Predictive Value of Echocardiographic Parameters for Clinical Events in Patients Starting Hemodialysis

Echocardiographic parameters can predict cardiovascular events in several clinical settings. However, which echocardiographic parameter is most predictive of each cardiovascular or non-cardiovascular event in patients starting hemodialysis remains unresolved. Echocardiography was used in 189 patients at the time of starting hemodialysis. We established primary outcomes as follows: cardiovascular events (ischemic heart disease, cerebrovascular disease, peripheral artery disease, and acute heart failure), fatal non-cardiovascular events, all-cause mortality, and all combined events. The most predictable echocardiographic parameter was determined in the Cox hazard ratio model with a backward selection after the adjustment of multiple covariates. Among several echocardiographic parameters, the E/e' ratio and the left ventricular end-diastolic volume (LVEDV) were the strongest predictors of cardiovascular and non-cardiovascular events, respectively. After the adjustment of clinical and biochemical covariates, the predictability of E/e' remained consistent, but LVEDV did not. When clinical events were further analyzed, the significant echocardiographic parameters were as follows: s' for ischemic heart disease and peripheral artery disease, LVEDV and E/e' for acute heart failure, and E/e' for all-cause mortality and all combined events. However, no echocardiographic parameter independently predicted cerebrovascular disease or non-cardiovascular events. In conclusion, E/e', s', and LVEDV have independent predictive values for several cardiovascular and mortality events.

Rituximab for Rheumatoid Arthritis Following TNF-alpha Inhibitor Associated Splenic Tuberculosis

One of the most important adverse effects of a tumor necrosis factor (TNF)-alpha inhibitor is the reactivation of tuberculosis. Most of them occur in the lung, but sometimes they can be found in other organs. Moreover, the proper management of active rheumatoid arthritis (RA) in patients with anti-TNF-alpha associated tuberculosis is still in debate. We present the case of a seropositive RA patient who showed good response with rituximab, an anti-CD20 monoclonal antibody, after developing splenic tuberuculosis, following treatment with TNF-alpha inhibitor. Confirming a diagnosis of splenic tuberculosis is difficult and can be delayed due to its nonspecific symptoms and rare occurrence. This case suggests that splenic tuberculosis should be doubted in RA patients treated with TNF-alpha inhibitor, and that rituximab may be considered as an alternative treatment option in RA patients with anti-TNF-alpha associated tuberculosis.

Clinical Significance of Acute Kidney Injury in Patients with Colistin Treatment / 대한신장학회지

PURPOSE: Colistin (colistimethate sodium) became available for clinical use in 1959 and was used until the early 1980s to treat infections caused by Gram-negative rods. It was abandoned during the last two decades mainly due to its significant nephrotoxicity. However, the emergence of multidrug-resistant (MDR) bacteria such as Pseudomonas aeruginosa and Acinetobacter baumanii has resulted in significantly increased use of intravenous colistin. This study was designed to investigate the incidence and risk factors of acute kidney injury (AKI) associated with intravenous colistin (colistimethate sodium) treatment. METHODS: We retrospectively collected the data from patients who were admitted to Chung-Ang University Hospital and treated with colistin from May 2007 to June 2009. Among these, we excluded the patients with baseline glomerular filtration rate (GFR) less than 15 ml/min/1.73m2. AKI was defined as an increase of creatinine more than 150% from the baseline, according to RIFLE criteria. RESULTS: A total of 92 patients met the inclusion criteria and were included in the analysis. AKI occurred in 43 (47%) of the 92 patients. The cumulative doses (2.51+/-1.89 vs. 1.75+/-1.35 g, p=0.032) of colistin were significantly greater in the AKI group than in the normal kidney function (NKF) group. Serum creatinine level showed a significant increase in the AKI group, from day 3 (1.6+/-1.1 vs. 0.9+/-0.5 mg/dL, p=0.001) to day 90 (2.1+/-1.9 vs. 0.7+/-0.2 mg/dL, p=0.033). Furthermore, the occurrence of AKI at day 3 was a significant predictor of shorter survival (Log rank test p=0.031). CONCLUSION: AKI was a relatively common side effect of colistin. The cumulative dose was critical, rather than the daily dose or duration of treatment. Early acute kidney injury may predict shorter cumulative survival in patients undergoing colistin treatment.