Leelaviwat, Natnicha

Background: Revascularization of small vessel coronary artery disease (SvCAD) is still challenging despite the extensive use of drug-eluting stents (DESs), mainly because of an increase in target vessel failure. Drug-coated balloon (DCB) has emerged as an alternative strategy in SvCAD. However, the safety and efficacy of DCB in SvCAD is still controversial. We conducted a meta-analysis comparing the clinical outcomes of DCB and DES in SvCAD patients. Methods: We comprehensively searched the databases of MEDLINE and EMBASE from inception to May 2024. Included studies were published randomized control trials (RCTs) that compared major adverse cardiac events (MACE), target-lesion revascularization (TLR), and target-vessel revascularization (TVR) between DCB and DES in SvCAD patients. Data from each study were combined using the random-effects model. Results: Six RCTs were included in this meta-analysis involving 1,534 SvCAD patients (775 underwent revascularization with DCB and 759 with DES). There was no difference in MACE, TLR, and TVR between DCB and DES groups ([OR] 1.14, 95% CI 0.64-2.00, I 2 =58.2%, p=0.657, [OR] 1.34, 95% CI 0.56-3.23, I 2 =48.5%, p=0.516, and [OR] 1.09, 95% CI 0.59-2.01, I 2 =49.6%, p=0.795, respectively) (Figure 1). There was no publication bias observed in Funnel plot as well as no small-study effect observed in Egger’s test. Conclusions: As compared to DES, our study showed that DCB was associated with similar clinical outcomes and could be a potential alternative strategy in SvCAD patients.

Introduction: Chronic total coronary occlusion (CTO) management remains a challenge. Several studies have reported the benefits of percutaneous coronary intervention (PCI) in CTO. However, the outcomes of PCI vs optimal medical therapy (OMT) are still controversial. We conducted an extensive review and meta-analysis to compare the clinical outcomes between PCI and OMT in CTO. Methods: We comprehensively searched the databases of MEDLINE and EMBASE from inception to May 2024. Included studies were published cohort (prospective or retrospective) with propensity score matching analysis and randomized trials that reported all-cause death, cardiac death, and myocardial infarction (MI) with PCI and OMT in CTO patients. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate odd ratios and 95% confidence intervals. Results: Sixteen studies, 6 randomized controlled trials (RCTs) and 11 observational studies with propensity score with matching (PSMs), were included in this meta-analysis involving 8,316 CTO patients (4,332 underwent PCI and 4,084 received OMT). In the overall analysis, all-cause death, cardiac death, and MI were significantly reduced in PCI compared to OMT group, respectively ([OR] 0.65, 95% CI 0.55-0.76, I 2 =0.0%, p<0.001, [OR] 0.60, 95% CI 0.49-0.74, I 2 =0.0%, p<0.001, and [OR] 0.72, 95% CI 0.52-0.99, I 2 =19.0%, p=0.041). Conclusions: Our study is the most updated meta-analysis to assess the impact of PCI compared to OMT in patients with CTO, analyzing the data being derived from PSMs and RCTs, that demonstrated significant impact of PCI on all-cause death, cardiac mortality, and MI.

Background: Cirrhosis and end-stage kidney disease (ESKD) are significant global health concerns, contributing to high mortality and morbidity. Haemodialysis (HD) is frequently used to treat ESKD in patients with cirrhosis. However, it often presents challenges such as haemodynamic instability during dialysis sessions, leading to less than optimal outcomes. Peritoneal dialysis (PD), while less commonly used in cirrhotic patients, raises concerns about the risks of peritonitis and mortality. Our systematic review and meta-analysis aimed to assess outcomes in PD patients with cirrhosis. Methods: We executed a comprehensive search in Ovid MEDLINE, EMBASE and Cochrane databases up to 25 September 2023. The search focused on identifying studies examining mortality and other clinical outcomes in ESKD patients with cirrhosis receiving PD or HD. In addition, we sought studies comparing PD outcomes in cirrhosis patients to those without cirrhosis. Data from each study were aggregated using a random-effects model and the inverse-variance method. Results: Our meta-analysis included a total of 13 studies with 15,089 patients. Seven studies compared ESKD patients on PD with liver cirrhosis (2753 patients) against non-cirrhosis patients (9579 patients). The other six studies provided data on PD (824 patients) versus HD (1943 patients) in patients with cirrhosis and ESKD. The analysis revealed no significant difference in mortality between PD and HD in ESKD patients with cirrhosis (pooled odds ratio (OR) of 0.77; 95% confidence interval (CI), 0.53–1.14). In PD patients with cirrhosis, the pooled OR for peritonitis compared to non-cirrhosis patients was 1.10 (95% CI: 1.03–1.18). The pooled ORs for hernia and chronic hypotension in cirrhosis patients compared to non-cirrhosis controls were 2.48 (95% CI: 0.08–73.04) and 17.50 (95% CI: 1.90–161.11), respectively. The pooled OR for transitioning from PD to HD among cirrhotic patients was 1.71 (95% CI: 0.76–3.85). Mortality in cirrhosis patients on PD was comparable to non-cirrhosis controls, with a pooled OR of 1.05 (95% CI: 0.53–2.10). Conclusions: Our meta-analysis demonstrates that PD provides comparable mortality outcomes to HD in ESKD patients with cirrhosis. In addition, the presence of cirrhosis does not significantly elevate the risk of mortality among patients undergoing PD. While there is a higher incidence of chronic hypotension and a slightly increased risk of peritonitis in cirrhosis patients on PD compared to those without cirrhosis, the risks of hernia and the need to transition from PD to HD are comparable between both groups. These findings suggest PD as a viable and effective treatment option for ESKD patients with cirrhosis.

Contrast-induced nephropathy (CIN) is a significant complication in patients undergoing coronary angiography, and its development is associated with increased morbidity and mortality. Left ventricular end-diastolic pressure (LVEDP) provides one index of left heart filling status. An elevated LVEDP can reflect volume overload or abnormal diastolic function and indicates a cardiac disorder. Data on the association between an elevated LVEDP and CIN are limited and have had conflicting results. We systematically searched the databases PubMed, Embase, and Scopus for full-text articles from database inception to May 2022. Studies were included if they evaluated the association between a high LVEDP and the incidence of CIN in patients undergoing coronary angiography. The study was registered in the PROSPERO CRD42022334070. A second search in PubMed identified randomized controlled trials using LVEDP to guide fluid administration during coronary procedures. Four studies were identified that used LVEDP to classify patients into groups to determine the association between the level and the development of CIN. In these studies, 240 patients of 2441 patients (9.8%) developed CIN. One study found no association between LVEDP levels and the development of CIN. Two studies found an increased frequency of CIN in patients with elevated levels using 2 cutoff points for LVEDP, ≥20 mm Hg and >30 mm Hg. One study found that lower LVEDP levels (5–14 mm Hg) were associated with the development of CIN. Three randomized control trials used LVDEP levels to manage fluid administration in patients undergoing coronary procedures; only one study found that the use of these levels to guide fluid administration resulted in better outcomes. In patients undergoing coronary angiography, an elevated LVEDP was not consistently associated with increased risk of CIN, and using LVEDP levels to guide fluid administration during these procedures did not always improve outcomes in comparison to other protocols. The use of LVEDP levels can help classify patients with cardiac disorders but does not necessarily provide an adequate description of the hemodynamic patterns in these patients to predict or prevent CIN in patients undergoing angiography.

Key Clinical MessagePre‐bariatric surgery dietary recommendations should take into account daily protein intake and other risk factors for kidney injury. This is important because a high protein intake can potentially lead to kidney injury.AbstractBariatric surgery has been shown to be a highly effective intervention for achieving weight loss and reducing obesity related‐comorbidities. Acute kidney injury (AKI) is considered one of the common complications in perioperative and post‐bariatric surgery. However, pre‐bariatric surgery AKI has never been reported. Several studies demonstrated that pre‐bariatric surgery weight loss improved surgical outcomes and decrease postoperative complications. Some diet regimens have been introduced including low‐caloric diet (LCD), very‐low caloric diet (VLCD), and very‐low caloric ketogenic diet (VLCKD). We present a patient who develops AKI after 10 days of having a high‐protein diet from a pre‐bariatric weight loss strategy.

Background: Iron deficiency in patients with systolic heart failure (HF) was found to be associated with poorer exercise capacity and quality of life. We conducted this systematic review and meta-analysis to assess whether iron supplementation in patients with systolic HF can improve exercise capacity and quality of life. Methods: We searched MEDLINE, and Embase databases from inception to May 2022 to identify the studies that reported the impact of iron therapy including oral and intravenous (IV) iron forms in systolic HF patients with iron deficiency. Outcomes of interest included 1) six minute walk test (6MWT) and 2) Quality of life (QoL) assessed by Kansas City Cardiomyopathy Questionnaire (KCCQ). Data from each study were combined using the random-effects model to calculate weight mean difference (WMD) and 95% confidence interval (CI) Results: Five studies (4 randomized controlled trials and 1 nonrandomized open-label study) with a total of 1,075 patients (610 in the intervention group and 465 in the control group) were included. In the intervention group, 474 patients received IV iron and 136 patients received oral iron therapy. Iron therapy was associated with significant improvement of 6MWT (WMD =22.81, 95% CI 0.47-45.14, p < 0.001) and KCCQ (WMD =4.68, 95%CI 0.43-8.93, p< 0.001). Interestingly, subgroup analysis showed that the main results were driven by IV iron therapy in both 6MWT (WMD =34.68, 95%CI 25.13-44.24, p< 0.001) and KCCQ (WMD =6.78, 95%CI 3.81-9.75, p< 0.001) as there was no significant improvement after oral iron therapy in 6MWT (WMD =0.15, 95% CI -23.86-24.16, p =0.99) and KCCQ (WMD =2.71, 95% CI-1.35-6.78, p =0.19). As shown in Figure 1. Conclusions: Intravenous iron therapy, but not oral iron therapy is associated with improved exercise capacity and QoL in patients with systolic HF.