A Combination of Chest Radiography and Estimated Plasma Volume May Predict In-Hospital Mortality in Acute Heart Failure

Background: Patients with heart failure (HF) often display dyspnea associated with pulmonary congestion, along with intravascular congestion, both may result in urgent hospitalization and subsequent death. A combination of radiographic pulmonary congestion and plasma volume might screen patients with a high risk of in-hospital mortality in the emergency department (ED).Methods: In the pathway of dyspneic patients in emergency (PARADISE) cohort, patients admitted for acute HF were stratified into 4 groups based on high or low congestion score index (CSI, ranging from 0 to 3, high value indicating severe congestion) and estimated plasma volume status (ePVS) calculated from hemoglobin/hematocrit.Results: In a total of 252 patients (mean age, 81.9 years; male, 46.8%), CSI and ePVS were not correlated (Spearman rho <0 .10, p > 0.10). High CSI/high ePVS was associated with poorer renal function, but clinical congestion markers (i.e., natriuretic peptide) were comparable across CSI/ePVS categories. High CSI/high ePVS was associated with a four-fold higher risk of in-hospital mortality (adjusted-OR, 95%CI = 4.20, 1.10-19.67) compared with low CSI/low ePVS, whereas neither high CSI nor ePVS alone was associated with poor prognosis (all-p-value > 0.10; Pinteraction = 0.03). High CSI/high ePVS improved a routine risk model (i.e., natriuretic peptide and lactate)(NRI = 46.9%, p = 0.02), resulting in high prediction of risk of in-hospital mortality (AUC = 0.85, 0.82-0.89).Conclusion: In patients hospitalized for acute HF with relatively old age and comorbidity burdens, a combination of CSI and ePVS was associated with a risk of in-hospital death, and improved prognostic performance on top of a conventional risk model.

High versus low ultrafiltration rates during experimental peritoneal dialysis in rats: Acute effects on plasma volume and systemic haemodynamics

Introduction: Intradialytic hypotension is a common complication of haemodialysis, but uncommon in peritoneal dialysis (PD). This may be due to lower ultrafiltration rates in PD compared to haemodialysis, allowing for sufficient refilling of the blood plasma compartment from the interstitial volume, but the underlying mechanisms are unknown. Here we assessed plasma volume and hemodynamic alterations during experimental PD with high versus low ultrafiltration rates. Methods: Experiments were conducted in two groups of healthy Sprague-Dawley rats: one group with a high ultrafiltration rate ( N = 7) induced by 8.5% glucose and a low UF group ( N = 6; 1.5% glucose), with an initial assessment of the extracellular fluid volume, followed by 30 min PD with plasma volume measurements at baseline, 5, 10, 15 and 30 min. Mean arterial pressure, central venous pressure and heart rate were continuously monitored during the experiment. Results: No significant changes over time in plasma volume, mean arterial pressure or central venous pressure were detected during the course of the experiments, despite an ultrafiltration (UF) rate of 56 mL/h/kg in the high UF group. In the high UF group, a decrease in extracellular fluid volume of −7 mL (−10.7% (95% confidence interval: −13.8% to −7.6%)) was observed, in line with the average UF volume of 8.0 mL (standard deviation: 0.5 mL). Conclusion: Despite high UF rates, we found that plasma volumes were remarkably preserved in the present experiments, indicating effective refilling of the plasma compartment from interstitial tissues. Further studies should clarify which mechanisms preserve the plasma volume during high UF rates in PD.

Estimated plasma volume status is a modest predictor of true plasma volume excess in compensated chronic heart failure patients

Plasma volume and especially plasma volume excess is a relevant predictor for the clinical outcome of heart failure patients. In recent years, estimated plasma volume based on anthropometric characteristics and blood parameters has been used whilst direct measurement of plasma volume has not entered clinical routine. It is unclear whether the estimation of plasma volume can predict a true plasma volume excess. Plasma volume was measured in 47 heart failure patients (CHF, 10 female) using an abbreviated carbon monoxide rebreathing method. Plasma volume and plasma volume status were also estimated based on two prediction formulas (Hakim, Kaplan). The predictive properties of the estimated plasma volume status to detect true plasma volume excess > 10% were analysed based on logistic regression and receiver operator characteristics. The area under the curve (AUC) to detect plasma volume excess based on calculation of plasma volume by the Hakim formula is 0.65 (with a positive predictive value (PPV) of 0.62 at a threshold of − 16.5%) whilst the AUC for the Kaplan formula is 0.72 (PPV = 0.67 at a threshold of − 6.3%). Only the estimated plasma volume status based on prediction of plasma volume by the Kaplan formula formally appears as an acceptable predictor of true plasma volume excess, whereas calculation based on the Hakim formula does not sufficiently predict a true plasma volume excess. The low positive predictive values for both methods suggest that plasma volume status estimation based on these formulas is not suitable for clinical decision making.

Estimated plasma volume status (ePVS) is a predictor for acute myocardial infarction in-hospital mortality: analysis based on MIMIC-III database

Background Estimated plasma volume status (ePVS) has been reported that associated with poor prognosis in heart failure patients. However, no researchinvestigated the association of ePVS and prognosis in patients with acute myocardial infarction (AMI). Therefore, we aimed to determine the association between ePVS and in-hospital mortality in AMI patients. Methods and results We extracted AMI patients data from MIMIC-III database. A generalized additive model and logistic regression model were used to demonstrate the association between ePVS levels and in-hospital mortality in AMI patients. Kaplan–Meier survival analysis was used to pooled the in-hospital mortality between the various group. ROC curve analysis were used to assessed the discrimination of ePVS for predicting in-hospital mortality. 1534 eligible subjects (1004 males and 530 females) with an average age of 67.36 ± 0.36 years old were included in our study finally. 136 patients (73 males and 63 females) died in hospital, with the prevalence of in-hospital mortality was 8.9%. The result of the Kaplan–Meier analysis showed that the high-ePVS group (ePVS ≥ 5.28 mL/g) had significant lower survival possibility in-hospital admission compared with the low-ePVS group (ePVS < 5.28 mL/g). In the unadjusted model, high-level of ePVS was associated with higher OR (1.09; 95% CI 1.06–1.12; P < 0.001) compared with low-level of ePVS. After adjusted the vital signs data, laboratory data, and treatment, high-level of ePVS were also associated with increased OR of in-hospital mortality, 1.06 (95% CI 1.03–1.09; P < 0.001), 1.05 (95% CI 1.01–1.08; P = 0.009), 1.04 (95% CI 1.01–1.07; P = 0.023), respectively. The ROC curve indicated that ePVS has acceptable discrimination for predicting in-hospital mortality. The AUC value was found to be 0.667 (95% CI 0.653–0.681). Conclusion Higher ePVS values, calculated simply from Duarte’s formula (based on hemoglobin/hematocrit) was associated with poor prognosis in AMI patients. EPVS is a predictor for predicting in-hospital mortality of AMI, and could help refine risk stratification.

The Impact of Revised Definitions for TACO and TRALI on Hemovigilance Reporting

Introduction Transfusion-associated circulatory overload (TACO) and transfusion-related acute lung injury (TRALI) are serious adverse transfusion reactions. Standardized surveillance definitions are important to ensure consistent and accurate reporting of cases. Recently, revised definitions have been developed for both TACO and TRALI, the latter which have not yet been widely implemented. The primary aim of this study is to assess the impact of the new TACO and TRALI definitions on hemovigilance reporting. The secondary aim is to collate a TRALI case series to describe the epidemiological and laboratory features of this uncommon condition. Methods The Australian Red Cross Lifeblood Adverse Transfusion Reaction database, a passive reporting system, was accessed to identify all cases of suspected or confirmed TACO and TRALI referred from 1 July 2015 to 30 June 2019. Cases were assessed against both the former and new definitions of TACO and TRALI and results compared. For confirmed cases of TRALI the following information was collected: patient demographics, antibody investigation results, type and age of products implicated, donor gender and donor outcomes. Statistical analysis was performed using Fisher's exact test. Results In total 99 cases were identified, of which 12 cases were excluded from analysis due to insufficient clinical details. A further 14 cases were excluded as they were deemed not to be transfusion related. The final number of cases assessed was 73. There were 48 TACO cases identified. Only 26 cases strictly met the former 2011 International Society of Blood Transfusion (ISBT) definition of TACO; 6 cases did not meet the definition and 16 cases lacked sufficient clinical details due to the passive nature of the reporting system. In comparison, 46 cases met the revised 2018 ISBT definition, with only 2 cases having insufficient details. There were 24 cases of TRALI according to the 2004 Canadian Consensus Conference (CCC) definition compared with 25 cases according to the proposed 2019 revised definition. Of the 24 cases of TRALI, 15 were classified as TRALI and 9 as possible TRALI. One case was excluded from having TRALI or possible TRALI under the 2004 CCC definition as the patient had pre-existing acute respiratory distress syndrome from influenza A pneumonia, but could be diagnosed as a TRALI Type II under the revised definition as their respiratory status had been stable for more than 12 hours. A total of 62 components from 81 donors were associated with the 24 TRALI cases. Forty-nine (60%) of these donors were male, 31 (38%) female and 1 (1%) unknown (cadaveric liver). Thirty-three (41%) of these donors were deferred due to the presence of HLA antibodies or being the only donor associated with a case. Sixteen cases (67%) were associated with donor antibodies, most commonly HLA class I and HLA class II antibodies that were non-recipient specific. HNA antibodies were present in 3 cases. There were 8 cases in which an HLA or HNA antibody was not implicated. There was no difference in antibody detection rates between low plasma volume components (red cells, pooled platelets and cryoprecipitate) and high plasma volume components (fresh frozen plasma and apheresis platelets) (45% versus 34%, p=0.44). There was a trend towards higher antibody detection rates in female donors (46%) compared with male donors (29%), however this was not statistically significant (p=0.10). Conclusions The revised TACO definition appears to capture more cases than the former definition. There appears to be no significant difference in the number of TRALI cases under the proposed new definition compared to the definition currently in use. This is the first study to provide validation data for the revised TRALI definition. TRALI is a rare condition and further studies such as these are required to improve our understanding of its pathophysiology and laboratory findings. Disclosures No relevant conflicts of interest to declare.