Hypertension/prehypertension and its determinants in pediatric IgA nephropathy
MEDICINE
Authors: Fu, Qing-Ying; Ma, Lu; Li, Chang-Chun; He, Zhi-Jun; Wang, Wei-Hua; Luo, Kai-Fa; Liu, Yang; Zhang, Zhi-Hao; Yang, Zai-Bo; Tang, Hai-Lian; Yan, Jun-Hui
Abstract
Immunoglobulin A nephropathy (IgAN) is a major cause of secondary hypertension (HT) of renal origin - a significant prognostic factor of IgAN. In children, similar to HT, prehypertension (pre-HT) is becoming a significant health issue. However, the role of secondary HT and pre-HT (HT/pre-HT) in the progression of pediatric IgAN remains unclear. We investigated the effects of HT/pre-HT on prognosis and its determinants as well as their correlation with clinicopathological parameters to identify more effective therapeutic targets. This single-center retrospective study compared clinicopathological features and treatment outcomes between patients with and without HT/pre-HT in 108 children with IgAN. Independent risk factors for HT/pre-HT were evaluated; segmental glomerulosclerosis was a significant variable, whose relationship with clinicopathological parameters was analyzed. Clinical outcomes of patients with and without HT/pre-HT differed considerably (P = .006) on >= 6 months follow-up. Patients with HT/pre-HT reached complete remission less frequently than those without HT/pre-HT (P = .014). Age, serum creatinine, prothrombin time, and segmental glomerulosclerosis or adhesion were independent risk factors for HT/pre-HT in pediatric IgAN (P = .012,P = .017,P = .002, andP = .016, respectively). Segmental glomerulosclerosis or adhesion was most closely associated with glomerular crescents (r = 0.456,P < .01), followed by Lees grades (r = 0.454,P < .01), renal arteriolar wall thickening (r = 0.337,P < .01), and endocapillary hypercellularity (r = 0.306,P = .001). The intensity of IgA deposits, an important marker of pathogenetic activity in IgAN, was significantly associated with the intensity and location of fibrinogen deposits (intensity:r = 0.291,P = .002; location:r = 0.275,P = .004). HT/pre-HT in pediatric IgAN patients is an important modifiable factor. A relationship is observed between HT/pre-HT and its determinants, especially segmental glomerulosclerosis. Potential therapeutic approaches for IgAN with HT/pre-HT might be directed toward the management of coagulation status, active lesions, and hemodynamics for slowing disease progression.
The CELIOtomy Risk Score: An effort to minimize futile surgery with analysis of early postoperative mortality after emergency laparotomy
SURGERY
Authors: Kao, Angela M.; Maloney, Sean R.; Prasad, Tanushree; Reinke, Caroline E.; May, Addison K.; Heniford, B. Todd; Ross, Samuel W.
Abstract
Background: Emergency surgical services often encounter patients with generalized peritonitis. Difficult perioperative decisions impact morbidity, mortality, cost, and utilization of hospital resources. The ability to preoperatively predict patient nonsurvival despite surgical intervention using clinical physiologic indicators was the aim of this study and would be helpful in counseling patients/families. Methods: A retrospective cohort from an institutional database was queried for nontrauma patients with peritonitis undergoing emergency laparotomy from 2012 to 2016. Time to mortality after surgery was compared: early (<= 72 hours) versus late (>72 hours) and no death. Results: After 534 emergency laparotomies, there were 74 (13.9%) mortalities. Of these, death occurred early (<= 72 hours) after surgery in 28 (37.8%) patients and late (>72 hours) in 46 (62.2%). Early death patients had a significantly more deranged physiology, as evidenced by higher Acute Physiology and Chronic Health Evaluation II scores (mean 28.1 +/- 8.4 vs 22.9 +/- 8.7, P = .01), worse acute kidney injury (preoperative creatinine 3.7 +/- 3.2 vs 1.9 +/- 1.4, P = .001), and greater level of acidosis (pH 7.19 +/- 0.12 vs 7.27 +/- 0.13, P = .017). Additionally, preoperative lactate was significantly increased in patients with early mortality (6.8 +/- 4.1 vs 5.1 +/- 4.0, P = .045). Using logarithmic regression, a nomogram was constructed using age, Glasgow Coma Scale, lactate, creatinine, and pH. This nomogram had an area under the curve of 0.908 on receiver operator curve analysis. A score of 13 equates to greater than 50% risk of early mortality after surgery. Conclusion: Early mortality (<72 hours after emergency laparotomy) is associated with decreased pH, elevated creatinine, and elevated lactate. These factors combined into the nomogram constructed may assist surgical teams with patient and family discussions to prevent futile surgical interventions. (c) 2020 Elsevier Inc. All rights reserved.