Renal Injury in All-Comers After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis.

Background Acute kidney injury (AKI) following aortic valve replacement is associated with poor prognosis. Transcatheter aortic valve replacement (TAVR) is a novel strategy with a percutaneous approach and early recovery time. We conducted this meta-analysis to compare TAVR to surgical aortic valve replacement (SAVR) and their respective renal outcomes. Methods We searched for randomized controlled trials (RCTs) using MEDLINE, PUBMED, and Google Scholar databases from their inception till April 6, 2019, and included eight trials comparing TAVR to SAVR in cases that reported AKIs. Results We found a significant reduction in AKI after TAVR compared to SAVR at 30 days [n = 66 vs. n = 160, respectively; odds ratio (OR) = 0.38, 95% confidence interval (CI) = 0.28-0.51; p: <0.00001, I2 = 0%]. At one year, a trend towards reduced renal failure was noted in the TAVR arm compared to the SAVR arm (n = 74 vs. n = 129, respectively; OR = 0.57, 95% CI = 0.32-1.01; p = 0.05, I2 = 69%). Conclusion Based on our findings and analysis, we have concluded that TAVR is associated with significantly reduced renal injury at 30 days when compared to SAVR.

Nephrology Fellows' and Program Directors' Perceptions of Hospital Rounds in the United States.

BACKGROUND AND OBJECTIVES: Hospital rounds are a traditional vehicle for patient-care delivery and experiential learning for trainees. We aimed to characterize practices and perceptions of rounds in United States nephrology training programs. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a national survey of United States nephrology fellows and program directors. Fellows received the survey after completing the 2019 National Board of Medical Examiners Nephrology In-Training Exam. Program directors received the survey at the American Society of Nephrology's 2019 Nephrology Training Program Directors' Retreat. Surveys assessed the structure and perceptions of rounds, focusing on workload, workflow, value for patient care, and fellows' clinical skill-building. Directors were queried about their expectations for fellow prerounds and efficiency of rounds. Responses were quantified by proportions. RESULTS: Fellow and program director response rates were 73% (n=621) and 70% (n=55). Most fellows (74%) report a patient census of >15, arrive at the hospital before 7:00 am (59%), and complete progress notes after 5:00 pm (46%). Among several rounding activities, fellows most valued bedside discussions for building their clinical skills (34%), but only 30% examine all patients with the attending at the bedside. Most directors (71%) expect fellows to both examine patients and collect data before attending-rounds. A majority (78%) of directors commonly complete their documentation after 5:00 pm, and for 36%, after 8:00 pm. Like fellows, directors most value bedside discussion for development of fellows' clinical skills (44%). Lack of preparedness for the rigors of nephrology fellowship was the most-cited barrier to efficient rounds (31%). CONCLUSIONS: Hospital rounds in United States nephrology training programs are characterized by high patient volumes, early-morning starts, and late-evening clinical documentation. Fellows use a variety of prerounding styles and examine patients at the beside with their attendings at different frequencies. PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_03_17_CJN.10190819.mp3.

Readmission rate after ultrafiltration in acute decompensated heart failure: a systematic review and meta-analysis.

Significance of ultrafiltration in acute decompensated heart failure remains unclear. We performed meta-analysis to determine its role in reducing readmissions after acute decompensated heart failure. MEDLINE was searched using PUBMED from inception to March 22, 2017 for prospective randomized control trials comparing ultrafiltration to diuretics in acute decompensated heart failure. Five hundred ninety studies were found; nine studies with 820 patients were included. Studies with renal replacement therapy bar ultrafiltration, chronic decompensated heart failure, and non-English language were excluded. RevMan Version 5.3 was used for analysis. The primary outcomes analyzed were cumulative and 90 days readmissions secondary to heart failure and all-cause readmissions. Baseline characteristics were similar. One hundred eighty-eight patients were readmitted with heart failure, 77 vs 111 favoring ultrafiltration; risk ratio (RR) = 0.71 (95% confidence interval (CI), 0.49-1.02, p = 0.07, I 2  = 47%). Ninety days readmissions were 43 vs 67 favoring ultrafiltration; RR = 0.65 (95%CI, 0.47-0.90, p = 0.01, I 2  = 0%). Ultrafiltration showed significantly higher fluid removal and weight loss. Hypotension was common in ultrafiltration (24 vs 13, OR = 2.06, 95%CI = 0.98-4.32, p = 0.06, I 2  = 0%). Ultrafiltration showed reduced 90 days heart failure readmissions and trend towards reduced cumulative hospital readmissions. Renal and cardiovascular outcomes and hospital stay were similar.

Tenecteplase for the improvement of blood flow rate in dysfunctional hemodialysis catheters.

BACKGROUND: We evaluated the efficacy and safety of the thrombolytic agent tenecteplase for the treatment of dysfunctional hemodialysis (HD) catheters. METHODS: Data were pooled from 2 Phase III clinical studies: the randomized, placebo-controlled TROPICS 3 trial and the open-label TROPICS 4 trial. Eligible patients received either an initial dose of tenecteplase (2 mg/lumen) or placebo (TROPICS 3 only) for a 1-h intracatheter dwell. Treatment success was defined as blood flow rate (BFR) ≥ 300 ml/min and a ≥ 25 ml/min increase from baseline BFR, without line reversal, 30 min before and at the end of HD. All TROPICS 4 patients and the TROPICS 3 patients enrolled after the final protocol amendment without treatment success received an instillation of tenecteplase at the end of the initial visit for an extended dwell of up to 72 h. RESULTS: A total of 372 patients with dysfunctional catheters were enrolled in the 2 studies. Of the 297 patients treated with tenecteplase at the initial visit, 31% achieved treatment success, with a mean (SD) change from baseline BFR of 73 (120) ml/min. Among the 179 patients who received a 1-h dwell of study drug followed by extended-dwell tenecteplase, 46% had treatment success at the end of the next HD session. Six catheter-related bloodstream infections and 2 thromboses were reported in patients following tenecteplase exposure. CONCLUSION: Tenecteplase, administered as a 1-h dwell or a 1-h dwell followed by an extended dwell, was associated with improved BFR in dysfunctional HD catheters in the TROPICS 3 and 4 clinical trials.

A phase III, randomized, double-blind, placebo-controlled study of tenecteplase for improvement of hemodialysis catheter function: TROPICS 3.

BACKGROUND AND OBJECTIVES: Despite widespread use of tunneled hemodialysis (HD) catheters, their utility is limited by the development of thrombotic complications. To address this problem, this study investigated whether the thrombolytic agent tenecteplase can restore blood flow rates (BFRs) in dysfunctional HD catheters. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In this randomized, double-blind study, patients with dysfunctional tunneled HD catheters, defined as a BFR <300 ml/min at -250 mmHg pressure in the arterial line, received 1-hour intracatheter dwell with tenecteplase (2 mg) or placebo. The primary endpoint was the percentage of patients with BFR > or =300 ml/min and an increase of > or =25 ml/min above baseline 30 minutes before and at the end of HD. Safety endpoints included the incidence of hemorrhagic, thrombotic, and infectious complications. RESULTS: Eligible patients (n = 149) were treated with tenecteplase (n = 74) or placebo (n = 75). Mean baseline BFR was similar for the tenecteplase and placebo groups at 151 and 137 ml/min, respectively. After a 1-hour dwell, 22% of patients in the tenecteplase group had functional catheters compared with 5% among placebo controls (P = 0.004). At the end of dialysis, mean change in BFR was 47 ml/min in the tenecteplase group versus 12 ml/min in the placebo group (P = 0.008). Four catheter-related bloodstream infections (one tenecteplase, three placebo) and one thrombosis (tenecteplase) were observed. There were no reports of intracranial hemorrhage, major bleeding, embolic events, or catheter-related complications. CONCLUSIONS: Tenecteplase improved HD catheter function and had a favorable safety profile compared with placebo.

Establishing a new option for target-organ protection: rationale for ARB plus ACE inhibitor combination therapy.

Activation of the renin-angiotensin system (RAS) plays an important role in the promotion of cardiovascular disease and target-organ damage, mediated in part by hypertension. Combination therapy targeting RAS activation may reduce target-organ damage and provide superior blood pressure (BP) control; combining angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) represents one possible approach. In monotherapy studies, both ACE inhibitors and ARBs have demonstrated similar positive effects on BP and on RAS-related target-organ damage, including nephropathy and congestive heart failure. Studies of combination therapy, most of which involved addition of an ARB to existing ACE inhibitor therapy, have demonstrated benefits among patients with congestive heart failure and renal disease. However, variances in study design and populations, dosing and titration methods, and clinical end points, in addition to inherent differences between agents, limit the ability to reach clinically meaningful conclusions about the value of dual RAS inhibition. Trials designed to document such efficacy are currently underway.