Cheungpasitporn, Wisit

Background: There have been concerns regarding increased perioperative mortality, length of hospital stay, and rates of graft loss in kidney transplant recipients with functional limitations. The application of machine learning consensus clustering approach may provide a novel understanding of unique phenotypes of functionally limited kidney transplant recipients with distinct outcomes in order to identify strategies to improve outcomes. Methods: Consensus cluster analysis was performed based on recipient-, donor-, and transplant-related characteristics in 3205 functionally limited kidney transplant recipients (Karnofsky Performance Scale (KPS) < 40% at transplant) in the OPTN/UNOS database from 2010 to 2019. Each cluster’s key characteristics were identified using the standardized mean difference. Posttransplant outcomes, including death-censored graft failure, patient death, and acute allograft rejection were compared among the clusters Results: Consensus cluster analysis identified two distinct clusters that best represented the clinical characteristics of kidney transplant recipients with limited functional status prior to transplant. Cluster 1 patients were older in age and were more likely to receive deceased donor kidney transplant with a higher number of HLA mismatches. In contrast, cluster 2 patients were younger, had shorter dialysis duration, were more likely to be retransplants, and were more likely to receive living donor kidney transplants from HLA mismatched donors. As such, cluster 2 recipients had a higher PRA, less cold ischemia time, and lower proportion of machine-perfused kidneys. Despite having a low KPS, 5-year patient survival was 79.1 and 83.9% for clusters 1 and 2; 5-year death-censored graft survival was 86.9 and 91.9%. Cluster 1 had lower death-censored graft survival and patient survival but higher acute rejection, compared to cluster 2. Conclusion: Our study used an unsupervised machine learning approach to characterize kidney transplant recipients with limited functional status into two clinically distinct clusters with differing posttransplant outcomes.

AbstractIntroductionAtrial fibrillation (AF) ablation is increasingly performed worldwide. As comfort with AF ablation increases, the procedure is increasingly used in patients that are older and in those with more comorbidities. However, it is not well established whether AF ablation in the elderly, especially those >75 years old, has comparable safety and efficacy to younger populations.ObjectiveTo compare the efficacy and safety profiles in patients older than 75 years undergoing AF ablation with younger patients.MethodsDatabases from EMBASE, Medline, PubMed, and Cochrane, were searched from inception through September 2021. Studies that compared the success rates in AF catheter ablation and all complications rates between patients who were older vs under 75 years were included. Effect estimates from the individual studies were extracted and combined using random effect, generic inverse variance method of DerSimonian and Laird.ResultsTwenty‐seven observational studies were included in the analysis consisting of 363,542 patients who underwent AF ablation. Comparing patients older than 75 years old to younger patients, there was no difference in the success of ablation rates between elderly and younger patients (pooled OR 0.85: 95% CI:0.69–1.05, p = .131). On the other hand, AF ablation in the elderly was associated with higher complication rates (pooled OR 1.42: 95% CI:1.21–1.68, p < .001).ConclusionAs AF ablation is expanded to elderly populations, our study found that AF ablation success rates were similar in both elderly and younger patients. However, older patients experience higher rates of complications that should be considered when offering the procedure and as a means to improve outcomes with future innovations.

Over the past decade, the number of organ transplants performed worldwide has significantly increased for patients with advanced organ failure [...]

Abstract Background Serum chloride derangement is common in critically ill patients requiring continuous renal replacement therapy (CRRT). We aimed to assess the association between serum chloride levels before and during CRRT with mortality. Methods This is a retrospective cohort study of critically ill patients receiving CRRT for acute kidney injury from December 2006 through November 2015 in a tertiary referral hospital in the United States. We used logistic regression to assess serum chloride before and mean serum chloride during CRRT as predictors for 90 days mortality after CRRT initiation. The normal reference range for serum chloride was 99–108 mmol/L. Results Of 1282 eligible patients, 25%, 50%, and 25% had hypochloremia, normochloremia, and hyperchloremia, respectively. The adjusted odds ratio for 90 days mortality in patients with hypochloremia before CRRT was 1.82 (95% CI 1.29–2.55). During CRRT, 4%, 70%, 26% of patients had mean serum chloride in the hypochloremia, normochloremia, and hyperchloremia range, respectively. The adjusted odds ratio for 90 days mortality in patients with mean serum chloride during CRRT in the hypochloremia range was 2.96 (95% CI 1.43–6.12). Hyperchloremia before and during CRRT was not associated with mortality. The greater serum chloride range during CRRT was associated with increased mortality (OR 1.29; 95% CI 1.13–1.47 per 5 mmol/L increase). Conclusion Hypochloremia before and during CRRT is associated with higher mortality.

Background: There are limited data on uninsured patients presenting with acute myocardial infarction-cardiogenic shock (AMI-CS). This study sought to compare the management and outcomes of AMI-CS between uninsured and privately insured individuals. Methods: Using the National Inpatient Sample (2000–2016), a retrospective cohort of adult (≥18 years) uninsured admissions (primary payer—self-pay or no charge) were compared with privately insured individuals. Interhospital transfers were excluded. Outcomes of interest included in-hospital mortality, temporal trends in admissions, use of cardiac procedures, do-not-resuscitate status, palliative care referrals, and resource utilization. Results: Of 402 182 AMI-CS admissions, 21 966 (5.4%) and 93 814 (23.3%) were uninsured and privately insured. Compared with private insured individuals, uninsured admissions were younger, male, from a lower socioeconomic status, had lower comorbidity, higher rates of acute organ failure, ST-segment elevation AMI-CS (77.3% versus 76.4%), and concomitant cardiac arrest (33.8% versus 31.9%; all P <0.001). Compared with 2000, in 2016, there were more uninsured (adjusted odds ratio, 1.15 [95% CI, 1.13–1.17]; P <0.001) and less privately insured admissions (adjusted odds ratio, 0.85 [95% CI, 0.83–0.87]; P <0.001). Uninsured individuals received less frequent coronary angiography (79.5% versus 81.0%), percutaneous coronary intervention (60.8% versus 62.2%), mechanical circulatory support (54% versus 55.5%), and had higher palliative care (3.8% versus 3.2%) and do-not-resuscitate status use (4.4% versus 3.2%; all P <0.001). Uninsured admissions had higher in-hospital mortality (adjusted odds ratio, 1.62 [95% CI, 1.55–1.68]; P <0.001) and resource utilization. Conclusions: Uninsured individuals have higher in-hospital mortality and lower use of guideline-directed therapies in AMI-CS compared with privately insured individuals.

AbstractBackgroundReal‐world data on atrial fibrillation (AF) ablation outcomes in obese populations have remained scarce, especially the relationship between obesity and in‐hospital AF ablation outcome.HypothesisObesity is associated with higher complication rates and higher admission trend for AF ablation.MethodsWe drew data from the US National Inpatient Sample to identify patients who underwent AF ablation between 2005 and 2018. Sociodemographic and patients' characteristics data were collected, and the trend, incidence of catheter ablation complications and mortality were analyzed, and further stratified by obesity classification.ResultsA total of 153 429 patients who were hospitalized for AF ablation were estimated. Among these, 11 876 obese patients (95% confidence interval [CI]: 11 422–12 330) and 10 635 morbid obese patients (95% CI: 10 200–11 069) were observed. There was a substantial uptrend admission, up to fivefold, for AF ablation in all obese patients from 2005 to 2018 (p < .001). Morbidly obese patients were statistically younger, while coexisting comorbidities were substantially higher than both obese and nonobese patients (p < .01) Both obesity and morbid obesity were significantly associated with an increased risk of total bleeding, and vascular complications (p < .05). Only morbid obesity was significantly associated with an increased risk of ablation‐related complications, total infection, and pulmonary complications (p < .01). No difference in‐hospital mortality was observed among obese, morbidly obese, and nonobese patients.ConclusionOur study observed an uptrend in the admission of obese patients undergoing AF ablation from 2005 through 2018. Obesity was associated with higher ablation‐related complications, particularly those who were morbidly obese.

AbstractIntroductionWe aimed to assess the association between serum potassium and mortality in patients receiving continuous renal replacement therapy (CRRT).MethodsWe studied 1279 acute kidney injury patients receiving CRRT in a tertiary referral hospital in the United States. We used logistic regression to assess the association of serum potassium before CRRT and mean serum potassium during CRRT with 90‐day mortality after CRRT initiation, using serum potassium 4.0–4.4 mmol/L as reference group.ResultsBefore CRRT, there was a U‐shaped association between serum potassium and 90‐day mortality. There was a significant increase in mortality when serum potassium before CRRT was ≤3.4 and ≥4.5 mmol/L. During CRRT, progressively increased mortality was noted when mean serum potassium was ≥4.5 mmol/L. The odds ratio of 90‐day mortality was significantly higher when mean serum potassium was ≥4.5 mmol/L.ConclusionHypokalemia and hyperkalemia before CRRT and hyperkalemia during CRRT predicts 90‐day mortality.

AbstractIntroductionReal‐world data on atrial fibrillation (AF) ablation among moderate and advanced chronic kidney disease (CKD) patients have so far remained scarce, especially in‐hospital AF ablation outcomes.MethodsWe drew data from the US National Inpatient Sample to identify hospitalized patients who underwent AF ablation between 2005 and 2018, and further stratified by CKD classification. We assessed the trend of AF ablation, as well as its complications.ResultsA total of 152 630 patients who were primarily hospitalized for AF and underwent ablation were estimated. Among these, CKD patients were found in a total of 1509 participants, with 978, 206, and 325 under CKD3, CKD4, and CKD5/ESKD, respectively. There was a significant increment in admission rates for AF ablation in the CKD population across all CKD classifications (p < .001). All CKD patients were statistically older, with higher coexisting comorbidities, while hypertension was found substantially lower than non‐CKD patients (p ≤ .001). Importantly, CKD, especially CKD3 and CKD5/ESKD, was significantly associated with an increased risk of total complications, and total bleeding, Neurological complications were found statistically lower in CKD patients (p = .029), and no mortality rates were significantly different (p = .287).ConclusionOur study observed an increase in admission trends for AF ablation among moderate and advanced CKD patients from 2005 to 2018. CKD was strongly associated with higher procedure‐related complications and bleeding, but neurological safety profiles and mortalities rates were nonsignificantly different.

AbstractBackgroundQRS area, a three‐dimensional QRS complex, is a novel vectorcardiography method of measuring the magnitude of electrical forces in the heart. Hypothetically, a greater QRS area denotes higher dyssynchrony and indicates potential benefits from cardiac resynchronization therapy (CRT). Previous studies suggest a positive correlation between QRS area and the degree of response to CRT, but its clinical use remains unclear. We performed a meta‐analysis of the relationship between QRS area and survival benefit following CRT.MethodsWe comprehensively searched the MEDLINE, EMBASE, and Cochrane databases from inception to August 2021. We included studies with prospective and retrospective cohort designs that reported QRS area before CRT and total mortality. Data from each study were analyzed using a random‐effects model. The results were reported as a hazard ratio (HR) and 95% confidence intervals.ResultsFive observational studies including 4931 patients were identified. The cut‐off values between large and small QRS areas ranged from 102 to 116 μVs. Our analysis showed a larger QRS area was statistically associated with increased 5‐year survival in patients implanted with CRT (HR pooled 0.48, 95% CI 0.46–0.51, I2 = 54%, p < .0001). Greater QRS area reduction (pre‐ and post‐implantation) were associated with a lower total mortality rate (HR pooled 0.45, 95% CI 0.38–0.52, I2 = 0%, p < .0001).ConclusionLarger pre‐implantation QRS area was associated with increased survival after CRT. QRS area reduction following CRT implantation was also associated with lower mortality. QRS area may potentially become an additional selection criterion for CRT implantations.