A retrospective observational cohort study investigating the association between acute kidney injury and all-cause mortality among patients undergoing endovascular repair of abdominal aortic aneurysms

Abstract

Background

Acute kidney injury (AKI) has been found to be associated with short- and long-term mortality and morbidity in various clinical settings. However, it is unknown whether AKI after endovascular repair of abdominal aortic aneurysms (EVAR) is associated with postoperative mortality.

Methods

This observational study analyzed patients who underwent EVAR. The primary outcome was all-cause mortality. The outcomes of patients with and without postoperative AKI were compared using the Kaplan–Meier method and log-rank test. Factors with P < 0.05 on the univariate analysis were entered into the multivariate Cox regression model. Predictors of AKI were also determined using Cox univariate and multivariate analysis. The identified predictors of AKI were excluded from multivariate analysis for all-cause mortality because these factors could intermediate outcome.

Results

There were 490 eligible patients. After a follow-up of 28.3 (16.8) months [mean (standard deviation)], 62 patients (12.7%) died. AKI occurred in 59 patients (12.0%). AKI was found by the log-rank test to be associated with a significant increase of all-cause mortality (P < 0.001). Preoperative estimated glomerular filtration rate, preoperative peripheral vascular disease, and emergency surgery were found to be independent predictors of AKI and these variables were excluded from the main analysis. Multivariate analysis showed AKI [hazard ratio (HR) = 1.19, 95% confidence interval (CI) 1.01–3.60, P = 0.045] and transfusion (HR = 1.05, 95% CI 1.01–1.09, P = 0.011) were independent predictors of mortality.

Conclusions

In the present study, AKI and transfusion were associated with significant increases in all-cause mortality after EVAR.

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An Unexpected Cause of Bradycardia in a Patient with Bacterial Meningitis

Sinus bradycardia which is a sinus rhythm with a resting heart rate of less than 60 bpm is caused by intrinsic cardiac disorders like sick sinus syndrome or inferior myocardial infarction, metabolic and environmental causes (such as hypothyroidism and electrolyte disorders), medications (such as beta-blockers and amiodarone), infection (such as myocarditis), increased intracranial pressure, and toxic exposure, while it can sometimes be a normal phenomenon, especially during sleep, in athletes, and during pregnancy. Symptomatic sinus bradycardia should warrant a thorough work-up in order to identify any reversible causes; otherwise, placement of a permanent pacemaker could be needed. We present the case of a patient who was admitted due to confusion and fever and was found to have pneumococcal meningitis and bacteremia, and during his hospital stay he developed symptomatic sinus bradycardia that was of intractable cause and persistent. Placement of a permanent pacemaker was chosen until the night staff of the hospital discovered by chance the neglected cause of his bradycardia.

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POEMS syndrome: a rare cause of exudative ascites and chronic peripheral neuropathy

POEMS syndrome (Peripheral neuropathy, Organomegaly, Endocrinopathy, M protein, Skin changes) is a rare plasma cell disorder with multisystem involvement

A 40-year-old man with a chronic history of unexplained peripheral neuropathy , presented with exudative ascites.He was found to have an incidental osteolytic lesion of the sacrum proven to be a plasmacytoma. Immunoelectrophoresis for monoclonal protein was negative.

In addition, the patient was found to have hepatosplenomegaly, erectile dysfunction, hyperprolactinaemia and hypothyroidism.

The patient, was given steroid along with lenalidomide, and showed a good clinical response.

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Successful conservative management of a permanent pacemaker pocket infection: a less invasive approach

We present a successful conservative management strategy for a frail elderly patient with a cardiac resynchronisation pacemaker who presented with evidence of an Enterobacter cloacae pacemaker pocket infection. A device washout and debridement procedure was performed, with reburial of the device in a new prepectoral pocket and creation of a closed-loop continuous antibiotic infusion into the infected pacemaker pocket. This was followed by a 6-week course of ambulatory intravenous antibiotic therapy. This conservative management strategy avoided the need for a more invasive and high-risk full device extraction, which the patient clearly stated he did not wish to have. Up-to-date consensus management guidelines recommend extraction of the entire implanted system in this situation; however, in this case we demonstrate an alternative conservative management option, which may be suitable for frail elderly and comorbid patients or for patients who decline device extraction.

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Thromboembolism in active ulcerative colitis

Inflammatory bowel disease (IBD) has a range of both intestinal and extraintestinal manifestations. Thromboembolism involving the arterial and/or venous systems is rare. Early recognition and treatment of thrombosis in patients with IBD may prevent progression and minimise complications. However, clear guidelines on the duration of treatment and indications for primary prophylaxis need to be established. We report a case of a young patient with ulcerative colitis, who developed multiple site arterial and venous thrombosis, all occurring within short intervals of each other.

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A dirty cause of vancomycin-mediated Henoch-Schonlein purpura: oxygen tubing is not a foley

A 59-year-old male presented with methicillin-resistantStaphylococcus aureus bacteraemia from a prostatic abscess and was treated with vancomycin. Two weeks into his treatment course, he developed severe joint pains, abdominal pain with bloody, mucinous stools and a diffuse palpable purpuric rash on his extremities. Biopsy of the rash showed IgA immune-complex deposition consistent with Henoch-Schönlein purpura. After treatment with glucocorticoids, his symptoms resolved completely. Vancomycin is an extremely commonly used antibiotic with certain well-known adverse effects. Henoch-Schönlein purpura, a vasculitis involving abdominal pain, arthralgias and palpable purpura, is a much less common side effect, as seen in this patient. Given that vancomycin is widely used internationally, clinicians should be aware of the risks entailed by its use.

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Superior mesenteric artery syndrome in a healthy adolescent

Description

A 12-year-old, previously healthy, girl presented to our hospital with a 3-day history of epigastric pain and vomiting. She also reported having frequent epigastric pain for the past 2 years. Physical examination revealed a body mass index of 13.5 kg/m² and abdominal distension. Abdominal contrast-enhanced CT revealed a bloated stomach and a sandwiched horizontal portion of the duodenum between the aorta and superior mesenteric artery (SMA). The angle between the aorta and SMA was 17°, and the aorta–SMA distance was 5.2 mm (figure 1A,B), which met the diagnostic imaging adult criteria for SMA syndrome (SMAS).1 An upper gastrointestinal series also revealed that the contrast agent smoothly reached the proximal duodenum, but stopped at the horizontal portion of the duodenum where stenosis was suspected based on CT (figure 1C). Decompression using a nasogastric tube improved her clinical symptoms, and she was discharged. SMAS is characterised by...

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