 5 vs group 1). Conclusions: We conclude that baseline renal function is a powerful, independent predictor of cardiac arrhythmias in the coronary ICU population

Burnout Among Nephrologists in the United States: A Survey Study

Rationale & Objective: Burnout decreases job satisfaction and leads to poor patient outcomes but remains under-investigated in nephrology. We explored the prevalence and determinants of burnout among a sample of nephrologists. Study Design: Cross-sectional. Setting & Participants: The nephrologists were approached via the American Medical Association Physicians Masterfile, National Kidney Foundation listserv, email, and social media between April and August 2019. The predictors were demographics and practice characteristics. The outcome was burnout, defined as responding once a week or more on either 1 of the 2 validated measures of emotional exhaustion and depersonalization or both. Analytical Approach: Participant characteristics were tabulated. Responses were compared using χ2 tests. Multivariable logistic regression was used to estimate the odds ratios (ORs) of burnout for risk factors. Free text responses were thematically analyzed. Results: About half of 457 respondents were 40-59 years old (n=225; 49.2%), and the respondents were more predominantly men (n=296; 64.8%), US medical graduates (n=285; 62.4%), and in academic practice (n=286; 62.6%). Overall, 106 (23.2%) reported burnout. The most commonly reported primary drivers of burnout were the number of hours worked (n=27; 25.5%) and electronic health record requirements (n=26; 24.5%). Caring for ≤25 versus 26-75 patients per week (OR, 0.34; 95% confidence interval [95% CI], 0.15-0.77), practicing in academic versus nonacademic settings (OR, 0.33; 95% CI, 0.21-0.54), and spending time on other responsibilities versus patient care (OR, 0.32; 95% CI, 0.17-0.61) were each independently associated with nearly 70% lower odds of burnout after adjusting for age, sex, race, and international medical graduate status. The free text responses emphasized disinterested health care systems and dissatisfaction with remuneration as the drivers of burnout. Limitations: Inability to precisely capture response rate. Conclusions: Nearly one-quarter of the nephrologists in our sample reported burnout. Future studies should qualitatively investigate how the care setting, time spent on electronic medical records, and hours of clinical care drive burnout and explore other system-level drivers of burnout in nephrology

Spurious Hyponatremia: Back to the Laboratory

Hyponatremia (hypoNa) occurs in 15%–30% of hospitalized patients. Spurious hypoNa requires etiologic diagnosis but not therapy. This report describes pseudohyponatremia (PHNa) attributed to a systematic laboratory defect. Four patients with AKI were identified with 6-10mmol/L drop in serum sodium (SNa) overnight. This drop couldn\u27t be explained physiologically on review of last 24hrs intake/output. They were asymptomatic. Hence serum osmolality (Sosm) and whole blood Na were performed. Fig1 indicates PHNa with concern for lab error. Two of the four patients were dialysis dependent. We avoided adjusting dialysate Na, which could have induced true hypoNa due to confirmatory testing. General causes of PHNa are hypertriglyceridemia & paraproteinemia. In our cases, it turned out to be lab error due to a dysfunctional electrode in the indirect Ion specific electrode (ISE) analyzer. Indirect ISE is commonly employed in most hospitals to test SNa. It uses a small serum volume by a preanalytic dilution step. It is important to confirm hypoNa with Sosm and direct ISE which measures the Na concentration in the water phase of serum. If direct ISE is unavailable the SNa can be estimated. Fig2 SNa is one of the most frequently requested blood tests. It is imperative we understand how to interpret and investigate if there is a concern for PHNa. The dangers of failing to recognize and treating as if it were true hypoNa could potentially lead to dangerous consequences. [Figure Presented][Figure Presented

Magnesium Balance and Measurement

Magnesium is an essential ion in the human body, playing an important role in practically every major metabolic and biochemical process, supporting and maintaining cellular processes critical for human life. Magnesium plays an important physiological role, particularly in the brain, heart, and skeletal muscles. As the second most abundant intracellular cation after potassium, it is involved in over 600 enzymatic reactions including energy metabolism and protein synthesis. Magnesium has been implicated in and used as treatment of several diseases. Although the importance of magnesium is widely acknowledged, routine serum magnesium levels are not routinely evaluated in clinical medicine. This review provides a discussion as to where magnesium is stored, handled, absorbed, and excreted. We discuss approaches for the assessment of magnesium status

The independent association of renal dysfunction and arrhythmias in critically ill patients

Study objectives: The purpose of this study was to quantify the impact of baseline renal dysfunction on incidence and occurrence of cardiac arrhythmias in the coronary ICU. Background: Renal dysfunction is an established predictor of all-cause mortality in the ICU setting. We set out to evaluate the independent contributory effect of renal dysfunction to arrhythmias and mortality in this population. Design and setting: We analyzed a prospective coronary care unit registry of 12, 648 admissions by 9, 557 patients over 8 years at a single, tertiary center. An admission serum creatinine level was available for 9, 544 patients. Those patients not receiving long-term dialysis were classified into quartiles of corrected creatinine clearance with cutpoints of 46.2 mL/min/72 kg (group 1), 63.1 mL/min/72 kg, and 81.5 mL/min/72 kg. Dialysis patients (n = 527) were considered as a fifth comparison group (group 5). Measurements and results: Baseline characteristics including older age, African-American race, diabetes, hypertension, history of previous coronary disease, and heart failure were incrementally more common with increasing renal dysfunction strata. There were graded, independent increased risks for accelerated idioventricular rhythm (relative risk [RR], 2.43; 95% confidence interval [CI], 1.40 to 4.20; p = 0.002), sustained ventricular tachycardia (RR, 2.07; 95% CI, 1.02 to 4.22; p = 0.04), ventricular fibrillation (RR, 2.42; 95% CI, 1.13 to 5.15; p = 0.02), and complete heart block (RR, 3.64; 95% CI, 1.77 to 7.48; p = 0.0004, group 5 vs group 1). Conclusions: We conclude that baseline renal function is a powerful, independent predictor of cardiac arrhythmias in the coronary ICU population

Severe metabolic alkalosis in pregnant patient due to citrate load with plasma exchange

Sodium citrate has been widely utilized as an anticoagulant in plasmapheresis (PP). Metabolic alkalosis is a well-known complication of PP in patients with impaired ability to excrete byproducts of citrate metabolism. We report a rare case of iatrogenic citrate toxicity leading to profound metabolic alkalosis in a pregnant patient. A 22-year-old pregnant female, gestational age 16 weeks, was admitted with fever, rash and myalgias. She was intubated due to respiratory failure with diffuse alveolar hemorrhage. Autoimmune studies and skin biopsy were consistent with a new diagnosis of lupus. Steroids and daily PP were initiated. On admission, patient\u27s height was 150 cm and she weighed 71 kg. Lab data showed serum creatinine levels between 0.21 and 0.51 mg/dL. Patient received six daily PP treatments. Three days after initiation of PP, she was noted to have an increase in serum bicarbonate (TCO2) level from 23 to 42 mmol/L. ABG showed pH of 7.55, pCO2 46.2 mm Hg. Peak pH was 7.62, following which she received one dose of acetazolamide. Her TCO2 levels returned to baseline upon completion of apheresis. Volume of distribution of hydrophilic substances is increased in pregnancy. The patient received 10 L of plasma replacement with total citrate load of 294 mmol in the first three days. Under normal conditions citrate is rapidly metabolized to bicarbonate in the liver. One molecule of citrate can be converted to three molecules of bicarbonate, therefore total bicarbonate load was approximately 882 mmol. Iatrogenic bicarbonate load with plasma exchange led to elevation of TCO2 to a critical level. Contributing factors include hypocapnic state of pregnancy and delayed renal compensation. This case also highlights the utility of acetazolamide in such circumstances. Citrate delivery needs to be protocolized and monitored closely to make it safe and effective

Risks associated with renal dysfunction in patients in the coronary care unit

OBJECTIVES: The purpose of this study was to quantify the impact of baseline renal dysfunction on morbidity and mortality in patients in the coronary care unit (CCU). BACKGROUND: The presence of renal dysfunction is an established independent predictor of survival after acute myocardial infarction and revascularization procedures. METHODS: We analyzed a prospective CCU registry of 12,648 admissions by 9,557 patients over eight years at a single, tertiary center. Admission serum creatinine was available in 9,544 patients. Those not on long-term dialysis were classified into quartiles of corrected creatinine clearance, with cut-points of 46.2, 63.1 and 81.5 ml/min per 72 kg. Dialysis patients (n = 527) were considered as a fifth comparison group. RESULTS: Baseline characteristics, including older age, African-American race, diabetes, hypertension, previous coronary disease and heart failure, were incrementally more common across increasing renal dysfunction strata. There were graded increases in the relative risk for atrial and ventricular arrhythmias, heart block, asystole, development of pulmonary congestion, acute mitral regurgitation and cardiogenic shock across the risk strata. Survival analysis demonstrated an early mortality hazard for those with renal dysfunction, but not on dialysis, for the first 60 months, followed by graded decrements in survival across increasing renal dysfunction strata. CONCLUSIONS: Baseline renal function is a powerful predictor of short- and long-term events in the CCU population. There is an early hazard for in-hospital and postdischarge mortality for those with a corrected creatinine clearance \u3c 46.2 ml/min per kg, but not on dialysis. (C) 2000 by the American College of Cardiology

Determinants of mortality after myocardial infarction in patients with advanced renal dysfunction

Previous studies using administrative data have shown high mortality in patients with renal failure requiring dialysis after acute myocardial infarction (AMI). There has been little investigation into the mortality after AMI in those with advanced renal disease who are not on dialysis therapy. We analyzed a prospective coronary care unit registry of 1, 724 patients with ST segment elevation myocardial infarction admitted over an 8-year period at a single tertiary-care center. Those not on chronic dialysis therapy were stratified into groups based on corrected creatinine clearance, with cutoff values of 46.2, 63.1, and 81.5 mL/min/72 kg. Dialysis patients (n = 47) were considered as a fifth comparison group. Older age, black race, diabetes, hypertension, previous coronary disease, and heart failure were incrementally more common across increasing renal dysfunction strata. There were also graded increases in the relative risk for atrial and ventricular arrhythmias, heart block, asystole, development of pulmonary congestion, acute mitral regurgitation, and cardiogenic shock. Primary angioplasty, thrombolysis, and β-blockers were used less often across the risk strata (P \u3c 0.0001 for all trends). There was an early mortality hazard (age-adjusted relative risk, 8.76; P \u3c 0.0001) for those with renal dysfunction but not on dialysis therapy for the first 60 months, followed by graded decrements in survival across increasing renal dysfunction strata. The excess mortality in this population appears to be mediated through arrhythmias, adverse hemodynamic events, and the lower use of mortality-reducing therapy. © 2001 by the National Kidney Foundation, Inc

Improving Primary Care Delivery for Patients Receiving Maintenance Hemodialysis

The beneficial impact of primary care, focused on all aspects of a patients\u27 health (rather than a disease-specific focus) is well established. Recognized benefits include greater receipt of preventive care and counseling, lower utilization of emergency care and hospitalization for ambulatory care sensitive conditions, and decreased early mortality. While the importance of primary care and care coordination at the primary care-specialty interface is well recognized, the role of primary care within traditional and emerging care models for patients receiving maintenance in-center hemodialysis remains ill-defined. In this perspective article, we will describe: 1) the role of primary care for patients receiving maintenance hemodialysis and the current evidence regarding the receipt of primary care among those patients; 2) the key challenges to delivery of primary care for these complex patients, including suboptimal care coordination between nephrology and primary care providers (PCPs), the intensity of dialysis care, and the limited capacity of nephrologists and PCPs to meet the broad health needs of hemodialysis patients; 3) the potential strategies for improving the delivery of primary care for patients receiving hemodialysis; and 4) future research needs to improve primary care delivery for this high-risk population