Contrast-Associated Acute Kidney Injury This review summarizes the pathophysiology and definition of contrast-associated acute kidney injury, as well as risk stratification. The authors discuss con...

https://www.nejm.org/doi/pdf/10.1056/NEJMra1805256

Contrast-Associated Acute Kidney Injury.

1 ESGE recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include: a history of co-morbidities and medications that promote bleeding; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers A risk score can be used to aid, but should not replace, clinician judgment Strong recommendation, low quality evidence 2 ESGE recommends that, in patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of ≤ 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation Strong recommendation, moderate quality evidence 3 ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion A post-transfusion target hemoglobin concentration of 7–9 g/dL is desirable Strong recommendation, low quality evidence 4 ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 8 g/dL prompting red blood cell transfusion A post-transfusion target hemoglobin concentration of ≥ 10 g/dL is desirable Strong recommendation, low quality evidence 5 ESGE recommends that, in patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay because there is no high quality evidence that early colonoscopy influences patient outcomes Strong recommendation, low quality of evidence 6 ESGE recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding Strong recommendation, low quality evidence 7 ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk In patients with hemodynamic instability, we recommend administering intravenous vitamin K and four-factor prothrombin complex concentrate (PCC), or fresh frozen plasma if PCC is not available Strong recommendation, low quality evidence 8 ESGE recommends temporarily withholding direct oral anticoagulants at presentation in patients with major lower gastrointestinal bleeding Strong recommendation, low quality evidence 9 ESGE does not recommend withholding aspirin in patients taking low dose aspirin for secondary cardiovascular prevention If withheld, low dose aspirin should be resumed, preferably within 5 days or even earlier if hemostasis is achieved or there is no further evidence of bleeding Strong recommendation, moderate quality evidence 10 ESGE does not recommend routinely discontinuing dual antiplatelet therapy (low dose aspirin and a P2Y12 receptor antagonist) before cardiology consultation Continuation of the aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk If interrupted, the P2Y12 receptor antagonist should be restarted within 5 days, if still indicated Strong recommendation, low quality evidence

/pdf/diagnosis-and-management-of-acute-lower-gastrointestinal-2q60fmadmq.pdf

Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Haemodialysis (HD) is a life-sustaining treatment for patients with end-stage renal disease (ESRD). HD can bring about significant impairment in health-related quality of life (HRQOL) and outcomes. Therefore, we sought to describe the patterns of HRQOL and determine the independent factors associated with poor HRQOL in Palestinian patients on HD. A multicenter cross-sectional study was performed from June 2014 to January 2015 using the EuroQOL-5 Dimensions instrument (EQ-5D-5L) for the assessment of HRQOL. ESRD patients undergoing HD in all dialysis centres in the West Bank of Palestine were approached and recruited for this study. Multiple linear regression was carried out to identify factors that were significantly associated with HRQOL. Two hundred and sixty-seven patients were participated in the current study giving response rate of 96 %. Overall, 139 (52.1 %) were male, and the mean ± standard deviation age was 53.3 ± 16.2 years. The reported HRQOL as measured by mean EQ-5D-5L index value and Euro QOL visual analogue scale (EQ-VAS) score was 0.37 ± 0.44 and 59.38 ± 45.39, respectively. There was a moderate positive correlation between the EQ-VAS and the EQ-5D-5L index value (r = 0.42, p < 0.001). The results of multiple linear regression showed a significant negative association between HRQOL with age, total number of chronic co-morbid diseases and the total number of chronic medications. However, a significant positive association was found between HRQOL with male gender, university education level and patients who live in village. Our results provided insight into a number of associations between patient variables and their HRQOL. Healthcare providers should be aware of low HRQOL among patients with no formal education, female gender, patient’s residents of refugee camps, multiple co-morbid diseases, multiple chronic medications, and elderly patients to improve their quality of life.

/pdf/factors-affecting-quality-of-life-in-patients-on-3ue874qh4e.pdf

Factors affecting quality of life in patients on haemodialysis: a cross-sectional study from Palestine

https://www.gastrojournal.org/article/S0016-5085(20)34848-4/pdf

AGA Clinical Practice Update on Endoscopic Therapies for Non-Variceal Upper Gastrointestinal Bleeding: Expert Review.

BACKGROUND Assessment of quality of life (QOL) of patients with end-stage renal disease has become increasingly important, both in order to evaluate the influence of the disease on patients and the type of renal replacement therapy they require. Therefore, in this study, we aimed to assess QOL in patients undergoing hemodialysis and evaluated the effects of various sociodemographic factors affecting QOL of such patients in Nepal. METHODS A cross-sectional study was conducted among 150 patients with chronic kidney disease undergoing hemodialysis at two major centers in Nepal. Demographic data including age, sex, ethnicity, educational status, marital status, employment, income, duration of illness, and duration on hemodialysis were collected. QOL was assessed using the World Health Organization Quality of life (WHOQOL-BREF) questionnaire. Four domains (physical, psychological, social, and environmental) and two items (overall perception of QOL and health) of the WHOQOL-BREF were the primary end points of this study. Bivariate relationship between sociodemographic factors and QOL scores were analyzed using independent samples t-test and one-way analysis of variance. Multiple linear regression analysis was performed to determine independent predictors of QOL. RESULTS Following QOL scores were recorded: environmental domain (53.17±15.59), psychological domain (51.23±18.61), social domain (49.86±21.64), and physical domain (45.93±16.90). Older age was associated with a better QOL score in the social domain (p=0.005), and employed patients scored better in the environmental domain (p=0.019). Unemployed patients and those of the Terai/Madhesi ethnic group had significantly low scores in overall perception of health (p<0.05) as compared to other groups. Low income status and increased duration on hemodialysis were found to be the only independent negative predictors of QOL in patients with hemodialysis (p<0.05). CONCLUSION Patients with chronic kidney disease on dialysis had overall low QOL scores in all four domains. Age, ethnicity, employment status, income, and duration on hemodialysis affected one or more domains of QOL in such patients. Low income status and increased duration on hemodialysis were the only independent negative predictors of QOL of patients on maintenance hemodialysis.

/pdf/assessment-of-quality-of-life-in-patients-undergoing-564yxpll9l.pdf

Assessment of quality of life in patients undergoing hemodialysis using WHOQOL-BREF questionnaire: a multicenter study

BACKGROUND: Assessment of quality of life (QOL) of end-stage renal disease (ESRD) patients (physical, mental, and social well-being) has become an essential tool to develop better plans of care. Objective of this study is to determine which demographic and biochemical parameters correlate with the QOL scores in patients with ESRD on hemodialysis (HD) using Kidney Disease QOL-36 surveys (KDQOL). METHODS: A retrospective chart review of all ESRD patients who underwent HD at an outpatient center. The five components of the KDQOL were the primary end points of this study (burden of kidney disease, symptoms and problems, effects of kidney disease on daily life, mental component survey, and physical component survey). Scores were grouped into three categories (below average, average, and above average). In addition to demographics (age, sex, and race), the independent variables such as weight gain, number of years on dialysis, urea reduction ratio, calcium, phosphorus, parathyroid hormone, albumin, and hemoglobin in the serum were collected. Chi-square analysis for dependent variables and the nominal independent variables was used, and analysis of variance analysis was used for continuous independent variables. Ordinal regression using PLUM (polytomous universal model) method was used to weigh out possible effects of confounders. RESULTS: The cohort size was 111 patients. Mean age was 61.8 (±15.5) years; there were more males than females (64.9% vs 35.1%), the mean time-on-dialysis at the time of the study was 4.3 (4.8) years. Approximately two-thirds of the responses on all five domains of the questionnaire ranked average when compared to the national numbers. The remainders were split between above average (20.6%) and below average (13.4%). In our cohort, no relationships were statistically significant between the five dependent variables of interest and the independent variables by chi-square- and t-test analyses. This was further confirmed by regression analysis. Of note, sex carried the strongest statistical significance (with a P-value of 0.16) as a predictor of "the burden of kidney disease on daily life" in ordinal regression. CONCLUSION: Prior studies have shown variables such as serum phosphate level, intradialytic weight gain, and dialysis adequacy are associated with lower KDQOL scores; however, this was not evident in our analysis likely due to smaller sample size. Larger size studies are required to better understand the predictors of QOL in ESRD patients on HD.

/pdf/predictors-of-quality-of-life-in-patients-with-end-stage-1s9mma5asx.pdf

Predictors of quality of life in patients with end-stage renal disease on hemodialysis

Using the endoscopic overstitching device and fully covered esophageal stents for closure of a gastropleural fistula and repair of a deformed gastric sleeve.

High-resolution esophageal manometry (HRM) has become the gold standard to diagnose esophageal motility disorders. Usually, this procedure is performed by introducing the catheter, which has pressure sensors, into the esophagus and proximal stomach via the nares. Repeated coiling of the catheter and inability to pass through the gastroesophageal junction (GEJ) are common challenges encountered. Endoscopy-guided placement of the catheter can overcome these difficulties. However, sometimes even with the use of endoscopy, it is difficult to advance catheter due to anatomical variants. The extreme fragility of the catheter and sensors and the high cost of this reusable device precludes the use of biopsy forceps or snare to advance the catheter. There is no literature on using accessories during endoscopy in case of difficult placement under direct visualization. We report a unique case of using Roth Net via the suction channel to advance esophageal manometry catheter into the stomach by using endoscopy.

/pdf/roth-net-assisted-endoscopic-guided-manometry-catheter-5fu7jftokv.pdf

Roth Net-Assisted Endoscopic-Guided Manometry Catheter Placement.

Over-the-scope clip to the rescue of a bleeding gastroduodenal artery pseudoaneurysm

Critically ill patients receive a significant amount of fluids leading to a positive fluid balance; this dilutes serum creatinine resulting in an overestimated glomerular filtration rate The goal of our study is to identify undiagnosed or underestimated acute kidney injury (AKI) in the intensive care unit (ICU) It will also identify the morbidity and mortality associated with an underestimated AKI We reviewed records of patients admitted to our institution (Staten Island University Hospital) between 2012 and 2013 for more than 2 days Patients with end stage renal disease were excluded AKI was defined using the Acute Kidney Injury Network criteria The following formula was used to identify and restage patients with AKI: adjusted creatinine = serum creatinine × [(hospital admission weight (kg) 06 + Σ (daily cumulative fluid balance (L))/hospital admission weight × 06] The primary outcome identified newly diagnosed AKI and those who were restaged The secondary outcome identified associated morbidities Seven-hundred and thirty-three out of 1,982 ICU records reviewed, were used Two-hundred and fifty-seven (mean age 698±149) had AKI, out of which 159% were restaged using the equation Comparison of mean by Student's t-test showed no difference between patients who were restaged Similarly, chi-square revealed no differences between both arms, except mean admission weight (lower in patients who were restaged), fluid balance on days 1, 2, and 3 (higher in the restaged arm), and the presence of congestive heart failure (more prevalent in the restaged arm) Of note, the mean cost of stay was US$150,56282 vs $197,17463 for same stage vs restaged, respectively, however, without statistical significance (P=074) Applying the adjustment equation showed a modest (159%) increase in the AKI staging slightly impacting outcomes (mortality, length, and cost of stay) without statistical significance

/pdf/acute-kidney-injury-adjusted-to-volume-status-in-critically-2sr6nyyr4s.pdf

Acute kidney injury adjusted to volume status in critically ill patients: recognition of delayed diagnosis, restaging, and associated outcomes.

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