Acute kidney injury risk assessment at the hospital front door: what is the best measure of risk?

BACKGROUND: We examined the prevalence of acute kidney injury (AKI) risk factors in the emergency medical unit, generated a modified risk assessment tool and tested its ability to predict AKI. METHODS: A total of 1196 patients admitted to medical admission units were assessed for patient-associated AKI risk factors. Subsequently, 898 patients were assessed for a limited number of fixed risk factors with the addition of hypotension and sepsis. This was correlated to AKI episodes. RESULTS: In the first cohort, the prevalence of AKI risk factors was 2.1 ± 2.0 per patient, with a positive relationship between age and the number of risk factors and a higher number of risk factors in patients ≥65 years. In the second cohort, 12.3% presented with or developed AKI. Patients with AKI were older and had a higher number of AKI risk factors. In the AKI cohort, 72% of the patients had two or more AKI risk factors compared with 43% of the cohort with no AKI. When age ≥65 years was added as an independent risk factor, 84% of those with AKI had two or more AKI risk factors compared with 55% of those with no AKI. Receiver operating characteristic analysis suggests that the use of common patient-associated known AKI risk factors performs no better than age alone as a predictor of AKI. CONCLUSIONS: Detailed assessment of well-established patient-associated AKI risk factors may not facilitate clinicians to apportion risk. This suggests that additional work is required to develop a more sensitive validated AKI-predictive tool that would be useful in this clinical setting.

Metformin reduces arterial stiffness and improves endothelial function in young women with polycystic ovary syndrome: a randomized, placebo-controlled, crossover trial.

CONTEXT: Patients with polycystic ovary syndrome (PCOS) have an increased prevalence of insulin resistance and display subclinical evidence of early cardiovascular disease. Metformin improves insulin sensitivity and circulating markers of cardiovascular risk in patients with PCOS, but it is unclear whether this translates into improvements in vascular function. OBJECTIVE: Our objective was to evaluate the effects of metformin on arterial stiffness and endothelial function in women with PCOS. DESIGN AND INTERVENTION: Thirty women with PCOS were assigned to consecutive 12-wk treatment periods of metformin or placebo in a randomized, double-blind, crossover design separated by an 8-wk washout. MAIN OUTCOME MEASURES: The primary outcome measures were assessments of arterial stiffness [augmentation index (AIx), central blood pressure, and brachial and aortic pulse wave velocity (PWV)] and endothelial function. Anthropometry, testosterone, and metabolic biochemistry (lipids, homeostasis model of assessment for insulin resistance, high-sensitivity C-reactive protein, adiponectin, and plasminogen activator inhibitor-1) were also assessed. RESULTS: Metformin improved AIx [-6.1%; 95% confidence interval (CI) for the difference -8.5 to -3.5%; P < 0.001], aortic PWV (-0.76 m/sec; 95% CI for the difference -1.12 to -0.4 m/sec; P < 0.001), brachial PWV (-0.73 m/sec; 95% CI for the difference -1.09 to -0.38; P < 0.001), central blood pressure (P < 0.001), and endothelium-dependent (AIx after albuterol; P = 0.003) and endothelium-independent (AIx after nitroglycerin; P < 0.001) vascular responses. Metformin also reduced weight (P < 0.001), waist circumference (P < 0.001), and triglycerides (P = 0.004) and increased adiponectin (P = 0.001) but did not affect testosterone or other metabolic measures. CONCLUSIONS: Short-term metformin therapy improves arterial stiffness and endothelial function in young women with PCOS.

Effects of dehydroepiandrosterone replacement on vascular function in primary and secondary adrenal insufficiency: a randomized crossover trial.

CONTEXT: Patients with Addison's disease and hypopituitarism have increased mortality, chiefly related to vascular disease. Both diseases are characterized by dehydroepiandrosterone (DHEA) deficiency, yet this is not usually corrected. It is unclear whether treatment of these conditions with DHEA improves cardiovascular risk. OBJECTIVE: The aim of the study was to evaluate the effects of DHEA on arterial stiffness and endothelial function in subjects with Addison's disease and hypopituitarism. DESIGN AND INTERVENTION: Forty subjects (20 with Addison's disease, 20 with panhypopituitarism) were assigned to consecutive 12-wk treatment periods of DHEA 50 mg or placebo in a randomized, double-blind, crossover design separated by an 8-wk washout. MAIN OUTCOME MEASURES: Primary outcome parameters were measures of arterial stiffness [augmentation index, central blood pressure, brachial and aortic pulse wave velocity (PWV)] and endothelial function. Serum androgens, anthropometry, and metabolic biochemistry (lipids, homeostasis model of assessment for insulin resistance, high sensitivity C-reactive protein, adiponectin, plasminogen activator inhibitor-1) were also assessed. RESULTS: Despite normalization of DHEA sulfate, androstenedione, and testosterone (females), DHEA replacement did not affect augmentation index, aortic PWV, brachial PWV, central blood pressure, or endothelial function. DHEA did not affect any anthropometric or metabolic measures, apart from a small reduction in high-density lipoprotein cholesterol (-0.08 mmol/liter; P = 0.007; 95% confidence interval for the difference, -0.13 to -0.02 mmol/liter). CONCLUSIONS: Short-term DHEA supplementation does not significantly affect measures of arterial stiffness or endothelial function in patients with adrenal insufficiency.

Determinants of long-term outcome after radioiodine therapy for solitary autonomous thyroid nodules.

OBJECTIVE: To determine the incidence and clinical predictors of hypothyroidism in one institution after radioiodine treatment of solitary toxic nodules. METHODS: We retrospectively analyzed the outcome of radioiodine therapy in 105 patients with solitary autonomous thyroid nodules treated at our institution during a 10-year period (January 1996 to December 2005; mean duration of follow-up, 53 +/- 34 months). Patients were monitored until the development of hypothyroidism, death, or the end of the study period. The cumulative incidence of hypothyroidism was determined by Kaplan-Meier life-table analysis, and predictors of hypothyroidism were determined by using a Cox regression model. RESULTS: The cumulative incidence of hypothyroidism was 11% at 1 year, 33% at 5 years, and 49% at 10 years. The development of hypothyroidism was not associated with age, sex, radioiodine dose, radioiodine uptake, or degree of suppression of extranodal tissue on scintiscans. The predictors of occurrence of hypothyroidism were pretreatment with antithyroid medications (P = .004; relative risk = 1.94) and positive thyroid antibody status (P = .008; relative risk = 1.84). Antibody-positive patients showed an earlier progression toward hypothyroidism than did antibody-negative patients. CONCLUSION: Hypothyroidism is a common outcome of radioiodine treatment for autonomous thyroid nodules. In this study, coexistent thyroid autoimmunity and pretreatment with antithyroid medications were significant risk factors for the development of hypothyroidism.

Can admission and fasting glucose reliably identify undiagnosed diabetes in patients with acute coronary syndrome?

OBJECTIVE: Our objectives were to determine the prevalence of previously undiagnosed abnormal glucose tolerance, i.e., diabetes and impaired glucose tolerance (IGT) in patients with acute coronary syndrome and to assess the utility of admission and fasting glucose in identifying diabetes in these patients. RESEARCH DESIGN AND METHODS: Glycemic status was characterized on the basis of admission plasma glucose (APG), fasting plasma glucose (FPG), and an oral glucose tolerance test (OGTT) in 140 patients admitted to the hospital with acute coronary syndrome, who were not known to have diabetes (mean +/- SD age 67.3 +/- 13.4 years; 79% men). OGTTs were performed on days 5-7 after admission. RESULTS: The prevalences of diabetes and IGT were 27 and 39%, respectively, according to OGTT criteria. Receiver operating characteristic curves showed that the area under the curve for diagnosing diabetes was 0.83 (P < 0.001) for FPG, 0.79 (P < 0.001) for APG, and 0.84 (P < 0.001) for FPG and APG applied in combination. A FPG cutoff >or=5.6 mmol/l (100 mg/dl) and/or APG >or=7.8 mmol/l (140 mg/dl) yielded a sensitivity of 89.5% and a positive predictive value of 43.6% for detecting diabetes. CONCLUSIONS: A high prevalence of abnormal glucose tolerance was seen in patients with acute coronary syndrome. The combination of FPG >or=5.6 mmol/l (100 mg/dl) and/or APG >or=7.8 mmol/l (140 mg/dl) was highly sensitive for identifying diabetes. Although weakly specific, this simple algorithm could offer a practical initial screening tool at the acute setting in the high-risk population with acute coronary syndrome.