Enalapril and Acute Kidney Injury in a Hypertensive Premature Newborn - Should It Be Used or Not?

Extremely low birth weight infants (birth weight ≤1000 g) have a significantly lower nephron number. The glomerular filtration rate (GFR) is usually sufficient under normal conditions but is unable to meet the needs during stress, which results in acute kidney injury (AKI). We describe the case of an extremely low birth weight infant (970 g) with a gestational age of 27 weeks (immature preterm) who was mechanically ventilated because of hyaline membrane disease. AKI with anuria and a rise in serum creatinine to 3.4 mg/dL developed in the second week. Diuresis was restored after diuretics and dopamine were administered intravenously and kidney function recovered in the next two weeks. However, he slowly became hypertensive, so intravenous enalapril was introduced in the 6th week. After the third dose, he suffered another AKI. After cessation of enalapril, kidney function recovered over the next few days. Although angiotensin-converting enzyme inhibitors (ACEi) may cause kidney injury, it can be used with great caution in the treatment of hypertension or heart failure in preterm infants. There remains a real dilemma of whether enalapril should be used in extremely low birth weight immature infants.

An obesity paradox in patients with myocardial infarction undergoing percutaneous intervention.

BACKGROUND AND AIMS: Data concerning the relationship between body mass index (BMI) and outcome in myocardial infarction (MI) patients are inconclusive. Long-term data on the influence of BMI on survival in patients with MI who have undergone percutaneous intervention (PCI) are lacking. We aimed to assess the effect of different categories of BMI on long-term mortality. METHODS AND RESULTS: A single-center retrospective study of 6496 patients with MI who underwent PCI was performed. Patients were divided into six categories according to their BMI and these were compared. All-cause mortality was assessed over a median period of 6.0 years. An inverse J-shaped relationship was observed between BMI and long-term mortality. The lowest mortality was observed in patients with class I obesity. The patients with a BMI below 25.0 kg/m2 were more likely to die than patients with class I obesity. A gradual decrease in BMI below 25.0 kg/m2 was associated with a progressively increased risk of dying, with underweight patients showing a 2.18-fold increase in mortality risk. An obesity paradox was present. In addition, the patients with class III obesity had a more than 70% higher long-term mortality risk as compared to the reference group. Both lower and higher degrees of BMI were found to be harmful in patients with MI who underwent PCI. CONCLUSION: The obesity paradox was present in a very long-term follow-up of patients with MI who underwent PCI. However, both lower and higher BMI values are harmful, and an inverse J-shaped relationship between BMI and outcome was observed.

Outcome in Patients Resuscitated following Myocardial Infarction with Acute Kidney Injury.

Background: Data on acute kidney injury (AKI) in patients with myocardial infarction (MI) who underwent percutaneous coronary intervention (PCI) after cardiac arrest are scarce. The prevalence of AKI, as classified by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria; and its possible association with 30-day mortality were assessed. Methods: Data on 6387 patients with MI, 342 (5.3%) with out-of-hospital cardiac arrest or arrest immediately after admission before PCI, were retrospectively analyzed. The AKI and no-AKI groups were compared. The 30-day mortality was determined. Results: Ninety-three (27.2%) patients suffered AKI. AKI KDIGO stages 1, 2 and 3 occurred in 45 (13.2%), 8 (2.3%) and 40 (11.7%) patients, respectively. Higher mortality was found in AKI patients [56 (60.2%) vs. no-AKI patients 32 (12.9%); p<0.0001]. More patients died in the higher AKI KDIGO stages. In AKI KDIGO stages 1/2 and stage 3, 20 (37.7%) patients and 36 (90.0%) patients died, respectively compared to 32 (12.9%) no-AKI patients; p<0.0001. AKI was the strongest predictor of 30-day mortality (adjusted OR 6.98; 95% CI 3.42 to 14.23; p<0.0001). Other predictors were bleeding, cardiogenic shock, contrast volume-to-glomerular filtration rate ratio, and female sex. The adjusted OR for AKI KDIGO stages 1/2 and stage 3 were 3.68; 95% CI 1.53 to 8.32; p=0.002 and 29.10; 95% CI 8.31 to 101.88; p<0.0001, respectively. Conclusion: In patients resuscitated after MI undergoing PCI, AKI had a deleterious impact on the prognosis. A graded increase in the severity of AKI according to the KDIGO definition was associated with a progressively increased risk of 30-day mortality.

Age-Specific Sex-Based Differences in Anemia in Patients with Myocardial Infarction.

Background: Data are lacking concerning possible age-specific sex-based differences in anemia in myocardial infarction (MI) patients and its association with the outcome. The aim was to assess whether these differences in anemia (on admission and at discharge) in MI patients who underwent percutaneous coronary intervention (PCI) are associated with the outcome. Methods: Data from 5579 MI patients (31.0% women) undergoing PCI at our institution were analyzed. Men and women in different age groups were compared regarding anemia and its association with the 30-day and long-term all-cause mortality. Data were analyzed using descriptive statistics. Results: Women suffered anemia more than men (37.5% vs. 26.8%; p < 0.0001). The prevalence of anemia increased rapidly with age in men but not in women. A J-shaped relationship between age and anemia was found in women. The lower the age, the greater the difference in the prevalence of anemia between the sexes. The difference in the prevalence of anemia at discharge was even more pronounced. Anemia on admission (odds ratio [OR] = 1.39; 95% confidence interval [CI] = 1.10-1.76; p = 0.005) and at discharge (OR = 2.61; 95% CI = 1.98-3.44; p < 0.0001) predicted a higher 30-day mortality. Women had a better adjusted long-term prognosis (hazard ratio [HR] = 0.78; 95% CI = 0.69-0.87; p < 0.0001) for the total population. Anemia on admission (HR = 1.43; 95% CI = 1.29-1.60; p < 0.0001) and at discharge (HR = 1.96; 95% CI = 1.23-2.21; p < 0.0001) predicted a higher long-term mortality. Conclusion: Younger women with MI suffer anemia more frequently than their male peers. Anemia was associated with a worse outcome. Age-specific sex-based differences in anemia help to explain the increased sex-related mortality in MI patients undergoing PCI.

Sex-Related Anemia Contributes to Disparities in Outcome of Patients Younger Than 60 Years with ST-Elevation Myocardial Infarction.

BACKGROUND: Younger women with ST-segment elevation myocardial infarction (STEMI) have a worse outcome than their age-matched male peers. Our aim was to assess whether there are sex-based differences in anemia on admission, and if they are associated with the outcome of patients with STEMI younger than 60 years undergoing primary percutaneous coronary intervention (PCI). MATERIALS AND METHODS: Data of 2095 STEMI patients, 804 of whom were younger than 60 years, were analyzed. Data were analyzed using descriptive statistics. All-cause 30-day and 2-year mortality were documented. RESULTS: Women had a higher prevalence of anemia compared with men on admission (34.4% in women vs. 20.0% in men; p < 0.0001). The 30-day mortality was similar in both groups (5.5% in women vs. 3.3% in men; p = 0.17). Anemia on admission, age, cardiogenic shock, and diabetes predicted higher 30-day mortality. Two-year mortality was higher in women (9.8% in women vs. 4.8% in men; p = 0.023). Anemia on admission, age, cardiogenic shock, and diabetes were identified as independent predictors of 2-year mortality. Sex was not associated with 30-day or 2-year mortality. CONCLUSIONS: We found sex-based differences in anemia on admission in STEMI patients younger than 60 years. Anemia, but not sex, was linked to 30-day and 2-year mortality. Anemia on admission in women younger than 60 years may help to explain the increased 2-year sex-related mortality in younger STEMI patients undergoing primary PCI.

GPIIb-IIIa Receptor Inhibitors in Acute Coronary Syndrome Patients Presenting With Cardiogenic Shock and/or After Cardiopulmonary Resuscitation.

BACKGROUND: Data on the use of GPIIb-IIIa receptor inhibitors (GPI) in acute coronary syndrome (ACS) patients presenting with cardiogenic shock and/or after cardiopulmonary resuscitation is sparse. The aim of the study was to establish the possible influence of the adjunctive use of GPI on 30-day and 1-year mortality in these high-risk patients. METHODS: Acute coronary syndrome patients (261), who presented with cardiogenic shock and/or were cardiopulmonary resuscitated on admission, were analysed. Groups receiving (170 patients) and not receiving (91 patients) GPI were compared regarding 30-day and 1-year mortality. RESULTS: The unadjusted all-cause 30-day and 1-year mortality were similar in patients receiving GPI and those not receiving GPI [79 patients (46.5%) vs 50 patients (54.9%) at 30 days; ns, 91 patients (53.5%) vs. 55 (61.1%) at 1 year; ns]. After the adjustment for baseline and clinical characteristics, the adjunctive usage of GPI was identified as an independent prognostic factor in lower 30-day mortality (adjusted OR: 0.41; 95%CI: 0.20 to 0.84; p=0.015) and 1-year mortality (HR 0.62; 95%CI 0.39-0.97; p=0.037). Age, left main PCI and major bleeding, were also identified as independent prognostic factors in worse 30-day and 1-year mortality. In addition, Thrombolysis in Myocardial Infarction (TIMI) flow 0/1 pre-percutaneous coronary intervention (PCI) predicted a worse 1-year outcome. Novel oral P2Y12 receptor antagonists predicted better 30-day and 1-year survival. CONCLUSION: Our study suggests that the adjunctive usage of GPI may be beneficial in this high-risk group of patients in whom a delayed onset of action of oral antiplatelet therapy would be expected.

Deterioration of renal function at stent implantation can predict long-term outcome after stent thrombosis.

OBJECTIVES: The aim of the study was to examine the possible influence of minor deterioration of the renal function after stent implantation not fulfilling the criteria for acute kidney injury on long-term outcomes after stent thrombosis (ST). BACKGROUND: Decreased renal function (DRF) is associated with an increased risk for worse outcome after percutaneous coronary intervention. There is no data if the deterioration of renal function after stent implantation influences the prognosis after ST. If so patients with a higher risk for worse outcome after ST could be identified already at the time of stent implantation. METHODS: Data from 4824 consecutive patients treated with percutaneous coronary intervention in our center was recorded from March 2004 to April 2010. We excluded patients with acute kidney injury at stent implantation and 86 of them with ST without acute kidney injury at stent implantation were involved in the study. They were prospectively followed until December 2012 for 50.2 ± 28.1 months. Only patients with definite ST were included in the study. The Academic Research Consortium definition of ST was used. Data on death, myocardial infarction, and repeated percutaneous or operative revascularization after ST were ascertained from the hospital database, by phone or with clinical examinations. The outcomes after definite ST were compared in patients with and without deterioration of renal function after stent implantation (DRFafterSI). RESULTS: During the observational period patients with DRFafterSI had a higher mortality rate after ST than patients without DRFafterSI (35.1 vs. 10.3 %; p <0.019). The incidence of major adverse cardiac events (major adverse coronary event (MACE)-death, myocardial infarction, repeated revascularization) rate after ST was similar in both groups (66.1 % with DRFafterSI vs. 55.2 % without DRFafterSI). The prevalence of myocardial infarction was also similar in both groups (31.6 vs. 34.5 %) as was the revascularizations rate (43.9 vs. 48.3 %). Death was predicted by DRFafterSI (adjusted hazard ratio (HR) 3.96; 95 % confidence interval (CI) 1.11 to 14.10; p <0.034) and age > 75 years (adjusted HR 2.85: 95 % CI 1.12-7.30; p = 0.029). We could not find any predictor for MACE. CONCLUSIONS: Even more subtle DRFafterSI (not fulfilling the criteria for acute kidney injury) at stent implantation were associated with higher long-term mortality after ST. Especially at risk were patients older than 75 years at stent implantation. DRFafterSI and age more than 75 years pointed out the group of patients with a high risk for death after ST already at the time of stent implantation. The best treatment option for preventing ST in these patients is still to be determined. Until then, we must pay a special attention to proper patients' preparation and hydration to avoid DRFafterSI.

Influence of a combination of probiotics on bacterial infections in very low birthweight newborns.

BACKGROUND: Late-onset infections are an important cause of morbidity and mortality in preterm infants. The purpose of our prospective randomised study was to establish whether a combination of probiotics (Lactobacillus acidophilus, Enterococcus faecium and Bifidobacterium infantum) affects the incidence of late-onset sepsis and other infections in very low birthweight infants (birthweight under 1500 g, gestational age under 33 weeks). METHODS: From 80 included infants, one half received probiotics (L. acidophilus, E. faecium and B. infantum) in the ratio 1.5:1:1.5, at a dose of 0.6 × 107 colony-forming units twice daily, given with the first portions of milk until discharge, whereas the other half did not. RESULTS: In the group receiving probiotics, 16 children had late-onset sepsis compared with 29 in the group without probiotics; p = 0.006. The number of late-onset septic events was lower (30) in the group receiving probiotics than in the group that did not receive probiotics (69); p = 0.003. Furthermore, fewer children had at least one late-onset infection (20 infants in the group receiving probiotics compared with 32 in the group without them; p = 0.009). There were less episodes of late-onset infections in the group receiving probiotics (35) than in the group without probiotics (79); p = 0.002. CONCLUSIONS: A combination of probiotics at a low dose (1.2 × 107 colony-forming units) decreased the frequency of late-onset sepsis and other infections, as described in previous studies. In addition, children were discharged at a lower postmenstrual age. There were no side effects of probiotics reported.