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BACKGROUND: Sub-Saharan Africans exhibit a higher frequency of chronic kidney disease (CKD) than other populations. In this study, we sought to determine the frequency of apolipoprotein L1 (APOL1) genotypes in hypertension-attributed CKD in Kinshasa, Democratic Republic of the Congo. METHODS: We performed a case-control study identifying 162 subjects: 79 with hypertension-attributed CKD and 83 controls living in Kinshasa who were genotyped for APOL1 risk variants between July 2013 and November 2016. We selected control subjects from the general population and matched them with the cases according to age. Logistic regression analysis was used to examine the relationship between APOL1 high-risk genotypes and CKD. RESULTS: The frequencies of the APOL1 G1 and G2 alleles were 19.1 and 7.1%, respectively. The number of individuals with the G1 and G2 risk alleles was significantly higher in the CKD group (12.7%) than in the control group (2.4%), particularly in individuals with end-stage kidney disease (14.3%). Subjects carrying two risk alleles was strongly and independently associated with hypertension-attributed nephropathy, with an adjusted odds ratio of 7.7 (95% confidence interval 1.5-39.7; P = 0.014). The high-risk APOL1 genotypes were G1/G1 and G1/G2, whereas G2/G2 was not found in the study population. CONCLUSIONS: The results of this study demonstrate the association of high-risk APOL1 genotypes with kidney disease in Kinshasa. The absence of G2/G2 may be consistent with powerful selective sweeps induced by Trypanosoma brucei gambiense infection. In contrast, the presence of APOL1 G2/G2 among individuals of African ancestry in the USA may indicate relaxation of natural selection in a trypanosome-free environment.
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Fuerza de la Mano , Riñón , Humanos , Corteza Renal , Imagen por Resonancia Magnética , PerfusiónRESUMEN
In addition to the classic and well-established "feedback control" of potassium balance, increasing investigative attention has focused on a novel and not widely recognized complementary regulatory paradigm for maintaining potassium homeostasis-the "feed-forward control" of potassium balance. This regulatory mechanism, initially defined in rumen, has recently been validated in normal human subjects. Studies are being conducted to determine the location for this putative potassium sensor and to evaluate potential signals, which might increase renal potassium excretion. Awareness of this more updated integrative control mechanism for potassium homeostasis is ever more relevant today, when the medical community is increasingly focused on the challenges of managing the hyperkalemia provoked by renin-angiotensin-aldosterone system inhibitors (RAASis). Recent studies have demonstrated a wide gap between RAASi prescribing guidelines and real-world experience and have highlighted that this gap is thought to be attributable in great part to hyperkalemia. Consequently we require a greater knowledge of the complexities of the regulatory mechanisms subserving potassium homeostasis. Sodium polystyrene sulfonate has long been the mainstay for treating hyperkalemia, but its administration is fraught with challenges related to patient discomfort and colonic necrosis. The current and imminent availability of newer potassium binders with better tolerability and more predictive dose-response potassium removal should enhance the management of hyperkalemia. Consequently it is essential to better understand the intricacies of mammalian colonic K+ handling. We discuss colonic transport of K+ and review evidence for potassium (BK) channels being responsible for increased stool K+ in patients with diseases such as ulcerative colitis.
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Integrated mechanisms controlling the maintenance of potassium homeostasis are well established and are defined by the classic "feedback control" of potassium balance. Recently, increasing investigative attention has focused on novel physiological paradigms that increase the complexity and precision of homeostasis. This review briefly considers the classic and well-established feedback control of potassium and then considers subsequent investigations that inform on an intriguing and not widely recognized complementary paradigm: the "feed-forward control of potassium balance." Feed-forward control refers to a pathway in a homeostatic system that responds to a signal in the environment in a predetermined manner, without responding to how the system subsequently reacts (i.e., without responding to feedback). Studies in several animal species, and recently in humans, have confirmed the presence of a feed-forward control mechanism that is capable of mediating potassium excretion independent of changes in serum potassium concentration and aldosterone. Knowledge imparted by this update of potassium homeostasis hopefully will facilitate the clinical management of hyperkalemia in patients with chronic and recurrent hyperkalemia. Awareness of this updated integrative control mechanism for potassium homeostasis is more relevant today when the medical community is increasingly focused on leveraging and expanding established renin-angiotensin-aldosterone system inhibitor treatment regimens and on successfully coping with the challenges of managing hyperkalemia provoked by renin-angiotensin-aldosterone system inhibitors. These new insights are relevant to the future design of clinical trials delineating renal potassium handling.
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BACKGROUND AND OBJECTIVES: Preoperative anemia adversely affects outcomes of cardiothoracic surgery. However, in patients with CKD, treating anemia to a target of normal hemoglobin has been associated with increased risk of adverse cardiac and cerebrovascular events. We investigated the association between preoperative hemoglobin and outcomes of cardiac surgery in patients with CKD and assessed whether there was a level of preoperative hemoglobin below which the incidence of adverse surgical outcomes increases. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This prospective observational study included adult patients with CKD stages 3-5 (eGFR<60 ml/min per 1.73 m(2)) undergoing cardiac surgery from February 2000 to January 2010. Patients were classified into four groups stratified by preoperative hemoglobin level: <10, 10-11.9, 12-13.9, and ≥ 14 g/dl. The outcomes were postoperative AKI requiring dialysis, sepsis, cerebrovascular accident, and mortality. RESULTS: In total, 788 patients with a mean eGFR of 43.5 ± 3.7 ml/min per 1.73 m(2) were evaluated, of whom 22.5% had preoperative hemoglobin within the normal range (men: 14-18 g/dl; women: 12-16 g/dl). Univariate analysis revealed an inverse relationship between the incidence of all adverse postoperative outcomes and hemoglobin level. Using hemoglobin as a continuous variable, multivariate logistic regression analysis showed a proportionally greater frequency of all adverse postoperative outcomes per 1-g/dl decrement of preoperative hemoglobin (mortality: odds ratio, 1.38; 95% confidence interval, 1.23 to 1.57; P<0.001; sepsis: odds ratio, 1.31; 95% confidence interval, 1.14 to 1.49; P<0.001; cerebrovascular accident: odds ratio, 1.31; 95% confidence interval, 1.00 to 1.67; P=0.03; postoperative hemodialysis: odds ratio, 1.38; 95% confidence interval, 1.11 to 1.75; P<0.01). Moreover, preoperative hemoglobin<12 g/dl was an independent risk factor for postoperative mortality (odds ratio, 2.6; 95% confidence interval, 1.1 to 7.3; P=0.04). CONCLUSIONS: Similar to the general population, preoperative anemia is associated with adverse postoperative outcomes in patients with CKD. Whether outcomes could be improved by therapeutically targeting higher preoperative hemoglobin levels before cardiac surgery in patients with underlying CKD remains to be determined.
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Procedimientos Quirúrgicos Cardíacos , Hemoglobinas/análisis , Insuficiencia Renal Crónica/sangre , Anciano , Femenino , Humanos , Masculino , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Cuidados Preoperatorios , Estudios Prospectivos , Resultado del TratamientoRESUMEN
Background and Objectives. Hypoparathyroidism in patients with functioning kidneys leads to hyperphosphatemia. This article reviews data suggesting that hypoparathyroidism in patients on dialysis leads to hypophosphatemia. Design. Clinical data of the following were reviewed: (a) a patient with hypoparathyroidism before and during chronic dialysis; (b) patients on dialysis with surgically created hypoparathyroidism; (c) dialysis patients being treated with Cinacalcet, a calcium-sensing receptor agonist that lowers parathyroid hormone (PTH) levels; and (d) dialysis patients being treated with Velcalcetide, a new calcium-sensing receptor agonist that also lowers PTH. Results. In the patient presented in this study, in patients with surgically created hypoparathyroidism, and those receiving Cinacalcet or Velcalcetide, a fall in PTH was associated with hypophosphatemia or a fall in serum phosphorus. Conclusion. In patients on dialysis, hypoparathyroidism may lead to hypophosphatemia.
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BACKGROUND: The proportion of elderly individuals is growing and the prevalence of chronic kidney disease (CKD) among elderly people undergoing cardiac surgery is increasing constantly. The aim of this study was to determine the influence of different degrees of preoperative renal dysfunction on postoperative outcomes in patients older than 80years of age. METHODS: This is an observational study that included adult patients undergoing cardiac surgery in which data were collected prospectively. Patients were divided into groups according to their preoperative plasma creatinine and eGFR levels. RESULTS: From February 1997 to January 2010, 318 octogenarians underwent cardiac surgery. Of these, 140 patients (44%) had abnormal preoperative creatinine levels. A significantly higher incidence of postoperative sepsis (4% vs. 17%, p 0.03), CVA (1% vs. 6%, p 0.03), and prolonged hospital stay (16±13 vs. 20±16days, p 0.04) were detected in patients with preoperative kidney dysfunction. Subgroup analysis revealed that preoperative CKD stage IV (eGFR 15-30ml/min/1.73m(2)) but not CKD stage III (eGFR 30-60ml/min/1.73m(2)) and preoperative creatinine >1.8mg/dl were independently associated with increased incidence of postoperative CVA (OR 4; 95% CI 0.07-0. 8, p=0.05 for eGFR, and OR 7.8; 95% CI 1.2-60, p=0.003 for creatinine). However, no significant increment in postoperative mortality with decreasing eGFR or increasing preoperative creatinine was demonstrated. CONCLUSIONS: A substantial increase in the risk of postoperative CVA and sepsis, but not mortality, was demonstrated in octogenarians with advanced but not mild degrees of preoperative CKD. Compared to younger patients, a high burden of comorbidities in octogenarians may have a greater influence on outcomes post cardiac surgery than impaired renal function. Our data may provide a rationale for modified risk stratification in octogenarian candidates for cardiac surgery.
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Procedimientos Quirúrgicos Cardíacos/efectos adversos , Insuficiencia Renal Crónica/complicaciones , Anciano de 80 o más Años , Procedimientos Quirúrgicos Cardíacos/mortalidad , Creatinina/sangre , Femenino , Tasa de Filtración Glomerular , Mortalidad Hospitalaria , Humanos , Israel/epidemiología , Tiempo de Internación/estadística & datos numéricos , Masculino , Complicaciones Posoperatorias , Periodo Preoperatorio , Estudios Prospectivos , Insuficiencia Renal Crónica/sangre , Insuficiencia Renal Crónica/fisiopatología , Sepsis/etiología , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/etiología , Resultado del TratamientoRESUMEN
CONTEXT: Uremic pruritus (UP) affects many patients suffering from chronic kidney disease (CKD) and has a negative impact on quality of life and survival. It has become increasingly evident that central transmission and sensitization processes similar to those observed in chronic pain are important mechanisms of pruritus. OBJECTIVES: To test the potential role of pregabalin in reducing the intensity of UP in CKD patients. METHODS: We prospectively collected data on CKD patients who suffered from severe intractable pruritus. Patients were asked to record the intensity of pruritus on a visual analogue scale. RESULTS: Twelve patients were studied. The average pretreatment pruritus score was 9.7 ± 0.9 and decreased to 3.7 ± 2.35, 3.2 ± 1.75, and 3 ± 1.5 after one, four, and 24 weeks of treatment, respectively (P < 0.05). The positive effect of pregabalin was demonstrated during the first week of therapy in six patients. Most patients required 25mg a day. Pregabalin was well tolerated, with somnolence and dizziness developing in two patients. CONCLUSION: We demonstrated dramatic improvement of long-standing UP after the initiation of pregabalin. We suggest that pregabalin can be used safely in CKD but careful titration of the dose is required to obtain an optimal response and minimize the possible adverse effects.
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Prurito/tratamiento farmacológico , Prurito/etiología , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/tratamiento farmacológico , Uremia/tratamiento farmacológico , Uremia/etiología , Ácido gamma-Aminobutírico/análogos & derivados , Anciano , Analgésicos/uso terapéutico , Anticonvulsivantes/uso terapéutico , Enfermedad Crónica , Femenino , Humanos , Masculino , Pregabalina , Prurito/diagnóstico , Insuficiencia Renal Crónica/diagnóstico , Resultado del Tratamiento , Uremia/diagnóstico , Ácido gamma-Aminobutírico/uso terapéuticoRESUMEN
BACKGROUND AND OBJECTIVES: Hypoparathyroidism in patients with functioning kidneys leads to hyperphosphatemia. This paper reviews data suggesting that hypoparathyroidism in patients on maintenance dialysis leads to hypophosphatemia. DESIGN: Clinical data in two patients on dialysis with hypoparathyroidism following parathyroid surgery; literature review of dialysis patients with hypoparathyroidism following parathyroid surgery. RESULTS: In the patients presented both here and in the literature, hypoparathyroidism in dialysis patients is associated with persistent hypophosphatemia or decrease in serum phosphorus from its pre-surgery level. CONCLUSION: In patients on maintenance dialysis, persistent hypoparathyroidism post-parathyroidectomy may lead to chronic hypophosphatemia, in contrast to the hyperphosphatemia usually associated with hypoparathyroidism. Proposed mechanisms for this paradoxical phenomenon include ongoing phosphorus deposition into bone (Hungry Bone Syndrome), phosphorus deposition into soft tissue and/or diminished intestinal phosphorus absorption or increased intestinal phosphorus loss.
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Hipofosfatemia/etiología , Paratiroidectomía/efectos adversos , Diálisis Renal , Insuficiencia Renal Crónica/sangre , Adulto , Anciano , Calcio/sangre , Femenino , Humanos , Masculino , Fosfatos/sangre , Insuficiencia Renal Crónica/terapiaRESUMEN
BACKGROUND/AIMS: Cardiovascular morbidity and mortality are high in patients with chronic kidney disease. We evaluated the influence of small differences in preoperative kidney function on mortality and complications following cardiac surgery. METHODS: This is an observational study that included adult patients undergoing cardiac surgery. Preoperative estimated glomerular filtration rate (eGFR) was estimated by the 4-component Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations based on preoperative creatinine levels. For analysis, patients were divided into groups according to their preoperative creatinine (0.2 mg/dl increments) and eGFR levels (15-30 ml/min/1.73 m(2) decrements). RESULTS: Data on 5,340 patients were analyzed. A significant increase in postoperative mortality was demonstrated with preoperative creatinine at high-normal versus low-normal values (OR 1.7, 95% CI: 1-2.5; p = 0.02). For preoperative creatinine >1.2 mg/dl, adjusted OR for in-hospital mortality increased stepwise with every 0.2-mg/dl increment of creatinine. In addition, a statistically significant increment of mortality was detected with every 15-ml/min/1.73 m(2) decrement in preoperative eGFR. CONCLUSIONS: Minimal changes of preoperative kidney function are associated with a substantial increase in the risk of mortality and morbidity following cardiac surgery. Even within the 'normal' range, minimal increases in serum creatinine levels are associated with increased risk of adverse events postoperatively.
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Procedimientos Quirúrgicos Cardíacos/efectos adversos , Tasa de Filtración Glomerular/fisiología , Riñón/fisiología , Complicaciones Posoperatorias/mortalidad , Cuidados Preoperatorios , Anciano , Estudios de Cohortes , Femenino , Mortalidad Hospitalaria/tendencias , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/fisiopatología , Cuidados Preoperatorios/tendencias , Estudios Prospectivos , Resultado del TratamientoRESUMEN
The past two decades have witnessed a striking paradigm shift with respect to our understanding of the widespread effects of aldosterone. There is substantive evidence that mineralocorticoid receptor (MR) activation promotes myriad 'off target' effects on the heart, the vasculature, and importantly the kidney. In the present review, we summarize the expanding role of MR activation in promoting both vascular and renal injury. We review the recent clinical studies that investigated the efficacy of MR antagonism (MRA) in reducing proteinuria and attenuating progressive renal disease. We also review in-depth both the utility and safety of MRA in the end-stage renal disease (ESRD) patient undergoing dialysis. Because the feasibility of add-on MRA is critically dependent on our ability to minimize or avoid hyperkalemia, and because controversy centers on the incidence of hyperkalemia, we critically review the risk of hyperkalemia with add-on MRA. Our present analysis suggests that hyperkalemia supervening in MRA-treated patients is overstated. Furthermore, recent studies demonstrating the efficacy of new non-absorbed, orally administered, potassium [K+]-binding polymers suggest that a multi-pronged approach encompassing adequate surveillance, moderate or low-dose MRA, and K-binding polymers may adequately control serum K in both chronic kidney disease and ESRD patients.
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Aldosterona/metabolismo , Fallo Renal Crónico/terapia , Riñón/efectos de los fármacos , Antagonistas de Receptores de Mineralocorticoides , Antagonistas de Receptores de Mineralocorticoides/uso terapéutico , Diálisis Renal , Aldosterona/sangre , Animales , Quelantes/uso terapéutico , Terapia Combinada , Progresión de la Enfermedad , Humanos , Hiperpotasemia/sangre , Hiperpotasemia/etiología , Hiperpotasemia/prevención & control , Riñón/metabolismo , Riñón/fisiopatología , Fallo Renal Crónico/tratamiento farmacológico , Fallo Renal Crónico/metabolismo , Fallo Renal Crónico/fisiopatología , Antagonistas de Receptores de Mineralocorticoides/efectos adversos , Potasio/sangre , Receptores de Mineralocorticoides/metabolismo , Diálisis Renal/efectos adversos , Medición de Riesgo , Factores de Riesgo , Transducción de Señal/efectos de los fármacos , Resultado del TratamientoRESUMEN
The purpose was to check the influence of enteric nutrition on BUN in very elderly patients. Clinical data on patients in whom enteral feeding was initiated after a period of poor oral intake are presented. Patients with evidence of volume depletion, signs of gastrointestinal bleeding or medicines that might increase BUN were excluded. We evaluated 5 patients (mean age 90.6 ± 3 years) who were admitted to geriatric department. Mean plasma creatinine concentration was 1.17 ± 0.34 mg/dl, but mean estimated glomerular filtration rate (eGFR) was 41.6 ± 17 ml/min/1.73 m(2). Enteral nutrition was administered at a dose of mean 1,580 ± 53ml/day at mean duration of 9 ± 4 days. Mean BUN was 52 ± 30 mg/dl at baseline, increases to 109 ± 9.4 mg/dl after initiation of feeding and decreased to 82 ± 1.1mg/dl with reduction of dose of enteral nutrition. Our conclusion was that initiation of enteral feeding may induce a large accumulation of nitrogen waste products in elderly patients in whom serum creatinine is an unreliable indicator of kidney function. High protein intake should be considered in differential diagnosis of disproportionate high increment of BUN.
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Nitrógeno de la Urea Sanguínea , Nutrición Enteral , Insuficiencia Renal Crónica/fisiopatología , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Insuficiencia Renal Crónica/sangreRESUMEN
INTRODUCTION: The prevalence of heparin-induced antibodies (HIA) varies widely among reported series, but is generally higher in cardiac surgery than hemodialysis patients. This study was designed to explore the reasons behind the different prevalence of HIA in these two populations. METHODS: Blood samples from all hemodialysis and cardiac surgery patients in our hospital were examined for HIA. Heparin-induced thrombocytopenia (HIT) was suspected when platelet count was <150,000 in the hemodialysis group, and >50% decline in platelet count in the cardiac surgery group. RESULTS: 79 hemodialysis and 40 cardiac surgery patients were studied. HIA prevalence was significantly higher in cardiac surgery than in hemodialysis patients (65% v 10.1%, respectively, P<0.00001). Conversely, the prevalence of suspected clinical HIT was 37.5% in the hemodialysis and 11.5% in the cardiac surgery group. Prevalence of HIA was higher in patients who were tested during the first 90 days of hemodialysis than in those tested at later times. One-year mortality was 37% in HIA positive and 19% in HIA negative hemodialysis patients. CONCLUSIONS: Prevalence of HIA was significantly lower in hemodialysis as compared with cardiac surgery patients. Our data suggest that the observed difference in HIA prevalence was either population dependent, or due to different timing of heparin administration in the two groups.
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Anticuerpos/sangre , Anticoagulantes/inmunología , Procedimientos Quirúrgicos Cardíacos , Heparina/inmunología , Diálisis Renal , Trombocitopenia/inmunología , Adulto , Anciano , Anciano de 80 o más Años , Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversos , Biomarcadores/sangre , Esquema de Medicación , Ensayo de Inmunoadsorción Enzimática , Femenino , Productos de Degradación de Fibrina-Fibrinógeno/análisis , Heparina/administración & dosificación , Heparina/efectos adversos , Humanos , Israel , Masculino , Persona de Mediana Edad , Recuento de Plaquetas , Valor Predictivo de las Pruebas , Prevalencia , Diálisis Renal/mortalidad , Trombocitopenia/sangre , Trombocitopenia/inducido químicamente , Trombocitopenia/mortalidad , Factores de TiempoRESUMEN
BACKGROUND: Enoxaparin, a low molecular weight heparin, has been shown to be a safe and effective anticoagulant to prevent clotting in the extracorporeal circulation during hemodialysis. Enoxaparin also possesses antiproliferative properties, and reduces neointimal proliferation following vascular injury in animals. Use of enoxaparin during hemodialysis may be associated with decreased myointimal proliferation and diminished vascular access stenosis or failure. AIM: The aim of our study was to test the efficacy of enoxaparin to reduce the incidence of recurrent vascular access stenosis in chronic hemodialysis patients. METHODS: Twenty-nine hemodialysis patients who suffered from recurrent arteriovenous (A-V) access stenosis were studied retrospectively to compare the incidence of vascular access procedures before and during enoxaparin administration. Enoxaparin was administered intravenously as a single bolus at the start of hemodialysis. RESULTS: Twenty-eight patients (14 male) were analyzed. Ten required a new fistula during the study period. Observed treatment times (years/patient) were 1.20 ± 0.87 for unfractionated heparin (UFH) and 3.04 ± 2.19 for enoxaparin (P = 0.0001). Angiographic procedure rates (procedures/year) were 1.76 ± 0.92 in the UFH group and 1.30 ± 1.01 in the enoxoparin group (P = 0.0786). There were no significant differences in time to first stenosis between the two groups (P = 0.5315). One patient receiving enoxaparin developed upper gastrointestinal bleeding and a second patient sustained a subdural hematoma after a fall. CONCLUSION: Our study demonstrated a trend toward a decreased number of angiographic procedures for maintaining A-V access patency in selected chronic hemodialysis patients treated with enoxaparin in comparison with UFH as anticoagulant during dialysis.
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Anticoagulantes/uso terapéutico , Derivación Arteriovenosa Quirúrgica/efectos adversos , Enoxaparina/uso terapéutico , Diálisis Renal , Trombosis/prevención & control , Constricción Patológica/etiología , Constricción Patológica/prevención & control , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Trombosis/etiologíaRESUMEN
INTRODUCTION: Contrast-induced acute kidney injury (CI-AKI) is one of the leading causes of hospital-acquired acute kidney injury. Multiple clinical studies have proposed several preventive strategies. AIMS: To examine the efficacy of sodium bicarbonate compared with sodium chloride and oral N-acetylcysteine (NAC) for preventive hydration after cardiac catheterization. METHODS: We conducted a prospective, single-center trial. Patients with chronic kidney disease (CKD) stage III-IV undergoing cardiac catheterization were allocated to receive either an infusion of 0.9% sodium chloride and oral NAC or 154 mEq/L sodium bicarbonate. MAIN: Outcome measure CI-AKI, defined as an increase of 25% or 0.3 mg/dL or more in plasma creatinine within 2 days of contrast administration. RESULTS: Ninety-three patients were allocated to one of the two groups: 42 patients in the saline plus NAC group and 51 patients in the bicarbonate group. There were no statistically significant differences between the groups in the most important clinical and procedural characteristics. Baseline plasma creatinine levels, estimated glomerular filtration rate, incidence of diabetes mellitus, hypertension, congestive heart failure, and contrast medium volume were similar. Mean plasma creatinine concentration was 1.76 +/- 0.54 mg/dL in the saline and NAC group and 1.9 +/- 1 mg/dL in the bicarbonate group (P = 0.23). The rate of CI-AKI was 9.8% in the bicarbonate group and 8.4% in the saline plus NAC group. No patient required renal replacement therapy. CONCLUSION: Hydration with sodium bicarbonate is not more effective than hydration with sodium chloride and oral NAC for prophylaxis of CI-AKI in patients with CKD stage III-IV undergoing cardiac catheterization.
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Acetilcisteína/uso terapéutico , Cateterismo Cardíaco/efectos adversos , Medios de Contraste/efectos adversos , Enfermedades Renales/prevención & control , Bicarbonato de Sodio/uso terapéutico , Cloruro de Sodio/uso terapéutico , Anciano , Creatina/sangre , Creatina/efectos de los fármacos , Deshidratación/prevención & control , Femenino , Depuradores de Radicales Libres/uso terapéutico , Tasa de Filtración Glomerular , Humanos , Enfermedades Renales/inducido químicamente , Fallo Renal Crónico/prevención & control , Masculino , Estudios Prospectivos , Análisis de Regresión , Medición de Riesgo , Estadística como AsuntoRESUMEN
BACKGROUND: The role of N-acetylcysteine (NAC) to protect against contrast-induced nephropathy (CN) in patients with pre-existing renal insufficiency remains controversial despite several randomized controlled trials and meta-analyses. The potential reasons of inconsistency may be due to differences in definition, type and dose of contrast medium, imaging procedures, and the frequency of other potential causes of acute renal injury. Renal function before contrast administration is a major determinant of deterioration in function after administration. METHODS: We conducted a retrospective review of patients with Stage III Chronic Kidney Disease (CKD) who underwent cardiac catheterization from January 2000 through January 2004 in our hospital. The incidence of CN was examined in patients pretreated and not pretreated with NAC. RESULTS: From January 2000 to January 2004, 189 patients with Stage III CKD underwent cardiac catheterization. All patients received 0.45% or 0.9% saline hydration prior to catheterization. NAC was given prior to 83 catheterizations and not given prior to 57. Eleven of 57 patients (19.3%) not pretreated with NAC developed acute renal injury (ARI) while 6 of 83 who received NAC (7.2%) developed ARI (p<0.05). Nineteen patients underwent more than one cardiac catheterization, but there was no pattern to their potential for multiple episodes of ARI irrespective of prophylactic NAC administration. CONCLUSION: In our study NAC offered significant protection against ARI in patients with Stage III CKD. No overt risk factor for multiple episodes of ARI was observed, nor was the occurrence of ARI after first cardiac catheterization predictive of ARI after a subsequent catheterization.