P1478LOWERING PREVALENCE OF ALKALOSIS AND IMPROVING ADHERENCE TO BICARBONATE TARGETS AMONGST HAEMODIALYSIS PATIENTS THROUGH THE USE OF REDUCED DIALYSATE BICARBONATE

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Caroline Tulley ◽  
Richard Hull ◽  
Martin Ford
Keyword(s):  
Patient Outcomes ◽  
Patient Survival ◽  
Target Range ◽  
Serum Bicarbonate ◽  
Bicarbonate Concentration ◽  
Ongoing Debate ◽  
Risk Of Mortality ◽  
Increased Risk ◽  
The Mean ◽  
Small Change

Abstract Background and Aims There is evidence that metabolic alkalosis in haemodialysis patients is harmful. Bommer et al demonstrated association between extremes of bicarbonate and clinical outcomes with significantly increased risk of mortality and hospitalisation with pre-dialysis serum bicarbonate >27mmol/L and <17mmol/L. No overall increased mortality risk was observed with moderate pre-dialysis acidosis (serum bicarbonate 19.1-23.0mmol/L). 2015 Renal Registry Data demonstrated 64.3% of haemodialysis patients overall had bicarbonates within target (18-24mmol/L) compared to 65.7% within our centre. Our reported mean pre-dialysis bicarbonate of 23.7mmol/L was above the mean serum bicarbonate 23.2mmol/L seen nationally. In addition, 33.7% of patients were alkalotic, with bicarbonates >24mmol/L. Given concerns of adverse patient outcomes with extremes of bicarbonate, we aimed to investigate whether reducing our dialysate bicarbonate would culminate in overall attainment of bicarbonate targets. Method Mid-week pre-dialysis bicarbonate levels were measured from in centre haemodialysis patients once monthly, from May to August 2017, across 7 dialysis units within our renal service. Following this, in early 2018, we reduced dialysate bicarbonate concentration from 32mmol/L to 31mmol/L. Monthly midweek pre-dialysis bicarbonate levels were then re-measured in March and April 2019. Results Initial analysis of 2103 pre-dialysis bicarbonate levels across May to August 2017 demonstrated median monthly bicarbonate levels of 24.0–25.0mmol/L. 40.7–54.2% (n=199-322) were alkalotic with pre-dialysis bicarbonates >24mmol/L across this period. Of note, 15-23% (n=66-120) had bicarbonate levels associated with increased mortality and hospitalisation (i.e. <17mmol/L or >27 mmol/L. Subsequent analysis of 1070 bicarbonate levels in March and April 2019 demonstrated a reduction in median pre-dialysis bicarbonate to 22.0mmol/L. Similarly, the proportion of alkalotic patients fell to 11.9–15.3% (n=71-91). 5-9% (n=26-46) bicarbonates were <17 or >27mmol/L. In March 2019, 77.9% of patients had serum bicarbonates in target range compared to 65.7% reported in 2015 overall. Conclusion Initial findings demonstrated substantial alkalosis amongst our dialysis population. A simple measure of altering dialysate by 1mmol/L achieved reductions in overall alkalaemia, and in turn, reduced the percentage of patients with bicarbonate values theoretically correlating with increased mortality and hospitalization risk. We have demonstrated that a small change in dialysate bicarbonate increased concordance with bicarbonate targets, without subsequent increased acidaemia. The extent to which adherence with such targets impacts on patient survival and morbidity remains an ongoing debate.

Abstract P017: Serum N-Carboxymethyl-Lysine and Risk of Mortality in Older Adults

Circulation ◽  
2014 ◽  
Vol 129 (suppl_1) ◽  
Author(s):  
Mary Lou Biggs ◽  
David Benkeser ◽  
Joachim Ix ◽  
Jorge Kizer ◽  
Luc Djousse ◽  
...  
Keyword(s):  
Renal Failure ◽  
Mortality Risk ◽  
Community Dwelling ◽  
Cardiovascular Health Study ◽  
Risk Of Death ◽  
Risk Of Mortality ◽  
Organ Systems ◽  
Increased Risk ◽  
Carboxymethyl Lysine ◽  
The Mean

Advanced glycation end products (AGEs) are compounds formed by the non-enzymatic glycation of proteins, lipids, and nucleic acids, and are thought to play a role in the pathogenesis of diseases across multiple organ systems. Carboxymethyl-lysine (CML) is a dominant AGE found in tissue proteins and in the circulation, and a commonly used AGE biomarker. Only a few epidemiological studies have evaluated the association between circulating CML and mortality risk, and none have evaluated the association between CML and cause-specific non-CVD mortality. We measured CML by ELISA on serum specimens collected from 3,373 Cardiovascular Health Study participants in 1996. Participants were followed for death through 2010, and cause of death was classified using death certificates, medical records, and proxy interview. We used Cox regression to estimate the relative risk of total and cause-specific mortality associated with circulating CML, adjusting for confounders (Models 1 & 2) and estimated glomerular filtration rate (eGFR) as a potential mediator (Model 3). We tested whether sex or diabetes modified the association between CML and mortality. The mean age among participants was 78 years and 60% were women. The mean CML level among participants was 629 ng/mL. Over median follow-up of 10 years, 2,322 deaths occurred (73.4 per 1,000 person-years). After adjustment for confounders (Models 1 & 2), CML was associated with an increased risk of death from CVD, dementia, infection, fracture/trauma, and renal failure (Table). Aside from renal failure, adjustment for eGFR attenuated the HR estimates modestly. There was no evidence for effect modification of the association of CML and all-cause mortality risk by sex or diabetes. In a cohort of community-dwelling older individuals, elevated circulating CML was associated with increased risk of mortality from cardiovascular causes, dementia, infection, fracture/trauma, and renal failure. A portion of the increased risk may be mediated through decreased renal function.

scholarly journals P0005TIME-VARYING DIALYSATE BICARBONATE CONCENTRATIONS CAN REDUCE PEAK INTRADIALTIC SERUM BICARBONATE CONCENTRATIONS

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Anna Ebinger ◽  
Jacek Waniewski ◽  
Jolanta Malyszko ◽  
Monika Wieliczko ◽  
Pietribiasi Mauro ◽  
...  
Keyword(s):  
Patient Outcomes ◽  
Step Function ◽  
Bicarbonate Transport ◽  
Time Varying ◽  
Serum Bicarbonate ◽  
Bicarbonate Concentration ◽  
Timing Resolution ◽  
Buffer Base ◽  
Dialysis Solutions ◽  
Dialysis Time

Abstract Background and Aims Hemodialysis (HD) treatments using bicarbonate-containing dialysis solutions can result in large intradialytic increases in serum bicarbonate concentration, potentially inducing intradialytic alkalemia. It has been suggested that a time-varying, compared with a constant, dialysate bicarbonate concentration may limit the intradialytic increase in serum bicarbonate concentration (Tobvin & Sherman, Semin Dial 2016). We tested this hypothesis using a mathematical model of bicarbonate transport during HD. Method We used the H+ mobilization model describing bicarbonate transport during HD (Sargent et al, Semin Dial 2018) to compare intradialytic serum bicarbonate concentrations when using constant or time-varying dialysate bicarbonate concentrations that deliver the same total amount of buffer base to the patient during the HD treatment. We employed this model to evaluate different time-varying dialysate bicarbonate concentration profiles that started at a high value and then decreased as a step function with a 10-minute timing resolution. Dialysis time was 210 minutes, dialysis solutions were assumed to contain acetate at 3 mEq/L, and all kinetic parameters were assumed to be identical to those reported by Sargent et al (Semin Dial 2018). All results with time-varying dialysate bicarbonate concentrations were compared to a constant dialysate concentration of 32 mEq/L. Results Example results comparing time-varying (36.0 mEq/L for the initial 40 min, 31.2 mEq/L thereafter) and constant (32 mEq/L) dialysate bicarbonate concentrations are shown in the figure. The time-varying dialysate bicarbonate concentration lowered the peak intradialytic serum bicarbonate by 0.4 mEq/L for approximately one-half of the treatment. Similar reductions in the peak intradialytic serum bicarbonate concentration could be achieved if the initial high dialysate bicarbonate concentration was 37.6 mEq/L for 30 min or 40.8 for 20 min. The optimal initial high dialysate bicarbonate concentrations and the reduction in the peak intradialytic serum bicarbonate concentrations were somewhat dependent on the assumed patient-dependent H+ mobilization coefficient. Conclusion We conclude that a time-varying dialysate bicarbonate concentration can lower the peak intradialytic serum bicarbonate concentrations while delivering the same total amount of buffer base to the patient. Whether this approach will yield improved patient outcomes requires further evaluation.

scholarly journals When More Means Less: The Prognosis of Recurrent Acute Myocardial Infarctions

2021 ◽  
Vol 10 (24) ◽  
pp. 5889
Author(s):  
Ygal Plakht ◽  
Harel Gilutz ◽  
Arthur Shiyovich
Keyword(s):  
Primary Outcome ◽  
Risk Group ◽  
High Risk Group ◽  
Myocardial Infarctions ◽  
Time Interval ◽  
Post Discharge ◽  
Risk Of Mortality ◽  
Increased Risk ◽  
All Cause Mortality ◽  
The Mean

Recurrent acute myocardial infarctions (AMI) are common and associated with dismal outcomes. We evaluated the clinical characteristics and the prognosis of AMI survivors according to the number of recurrent AMIs (ReAMI) and the time interval of events (TI). A retrospective analysis of patients who survived following hospitalization with an AMI throughout 2002–2017 was conducted. The number of ReAMIs for each patient during the study period was recorded and classified based on following: 0 (no ReAMIs), 1, 2, ≥3. Primary outcome: all-cause mortality up to 10 years post-discharge from the last AMI. A total of 12,297 patients (15,697 AMI admissions) were analyzed (age: 66.1 ± 14.1 years, 68% males). The mean number of AMIs per patient was 1.28 ± 0.7; the rates of 0, 1, 2, ≥3 ReAMIs were 81%, 13.4%, 3.6% and 1.9%, respectively. The risk of mortality increased in patients with greater number of AMIs, HR = 1.666 (95% CI: 1.603–1.720, p < 0.001) for each additional event (study group), attenuated following adjustment for potential confounders, AdjHR = 1.135 (95% CI: 1.091–1.181, p < 0.001). Increased risk of mortality was found with short TI (<6-months), AdjHR = 2.205 (95% CI: 1.418–3.429, p < 0.001). The risk of mortality following AMI increased as the number of ReAMIs increased, and the TI between the events shortened. These findings should guide improved surveillance and management of this high-risk group of patients (i.e., ReAMI).

Pre and interdialytic acid-base balance in hemodialysis patients

2001 ◽  
Vol 24 (4) ◽  
pp. 192-196 ◽  
Author(s):  
K.A Graham ◽  
N.A. Hoenich ◽  
T.H.J. Goodship
Keyword(s):  
Area Under The Curve ◽  
Hemodialysis Patients ◽  
Serum Bicarbonate ◽  
Acid Base Balance ◽  
Bicarbonate Concentration ◽  
Acid Base ◽  
Base Balance ◽  
The Mean ◽  
Mean Time ◽  
Linear Decline

In an observational study, nine hemodialysis patients using 35 mmol/l bicarbonate dialysate were studied over a 44-hour interdialytic interval. Serum bicarbonate was measured at regular intervals at home and the mean time averaged concentration was 27.0 ± 1.2 mmol/l. Seven of the nine patients showed a slow linear decline in bicarbonate whilst in two patients levels were unchanged. In 8 of 9 patients the average of the post and predialysis bicarbonate accurately predicted the time-averaged (area under the curve) bicarbonate concentration. In addition, pre-dialysis serum bicarbonate was measured in 46 patients after both a 2 and 3-day interdialytic interval. The serum bicarbonate was significantly lower after the 3-day interdialytic interval (3-day, 22.1 ± 0.6 vs 2-day, 23.0 ± 0.5 mmol/l, p<0.05). The results from this study emphasize the importance of standardization of bicarbonate measurement in order to avoid spurious acidosis.

scholarly journals Associations of longitudinal D-Dimer and Factor II on early trauma survival risk

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Richard M. Jiang ◽  
Arya A. Pourzanjani ◽  
Mitchell J. Cohen ◽  
Linda Petzold
Keyword(s):  
Risk Prediction ◽  
Patient Outcomes ◽  
Trauma Patients ◽  
Longitudinal Trajectories ◽  
Consumptive Coagulopathy ◽  
Risk Of Mortality ◽  
Increased Risk ◽  
Factor Ii ◽  
Unit Increase ◽  
D Dimer

Abstract Background Trauma-induced coagulopathy (TIC) is a disorder that occurs in one-third of severely injured trauma patients, manifesting as increased bleeding and a 4X risk of mortality. Understanding the mechanisms driving TIC, clinical risk factors are essential to mitigating this coagulopathic bleeding and is therefore essential for saving lives. In this retrospective, single hospital study of 891 trauma patients, we investigate and quantify how two prominently described phenotypes of TIC, consumptive coagulopathy and hyperfibrinolysis, affect survival odds in the first 25 h, when deaths from TIC are most prevalent. Methods We employ a joint survival model to estimate the longitudinal trajectories of the protein Factor II (% activity) and the log of the protein fragment D-Dimer ($$\upmu$$ μ g/ml), representative biomarkers of consumptive coagulopathy and hyperfibrinolysis respectively, and tie them together with patient outcomes. Joint models have recently gained popularity in medical studies due to the necessity to simultaneously track continuously measured biomarkers as a disease evolves, as well as to associate them with patient outcomes. In this work, we estimate and analyze our joint model using Bayesian methods to obtain uncertainties and distributions over associations and trajectories. Results We find that a unit increase in log D-Dimer increases the risk of mortality by 2.22 [1.57, 3.28] fold while a unit increase in Factor II only marginally decreases the risk of mortality by 0.94 [0.91,0.96] fold. This suggests that, while managing consumptive coagulopathy and hyperfibrinolysis both seem to affect survival odds, the effect of hyperfibrinolysis is much greater and more sensitive. Furthermore, we find that the longitudinal trajectories, controlling for many fixed covariates, trend differently for different patients. Thus, a more personalized approach is necessary when considering treatment and risk prediction under these phenotypes. Conclusion This study reinforces the finding that hyperfibrinolysis is linked with poor patient outcomes regardless of factor consumption levels. Furthermore, it quantifies the degree to which measured D-Dimer levels correlate with increased risk. The single hospital, retrospective nature can be understood to specify the results to this particular hospital’s patients and protocol in treating trauma patients. Expanding to a multi-hospital setting would result in better estimates about the underlying nature of consumptive coagulopathy and hyperfibrinolysis with survival, regardless of protocol. Individual trajectories obtained with these estimates can be used to provide personalized dynamic risk prediction when making decisions regarding management of blood factors.

scholarly journals Hyperkalemia excursions are associated with an increased risk of mortality and hospitalizations in hemodialysis patients

2020 ◽  
Author(s):  
Angelo Karaboyas ◽  
Bruce M Robinson ◽  
Glen James ◽  
Katarina Hedman ◽  
Carol P Moreno Quinn ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Cox Regression ◽  
Target Range ◽  
Risk Of Mortality ◽  
Increased Risk ◽  
All Cause Mortality ◽  
Using Data ◽  
Dialysis Outcomes ◽  
Mortality Hazard Ratio ◽  
New Strategies

Abstract Background Hyperkalemia is common among hemodialysis (HD) patients and has been associated with adverse clinical outcomes. Previous studies considered a single serum potassium (K) measurement or time-averaged values, but serum K excursions out of the target range may be more reflective of true hyperkalemia events. We assessed whether hyperkalemia excursions lead to an elevated risk of adverse clinical outcomes. Methods Using data from 21 countries in Phases 4–6 (2009–18) of the Dialysis Outcomes and Practice Patterns Study (DOPPS), we investigated the associations between peak serum K level, measured monthly predialysis, over a 4-month period (‘peak K’) and clinical outcomes over the subsequent 4 months using Cox regression, adjusted for potential confounders. Results The analysis included 62 070 patients contributing a median of 3 (interquartile range 2–6) 4-month periods. The prevalence of hyperkalemia based on peak K was 58% for &gt;5.0, 30% for &gt;5.5 and 12% for &gt;6.0 mEq/L. The all-cause mortality hazard ratio for peak K (reference ≤5.0 mEq/L) was 1.15 [95% confidence interval (CI) 1.09, 1.21] for 5.1–5.5 mEq/L, 1.19 (1.12, 1.26) for 5.6–6.0 mEq/L and 1.33 (1.23, 1.43) for &gt;6.0 mEq/L. Results were qualitatively consistent when analyzing hospitalizations and a cardiovascular composite outcome. Conclusions Among HD patients, we identified a lower K threshold (peak K 5.1–5.5 mEq/L) than previously reported for increased risk of hospitalization and mortality, with the implication that a greater proportion (&gt;50%) of the HD population may be at risk. A reassessment of hyperkalemia severity ranges is needed, as well as an exploration of new strategies for effective management of chronic hyperkalemia.

scholarly journals Use of the AFX Stent Graft in Patients with Extremely Narrow Aortic Bifurcation: A Multicenter Retrospective Study

2021 ◽  
Vol 2021 ◽  
pp. 1-9
Author(s):  
M. U. Wagenhäuser ◽  
N. Floros ◽  
E. Nikitina ◽  
J. Mulorz ◽  
K. M. Balzer ◽  
...  
Keyword(s):  
Aortic Aneurysm ◽  
Patient Outcomes ◽  
Stent Graft ◽  
Patient Survival ◽  
Type Ii ◽  
Aortic Bifurcation ◽  
Type Iii ◽  
Kaplan Meier ◽  
The Mean

Introduction. This study analyzed the patient outcomes following endovascular aortic aneurysm repair (EVAR) for infrarenal aortic pathologies with very narrow aortic bifurcations using the AFX stent graft. Methods. The data was retrieved from the archived medical records of 35 patients treated for abdominal aortic aneurysm (AAA) (48.6%) or penetrating aortic ulcer (PAU) (51.4%) with very narrow aortic bifurcation between January 2013 and May 2020. Patient survival, freedom from endoleak (EL), and limb occlusion were estimated applying the Kaplan–Meier method. Results. The mean follow-up time was 20.4 ± 22.8 months. The mean aortic bifurcation diameter was 15.8 ± 2.2   mm . Technical success was 100%, and no procedure-related deaths occurred. Two type II ELs occurred within 30-day follow-up. We observed one common iliac artery stenosis at four months and one type III EL at 54 months in the same patient, both of which required re-intervention. Overall patient survival was 95 ± 5 % (AAA: 100%; PAU: 89 ± 10 % ), freedom from limb occlusion was 94 ± 5 % (AAA: 91 ± 9 % ; PAU: 100%), freedom from type II EL was 94 ± 4 % (AAA: 88 ± 8 % ; PAU: 100%), and freedom from EL type III was 83 ± 15 % (AAA: 80 ± 18 % ; PAU: 100%) at the end of the follow-up period. Conclusions. Very narrow aortic bifurcations may predispose patients to procedure-related complications following EVAR. Our results suggest a safe use of the AFX stent graft in such scenarios. The overall short- and long-term procedure-related patient outcomes are satisfying albeit they may seem superior for PAU when compared to AAA.

scholarly journals Cancer and COVID-19: analysis of patient outcomes

2021 ◽  
Author(s):  
Mohamed Aboueshia ◽  
Mohammad Hosny Hussein ◽  
Abdallah S Attia ◽  
Aubrey Swinford ◽  
Peter Miller ◽  
...  
Keyword(s):  
Regression Analysis ◽  
Cohort Study ◽  
Hospital Stay ◽  
Cancer Patients ◽  
Patient Outcomes ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Active Smoking ◽  
Risk Of Mortality ◽  
Increased Risk

Background: We sought to investigate the outcomes associated with COVID-19 disease in cancer patients. Methods: We conducted a retrospective cohort study of laboratory-confirmed COVID-19 patients. Results: Of the 206 patients included, 57 had at least one preexisting malignancy. Cancer patients were older than noncancer patients. Of the 185 discharged cases, cancer patients had a significantly higher frequency of unplanned reintubation (7.1% vs 0.9%, p < 0.049), and required longer hospital stay (8.58 ± 6.50 days versus 12.83 ± 11.44 days, p < 0.002). Regression analysis revealed that obesity and active smoking were associated with an increased risk of mortality. Conclusion: Outcomes in COVID-19 appear to be driven by obesity as well as active smoking, with no difference in mortality between cancer and noncancer patients.

Wildfire Burn Patients: A Unique Population

2021 ◽  
Author(s):  
Sarah C Stokes ◽  
Kathleen S Romanowski ◽  
Soman Sen ◽  
David G Greenhalgh ◽  
Tina L Palmieri
Keyword(s):  
Wound Infection ◽  
Operating Room ◽  
Patient Outcomes ◽  
Primary Outcome ◽  
Burn Patients ◽  
The Past ◽  
Risk Of Mortality ◽  
Increased Risk ◽  
Time Of Presentation ◽  
Room Time

Abstract In the past ten years wildfires have burned an average of 6.8 million acres per year and this is expected to increase with climate change. Wildfire burn patient outcomes have not been previously well characterized. Wildfire burn patients from the Tubbs or Camp wildfires and non-wildfire burn matched controls were identified from the burn center database and outcomes were compared. The primary outcome was mortality. Secondary outcomes included length of stay (LOS), intensive care unit (ICU) LOS, readmission and development of wound infections. Time of presentation and operating room use after wildfires was evaluated. Sixteen wildfire burn patients were identified and matched with 32 controls. Wildfire burn patients trended towards higher mortality (19% wildfire vs. 9% non-wildfire, p=0.386), longer LOS (18 days wildfire vs. 15 days non-wildfire, p=0.406), longer ICU LOS (17 days wildfire vs. 11 days non-wildfire, p=0.991), increased readmission (19% wildfire vs. 3% non-wildfire, p=0.080) and higher rates of wound infection (31% wildfire vs. 19% non-wildfire, p=0.468). The majority of wildfire patients (88%) presented within 24 hours of the wildfire reaching a residential area. Operating room time within the first week was 13 hours 44 minutes for the Tubbs Fire and 19 hours 1 minute for the Camp Fire. Patients who sustain burns in wildfires are potentially at increased risk of mortality, prolonged LOS, wound infection and readmission.

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