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Post-intensive care syndrome: An overview

Abstract

Survival of critically unwell patients has improved in the last decade due to advances in critical care medicine. Some of these survivors develop cognitive, psychiatric and /or physical disability after treatment in intensive care unit (ICU), which is now recognized as post intensive care syndrome (PICS). Given the limited awareness about PICS in the medical faculty this aspect is often overlooked which may lead to reduced quality of life and cause a lot of suffering of these patients and their families. Efforts should be directed towards preventing PICS by minimizing sedation and early mobilization during ICU.All critical care survivors should be evaluated for PICS and those having signs and symptoms of it should be managed by a multidisciplinary team which includes critical care physician, neuro-psychiatrist, physiotherapist and respiratory therapist, with the use of pharmacological and non-apharmacological interventions. This can be achieved through an organizational change and improvement, knowing the high rate of incidence of PICS and its adverse effects on the survivor’s life and daily activities and its effect on the survivor’s family.

Open access
Prediction of survival following percutaneous biliary drainage for malignant biliary obstruction

Abstract

Background and Objectives

Percutaneous transhepatic biliary drain is an intervention used to relieve malignant biliary obstruction. This study aims to explore survival after biliary drain insertion, predictive factors of survival and effectiveness to reduce total bilirubin level.

Methods

We conducted a retrospective analysis of 72 patients who had malignant biliary obstruction and received biliary drain during the time period between March 2005 and February 2015.

Results

Median patients’ age was 56 years. 38 (52.7%) were males, 34(47.2%) were females. Median survival post biliary drain insertion was 46 days, 95% C/I (37.92–54.02), range (2–453 days). 1, 3, and 6 month survival rates were 64.7%, 26.5%, and 7.4% respectively. Multivariate analysis by Cox proportional hazards regression model showed the presence of ascites to be significant predictors of survival, other factors analyzed were: total bilirubin, serum creatinine, international normalization ratio, serum albumin, pleural effusion and liver metastasis.

Conclusion

Survival after biliary drain insertion can vary from few days to few months. Presence of ascites is an independent predictor of survival after this intervention.

Open access
The role of glucagon-like peptide-1 receptor agonists in the treatment of type 2 diabetes

Abstract

The role of GLP-1 agonists in the treatment of type 2 diabetes have been shown to be viable options for add-on therapy in diabetic patients, as well as potential monotherapy options. With six available GLP-1 agents, and new combination products in the pipeline, they are a promising drug class for type 2 diabetic patients, especially due to their extended dosing interval and potential weight loss benefits.

Open access
Upper gastrointestinal bleeding in patients with end stage renal disease: causes, characteristics and factors associated with need for endoscopic therapeutic intervention

Abstract

Background and Objectives

The risk of upper gastrointestinal bleeding (UGIB) is increased among the end-stage renal disease (ESRD) patients. The aim of the current study was to describe the causes and characteristics of UGIB in ESRD patients at our center and to assess the need for endoscopic therapeutic intervention (ETI) using Rockall (RS) and Glasgow Blatchford scores (GBS).

Material and Methods

All patients with ESRD and UGIB with age ≥14 years were included. Frequencies and percentages were computed for categorical variables. Chi square test or Fischer’s exact test was used for statistical analysis.

Results

A total of 59 subjects had a mean age of 47.25 ± 15 years.The most common endoscopic findings seen were erosions in 33 (55.9%) patients, followed by ulcers in 18 (30.3%) patients. ETI was required in 33 (55.9%) patients, which included adrenaline injection in 19 (32.3%), hemoclip in 9 (15.2%) and argon plasma coagulation in 5 (8.4%) patients. Factors associated with the need of ETI were identified as: a combined presentation of hematemesis and melena (P=0.033), ulcer (P=0.002) and associated chronic liver disease (P=0.015). Six (10.1%) patients died. Death was more common if ETI was not performed (P=0.018).

Conclusion

ETI was more commonly required in patients on maintenance hemodialysis with UGIB, who had presence of combined hematemesis and melena, ulcers and associated chronic liver disease. A Glasgow Blatchford score of >14 was helpful in assessing the need for ETI in these patients.

Open access
Acute Peritonitis Caused by Propionibacterium Acnes in a Peritoneal Dialysis Patient

Abstract

Propionibacterium acnes is a gram-positive human skin commensal that is involved in the pathogenesis of acne and prefers anaerobic growth conditions. It has been considered as a low virulence pathogen in different clinical conditions. We present the case of acute peritonitis caused by Propionibacterium acnes in a peritoneal dialysis patient.

Open access
Effect of Melatonin Administration on Prevention of Contrast- Induced Nephropathy following Coronary Angiography

Abstract

Introduction. Contrast-induced-nephropathy (CIN) is a common complication during angiography that may lead to long-term complications. This study was conducted to investigate the effect of melatonin administration on prevention of CIN in patients who underwent coronary angiography with intra-arterial contrast agents. Method. This is single-blind randomized clinical trial that was performed over 100 patients with indication for coronary angiography. Patients are randomly assigned to two equal groups. All patients in the 12 hours before and 12 hours after the procedure, were received adequate intravenous hydration with normal saline and for the intervention group in addition to hydration, the day before angiography and immediately after angiography 3 mg melatonin was administered. For all patients, serum level of creatinine (Cr), blood urea nitrogen (BUN) and glomerular filtration rate (GFR) before and 48 hours after the procedure were measured. Data were analyzed using SPSS 18 software. Results. Totally 100 participants with the mean age of 64.0±8.2 years were enrolled (63% male). There was no significant difference between intervention and control groups in baseline and demographic characteristics (P> 0.05). Although the mean serum Cr and BUN level increased in both groups, but the mean Cr, BUN and GFR before and after coronary angiography was not statistically significant. Based on the definition of CIN in the current study, 3(6%) patients from intervention group and 2(4%) patients from control group were affected by CIN (P = 0.243). Conclusion. It is likely that, melatonin administration has no significant effect on prevention of CIN following coronary angiography.

Open access
Evaluation of Clinical and Pathological Characteristics of Patients with IgA Nephropathy Based on Oxford Classification System: Should Crescents be Included?

Abstract

Introduction. None of the classification systems in immunoglobulin A (IgA) nephropathy has been widely agreed or implemented by clinicians or pathologists. In order to meet this need, "Oxford Classification System", which is highly reproducible and predictive for clinical course, was developed in 2009. In the present study, we investigated clinical and pathological characteristics of patients with IgA nephropathy based on current classification and the predictivity of crescent presence on prognosis. Methods. The study comprised 40 patients with diagnosis of primary IgA nephropathy on renal biopsy. The biopsy findings and follow-up parameters of patients were retrospectively re-evaluated. Pathological findings were examined based on the Oxford classification system. The presence of crescent formation in the specimens was noted. Results. The presence of crescent formation was predictive of poor prognosis regarding the glomerular filtration rate (eGFR), the level of proteinuria, and mean arterial pressure (MAP). Conclusion: Considering the importance of crescent formation in prediction of the clinical course and need for immunosuppressive therapy, it is suggested that crescent presence can be included in this classification system.

Open access
Five Years of Renal Transplantations in Montenegro: Results and Challenges

Abstract

First renal transplantation in Montenegro was performed on September 25th, 2012. Since then, 32 transplantations have been performed. Only one was from deceased donor, the remaining were from living donors. 40.4% of all patients with end-stage renal disease currently live with the functioning renal allograft (190 patients on dialysis, 129 transplanted patients). There are 32 patients on the waiting list. Further efforts will be focused on development of the deceased donor program and introduction of the AB0 incompatible renal transplantations.

Open access
Influence of Hemodialysis Treatment on Biochemical Markers of Bone Disease

Abstract

Introduction. Bone disease is a chronic complication of chronic kidney disease and major clinical problem in hemodialysis (HD) patients. The aim of our study was to assess the influence of treatment longevity on biochemical parameters of mineral and bone metabolism in HD patients, and to identify the most important parameters. Methods. The research was observational and retrospective, involved 70 patients, mean age 58.69±12.54, divided into groups in respect to the duration of dialysis treatment (Group I-5 years, Group II-5-10 years and Group III-over 10 years). Results. Serum phosphorus was increased, but the values tend to increase along with dialysis duration - (Group I: 1.93±0.45; Group II: 1.97±0.50; Group III: 2.01±0.37; p>0,05). Calcium values were also not significantly increased based on the duration of treatment [Group I: 2.3 (2.2-2.41); Group II: 2.46 (2.15-2.6), Group III: 2.35 (2.10-2.52)]. Dialysis and PTH correlated positively in the first group of patients (Rho=0.470, p=0.013). The values of calcium and alkaline phosphatase correlated positively in all patients (Rho=0.351, p=0.003). PTH was significantly higher in the second and third compared to the first group (p=0.009 and p=0.038, respectively), and there was no significant difference between the second and the third group. Interestingly, parathyroidectomized patients had higher PTH values compared to those without parathyroidectomy (557 vs. 359 pg/ml). Conclusion. The most reliable marker for clinical monitoring of bone disease in dialysis patients is PTH. The values of calcium and phosphorus are highly variable and not reliable parameters for bone disease follow-up.

Open access
Monitoring of Renal Allograft Function with Different Equations: What are the Differences?

Abstract

Introduction. Monitoring of graft function by creatinine concentrations in serum and calculated glomerular filtration rate (GFR) is recommended after kidney transplantation. KDIGO recommendations on the treatment of transplant patients advocate usage of one of the existing mathematical equations based on serum creatinine. We compared clinical application of three equations based on serum creatinine in monitoring the function of transplanted kidney. Methods. A total number of 55 adult patients who received their first renal allograft from living donors at our transplant center in between 2011-2014 were included into the study. Renal allograft GFR was estimated by the Cockroft-Gault, Nankivell and MDRD formula, and correlated with clinical parameters of donors and recipients. Results. The mean age of recipients was 35.7±9.5 (range 16-58), and the mean age of donors was 55.5±9.0 (34- 77) years. Out of this group of 55 transplant patients, 50(90.91%) were on hemodialysis (HD) prior to transplantation. HD treatment was shorter than 24 months in 37(74%) transplant patients. The calculated GFR with MDRD equation showed the highest mean value at 6 and 12 months (68.46±21.5; 68.39±24.6, respectively) and the lowest at 48 months (42.79±12.9). According to the Cockroft&Gault equation GFR was the highest at 12 months (88.91±24.9) and the lowest at 48 months (66.53±18.1 ml/min). The highest mean level (80.53±17.7) of the calculated GFR with the Nankivell equation was obtained at 12 months and the lowest (67.81±16.7 ml/min) at 48 months. The values of Pearson’s correlation coefficient between the calculated GFR and the MDRD at 2 years after transplantation according to donor’s age of r=-0.3224, correlation between GFR and the Cockfroft & Gault at 6 and 12 months and donor’s age (r=-0.2735 and r=-0.2818), and correlation between GFR and the Nankivell at 2 years and donor’s age of r=-0.2681, suggested a conclusion that calculated GFR was lower in recipients who had an older donors. Conclusion. Our analysis showed difference in the calculated GFR with different equations at the same time points. Using one mathematical equation during the total post-transplantation period would be a recommended method in order to eliminate the discrepancy in determining the stage of kidney failure.

Open access