Background Because of the major clinical and economic burden of diabetic nephropathy, new therapeutic tools to delay its progression are needed. Recent studies suggest that thiazolidinediones have ...renal benefits. We aimed to evaluate the effect of thiazolidinediones on urinary albumin and protein excretion in patients with diabetes mellitus. Study Design Systematic review and meta-analysis by searching MEDLINE/PubMed, EMBASE, and Cochrane CENTRAL databases (1991 to September 2009). Setting & Population Patients with diabetes mellitus. Selection Criteria for Studies Randomized controlled trials. Intervention Thiazolidinediones (rosiglitazone and pioglitazone) compared with placebo or other antidiabetic agents. Outcomes Weighted (WMDs) and standardized mean differences (SMDs) for changes in urine albumin or protein excretion between the thiazolidinedione and control groups. Results Of 171 originally identified articles, 15 studies (5 with rosiglitazone and 10 with pioglitazone) involving 2,860 patients were included in the analysis. In participants with baseline normo- or microalbuminuria, the WMD of proportional changes between the thiazolidinedione and control groups in urinary albumin excretion measured using time-specified collections was −64.8% (95% CI, −75.6 to −53.9) and the WMD of changes in albumin-creatinine ratio was −24.8% (95% CI, −39.6 to −10.0). Overall, in participants with normo- and microalbuminuria, thiazolidinedione treatment was associated with a significant decrease in urinary albumin excretion (SMD, −0.6 units of standard deviation SD; 95% CI, −0.8 to −0.4). Similarly, thiazolidinediones were associated with a significant decrease in urinary protein excretion in patients with proteinuria (SMD, −1.1 units of SD; 95% CI, −1.8 to −0.4). Limitations Significant heterogeneity across included studies in several subgroup analyses; patient-level data not available. Conclusions Treatment with thiazolidinediones significantly decreases urinary albumin and protein excretion in patients with diabetes. This finding calls for clinical trials with hard renal outcomes to elucidate the potential benefits of thiazolidinediones on diabetic nephropathy.
The incidence of, and risk factors for, acute kidney injury (AKI) after endovascular intervention for peripheral artery disease (PAD) remain unknown. The aim of this study was to assess the ...proportion of patients who develop AKI and explore the risk factors.
Prospectively collected data on patients undergoing femoropopliteal endovascular intervention for symptomatic PAD across three vascular centres were analysed. The proportion of patients developing AKI (according to the Kidney Disease Improving Global Outcomes definition) within 48 h, and the proportion developing the composite Major Adverse Kidney Events (MAKE) endpoints (death, dialysis, drop in estimated glomerular filtration rate at least 25 per cent) at 30 days (MAKE30) and remains 90 days (MAKE90) were calculated. Multivariable regression analysis was used to assess predictors of AKI, and the association between AKI and death.
Some 2041 patients were included in the analysis. AKI developed in 239 patients (11.7 per cent), with 47 (2.3 per cent) requiring dialysis within 30 days, and 18 (0.9 per cent) requiring ongoing dialysis. The MAKE30 and MAKE90 composite endpoints were reached in 358 (17.5 per cent) and 449 (22.0 per cent) patients respectively. Risk factors for AKI were age, sex, congestive heart failure, chronic limb-threatening ischaemia, emergency procedure, and pre-existing chronic kidney disease. AKI, dementia, congestive heart failure, and major amputation were risk factors for medium-term mortality.
AKI is a common complication after intervention for PAD and is associated with medium-term mortality.
Acute kidney injury (AKI) after any type of intervention negatively impacts
mortality, length of hospitalization, and perhaps long-term survival. In the
case of endovascular aneurysm repair (EVAR), ...the incidence of AKI ranges from
1% to 23% for elective and emergency procedures and is lower
compared to open repair. The pathophysiology of AKI in EVAR is complex:
contrast-induced nephropathy, renal microembolization, and acute tubular
necrosis are all implicated. Prevention strategies include hydration, ischemic
preconditioning, regional anesthesia, and pharmacological agents. There is no
level I evidence regarding the prevention of AKI in EVAR, so this review sought
to examine the mechanisms and prevention strategies for this potentially fatal
complication.
Abstract Objective To evaluate the proximal and distal (iliac) fixation of seven self-expanding endografts, used in the endovascular treatment (EVAR) of abdominal-aortic aneurysm (AAA), by measuring ...the displacement force (DF) necessary to dislocate the devices from their fixation sites. Methods A total of 20 human cadaveric aortas were exposed, left in situ and transected to serve as fixation zones. The Anaconda, EndoFit aorto-uni-iliac, Endurant, Powerlink, Excluder, Talent and Zenith stent grafts were deployed and caudal force was applied at the flow divider, through a force gauge. The DF needed to dislocate each device ≥ 20 mm from the infrarenal neck was recorded before and after moulding-balloon dilatation. Cephalad force was similarly applied to each iliac limb to assess distal fixation before and after moulding-balloon dilatation. Results Endografts with fixation hooks or barbs displayed a significantly higher DF necessary to dislocate the proximal portion compared with devices with no such fixation modalities ( p < 0.001). Balloon dilatation produced a significant increase in DF in both devices with ( p < 0.001) or without ( p = 0.003) hooks or barbs. Suprarenal support did not enhance proximal fixation ( p = 0.90). Balloon dilatation significantly increased the DF necessary to dislodge the iliac limbs ( p = 0.007). Conclusions Devices with fixation hooks displayed higher proximal fixation. Moulding-balloon dilatation increased proximal and distal fixation. Suprarenal support did not affect proximal fixation.
A 2011 meta-analysis comparing eversion (eCEA) with conventional (cCEA) carotid endarterectomy in 16,251 patients concluded that eCEA was associated with lower rates of peri-operative stroke and late ...occlusion compared with cCEA. However, randomised controlled trials (RCTs) showed no difference in outcomes. Since then, the literature contains outcome data on 49,500 patients undergoing eCEA or cCEA. An updated meta-analysis was performed to establish whether eCEA confers significant benefit over cCEA.
This was a systematic review of PubMed/Medline, Embase, and Cochrane databases for RCTs and observational studies (OSs) comparing eCEA with cCEA. A sensitivity analysis was also performed using data from OSs with a Newcastle-Ottawa score >5.
There were 25 eligible studies (5 RCTs, 20 OSs) involving 49,500 CEAs (16,249 eCEAs; 33,251 cCEAs). RCT data: Compared with cCEA, eCEA did not confer significant reductions in 30 day stroke, death, death/stroke, death/stroke/MI, or neck haematoma. However, eCEA was associated with reduced late restenosis (OR 0.40; p = .001). OS data: eCEA was associated with significant reductions in 30 day death (OR 0.46; p < .0001), stroke (OR 0.58; p < .0001), death/stroke (OR 0.52; p < .0001), death/stroke/MI (OR 0.50; p < .0001), and late restenosis (OR 0.49; p = .032) compared with cCEA. RCT and OS data combined: eCEA was associated with significant reductions in 30 day death (OR 0.55; p < .0001), stroke (OR 0.63; p = .004), death/stroke (OR 0.58; p < .0001), and late restenosis (OR 0.45; p = .004) compared with cCEA. eCEA vs. patched cCEA (RCT and OS data): There were no differences between the two procedures except for neck haematoma, where eCEA was better than patched cCEA.
Using combined RCT and OS data, eCEA was superior to cCEA regarding peri-operative outcomes (stroke, death, death/stroke) and late restenosis, but was similar to patched CEA in both early and late outcomes. This updated meta-analysis suggests that early and late outcomes following cCEA are similar to eCEA, provided the arteriotomy is patched.
Objectives The aim was to determine 30-day outcomes in patients with concurrent carotid and cardiac disease who underwent carotid artery stenting (CAS) followed by coronary artery bypass grafting ...(CABG). Methods This was a systematic review with searches of PubMed/Medline, Embase, and Cochrane databases. “Same-day” procedures involved CAS + CABG being performed on the same day, and “staged” interventions involved at least 1 day's delay between undergoing CAS and then CABG. Results There were 31 eligible studies (2727 patients), with 80% being neurologically asymptomatic with unilateral stenoses. Overall, the 30-day death/stroke rate was 7.9% (95% confidence interval CI 6.9–9.2), while death/stroke/MI was 8.8% (95% CI 7.3–10.5). Staged CAS + CABG was associated with 30-day death/stroke rate of 8.5% (95% CI 7.3–9.7) compared with 5.9% (95% CI 4.0–8.5) after “same-day” procedures. Outcomes following CAS + CABG in neurologically symptomatic patients were poorer, with procedural stroke rates of 15%. There were five antiplatelet (APRx) strategies: (a) no APRx (death/stroke/MI, 4.2%; no data on bleeding complications); (b) single APRx before CAS and CABG, then dual APRx after CABG (death/stroke/MI, 6.7%; 7.3% bleeding complications); (c) dual APRx pre-CAS down to one APRx pre-CABG (death/stroke/MI, 10.1%; 2.8% bleeding complications); (d) dual APRx pre-CAS, both stopped pre-CABG (death/stroke/MI, 14.4%); (e) dual APRx pre-CAS and continued through CABG (death/stroke/MI, 16%). There were insufficient data on bleeding complication in the last two strategies. Conclusions In a cohort of predominantly asymptomatic patients with unilateral carotid stenoses, the 30-day rate of death/stroke was about 8%. Notwithstanding the effect of potential biases, this meta-analysis did not find evidence that outcomes after same-day CAS + CABG were higher than after staged interventions. However, outcomes were poorer in neurologically symptomatic patients. More data are required to establish the optimal antiplatelet strategy in patients undergoing same-day or staged CAS + CABG.
New Horizons in Peripheral Artery Disease Houghton, John S M; Saratzis, Athanasios N; Sayers, Rob D ...
Age and ageing,
06/2024, Letnik:
53, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Abstract Peripheral artery disease (PAD) is the lower limb manifestation of systemic atherosclerotic disease. PAD may initially present with symptoms of intermittent claudication, whilst chronic ...limb-threatening ischaemia (CLTI), the end stage of PAD, presents with rest pain and/or tissue loss. PAD is an age-related condition present in over 10% of those aged ≥65 in high-income countries. Guidelines regarding definition, diagnosis and staging of PAD and CLTI have been updated to reflect the changing patterns and presentations of disease given the increasing prevalence of diabetes. Recent research has changed guidelines on optimal medical therapy, with low-dose anticoagulant plus aspirin recommended in some patients. Recently published randomised trials highlight where bypass-first or endovascular-first approaches may be optimal in infra-inguinal disease. New techniques in endovascular surgery have increased minimally invasive options for ever more complex disease. Increasing recognition has been given to the complexity of patients with CLTI where a high prevalence of both frailty and cognitive impairment are present and a significant burden of multi-morbidity and polypharmacy. Despite advances in minimally invasive revascularisation techniques and reduction in amputation incidence, survival remains poor for many with CLTI. Shared decision-making is essential, and conservative management is often appropriate for older patients. There is emerging evidence of the benefit of specialist geriatric team input in the perioperative management of older patients undergoing surgery for CLTI. Recent UK guidelines now recommend screening for frailty, cognitive impairment and delirium in older vascular surgery patients as well as recommending all vascular surgery services have support and input from specialist geriatrics teams.
Acute kidney injury (AKI) after surgery or intervention is an important complication that may impact mortality, morbidity, and health care costs. Endovascular procedures are now performed routinely ...for a variety of pathologies that were traditionally treated with open surgery because randomized trials comparing endovascular and open surgery have shown at least equally good results and reduced complication and hospitalization rates with endovascular techniques. However, endovascular procedures have been associated with an increased risk for postoperative AKI, predominantly owing to contrast nephrotoxicity. Over the years, endovascular techniques have progressively been applied for the treatment of complex cardiovascular pathologies, and in recent years, nephrologists have increasingly encountered patients who developed AKI after endovascular aneurysm repair or transcatheter aortic valve replacement. These 2 procedures typically involve high-risk patients who have several established AKI risk factors prior to intervention. Several studies have investigated the incidence, risk factors, and natural course of AKI after endovascular aneurysm repair and transcatheter aortic valve replacement. This review summarizes current data on incidence, risk factors, pathophysiology, prognostic implications, and treatment of AKI associated with endovascular aneurysm replacement and transcatheter aortic valve replacement.
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