Browsing by Author "Kittanamongkolchai, Wonngarm"
Now showing 1 - 7 of 7
- Results Per Page
- Sort Options
Item Open Access An Uncommon Cause Of Altered Mental Status In A Patient With Systemic Lupus Erythematosus(American Journal of Respiratory and Critical Care Medicine) Ungprasert, Patompong; Leeaphorn, Napat; Srivali, Narat; Kittanamongkolchai, WonngarmIntroduction: Altered mental status is one of the most common presentations that leads to an admission to intensive care unit. Posterior reversible encephalopathy syndrome (PRES), which is commonly encountered in association with various medical conditions, is an uncommon but probably under-diagnosed cause of this presentation. Case report: A 51-year-old woman was admitted to our ICU because of alteration of consciousness. She was in her usual state of health the night before although she complained of a mild headache. She became unarousable on the following morning and her husband immediately brought her to our institution. She had a significant history of SLE that was diagnosed five years ago with malar rash, photosensitivity rash, polyarthritis, positive ANA and anti-smith antibody. Her only current medication was hydroxychloroquine. Upon admission, she was found to be hypertensive with BP of 170/90 mmHg. Neurological examination was remarkable for GCS of five without any focal neurological deficit. Laboratory investigations were remarkable for an elevation of creatinine (2.4 mg/dL from baseline of 1.0 mg/dL) and an abnormal urinalysis with numerous dysmorphic RBCs and WBCs. CT brain demonstrated ill-defined hypodensity in the subcortical white matter of both posterior parietal lobes. A subsequent MRI brain revealed T2 hyper-intense signal in cortex and subcortical white matter of the same lobes (Figure). She was diagnosed with PRES and was immediately treated with intravenous labetalol. Her BP gradually came down to normal range and her mental status gradually improved as she became completely alert and oriented on the fourth day of admission. She underwent renal biopsy during this admission which revealed type IV lupus nephritis. Treatment with steroid and cyclophosphamide was initiated. Comment: Patient with PRES usually presents with headache, seizure, nausea, confusion or coma in a more severe case. A broad range of medical conditions, including hypertension, eclampsia, use of immunosuppressive agent, and autoimmune disorders has been implicated as causes of this syndrome. Neuroimaging is crucial to the diagnosis. Typical findings include symmetrical edema of white matter predominantly in the parieto-occipital lobes. These abnormalities are best depicted by MRI (hyper-intense signal on T2 and FLAIR technique). Prognosis is favorable as the neurological deficit is usually reversible in days to weeks after blood pressure control, as seen in this patient. However, delay in initiating the appropriate treatment can lead to a permanent neurological damage. Thus, physician should have a high index of suspicion for this syndrome especially in patients with known associated illnesses.Item Open Access CHANGING TRENDS IN THE USE OF VASOPRESSORS IN INTENSIVE CARE UNIT: A 7-YEAR STUDY(Critical Care Medicine, 2014-12) Srivali, Narat; Thongprayoon, Charat; Kittanamongkolchai, Wonngarm; Cheungpasitporn, Wisit; Erdogan, Aysen; Carrera, Perliveh; Kashani, KianoushLearning Objectives: The use of vasopressors was common in intensive care unit (ICU). Due to the lack of conclusive evidence in superiority in efficacy among various types of vasopressors, the choice of vasopressor use mainly depends on the physician preference. This study aims to describe the prevalence of vasopressor use and the trend in the use of each vasopressor medication in ICU over the past 7 years. Methods: This is a descriptive study conducted at a tertiary referral hospital. All ICU admissions, including both medical and surgical ICU, at our institution between January 2007 and December 2013 were included in this study. The use of vasopressors within given ICU day (12.00 am – 11.59 pm) during ICU stay was reviewed. Vasopressors were defined as the continuous intravenous administration of norepinephrine, epinephrine, dopamine, phenylephrine, or vasopressin regardless of duration and dosage. Results: A total of 52410 unique patients had 72005 ICU admissions in the course of study, (272271 patient*ICU day). Vasopressors were used in 17767 (24.7%) ICU admissions and on 53898 (19.8%) patient*ICU day, resulting in a total of 76564 vasopressor day. Vasopressin was used on 21955 (41%), epinephrine on 20958 (39%), norepinephrine on 17919 (33%), dopamine on 8636 (16%) and phenylephrine on 7096 (13%) patient*ICU day. Over 2007-2013, there was an upward trend in the use of norepinephrine (the proportion of ICU day on norepinephrine over total ICU day with vasopressor 0.24 in year 2007 to 0.45 in year 2013), and a downward trend in phenylephrine (the proportion of ICU day on phenylephrine over total ICU day with vasopressor 0.20 in year 2007 to 0.10 in year 2013). There was no specific trend in the usage of vasopressin, epinephrine, and dopamine. Conclusions: The vasopressors were used in about one fourth of ICU admission and about one fifth of ICU days. Vasopressin is the most commonly used vasopressor. The use of norepinephrine is in upward trajectory.Item Open Access HYDRATION FOR CONTRAST-INDUCED ACUTE KIDNEY INJURY PREVENTION A META-ANALYSIS(Critical Care Medicine, 2014-12-01) Srivali, Narat; Cheungpasitporn, Wisit; Charat, Thongprayoon; Edmonds, Peter; O’Corragain, Oisin; Kittanamongkolchai, Wonngarm; Brabec, Brady; Erickson, StephenLearning Objectives: The reports on efficacy of oral hydration compared to intravenous hydration for the prevention of contrast-induced acute kidney injury (CIAKI) in radiological procedures and cardiac catheterization remains controversial. The objective of this meta-analysis was to assess the efficacy of these hydration regimens for prevention of CIAKI. Methods: Comprehensive literature searches for randomized controlled trials (RCTs) of outpatient oral hydration treatment was performed using MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials Systematic Reviews and clinicaltrials.gov from inception until July 4th, 2014. Primary outcome was the incidence of CIAKI. Results: Three prospective RCTs were included in our analysis. Of 242 patients undergoing procedures with contrast exposures, 22 patients (9%) had CIAKI. These 3 RCTs, however, included only patients with relatively normal kidney function to CKD stage 3 and excluded those who had contrast exposure for urgent indications. There was no significant increased risk of CIAKI in oral fluid regimen group compared to IV fluid regimen group (RR = 1.83, 95% CI = 0.41–8.21). Conclusions: According to our analysis, there is no evidence that oral fluid regimen is associated with more risk of CIAKI in patients with contrast exposures compared to IV fluid regimen. This finding suggests that the oral fluid regimen is a possible treatment option for CIAKI prevention in non-urgent procedures in patients with normal to moderately reduced kidney function.Item Open Access Risk of coronary artery disease in patients with ankylosing spondylitis: a systematic review and meta-analysis.(Annals of translational medicine, 2015-03) Ungprasert, Patompong; Srivali, Narat; Kittanamongkolchai, WonngarmObjective
To investigate the association between coronary artery disease (CAD) and ankylosing spondylitis (AS).Methods
We conducted a systematic review and meta-analysis of observational studies that reported relative risks, hazard ratios, standardized prevalence ratio or standardized incidence ratios with 95% confidence comparing CAD risk in patients with AS versus non-AS controls. Pooled risk ratios and 95% confidence intervals (CIs) were calculated using a random-effect, generic inverse variance of DerSimonian and Laird.Results
Out of 229 potentially relevant articles, ten studies (five retrospective cohort studies and five cross-sectional studies) were identified and included in our data analysis. The overall pooled risk ratio of CAD in patients with AS was 1.41 (95% CI: 1.29-1.54). The pooled risk ratios for cross-sectional and cohort studies were 2.08 (95% CI: 1.28-3.40) and 1.36 (95% CI: 1.31-1.41), respectively. The statistical heterogeneity of this meta-analysis was moderate with an I(2) of 56%.Conclusions
Our study demonstrated a statistically significant increased CAD risk among patients with AS with 41% excess risk.Item Open Access The association between renal recovery after acute kidney injury and long-term mortality after transcatheter aortic valve replacement.(PloS one, 2017-01) Thongprayoon, Charat; Cheungpasitporn, Wisit; Srivali, Narat; Kittanamongkolchai, Wonngarm; Sakhuja, Ankit; Greason, Kevin L; Kashani, Kianoush BBackground
This study aimed to examine the association between renal recovery status at hospital discharge after acute kidney injury (AKI) and long-term mortality following transcatheter aortic valve replacement (TAVR).Methods
We screened all adult patients who survived to hospital discharge after TAVR for aortic stenosis at a quaternary referral medical center from January 1, 2008, through June 30, 2014. An AKI was defined as an increase in serum creatinine level of 0.3 mg/dL or a relative increase of 50% from baseline. Renal outcome at the time of discharge was evaluated by comparing the discharge serum creatinine level to the baseline level. Complete renal recovery was defined as no AKI at discharge, whereas partial renal recovery was defined as AKI without a need for renal replacement therapy at discharge. No renal recovery was defined as a need for renal replacement therapy at discharge.Results
The study included 374 patients. Ninty-eight (26%) patients developed AKI during hospitalization: 55 (56%) had complete recovery; 39 (40%), partial recovery; and 4 (4%), no recovery. AKI development was significantly associated with increased risk of 2-year mortality (hazard ratio [HR], 2.20 [95% CI, 1.37-3.49]). For patients with AKI, the 2-year mortality rate for complete recovery was 34%; for partial recovery, 43%; and for no recovery, 75%; compared with 20% for patients without AKI (P < .001). In adjusted analysis, complete recovery (HR, 1.87 [95% CI, 1.03-3.23]); partial recovery (HR, 2.65 [95% CI, 1.40-4.71]) and no recovery (HR, 10.95 [95% CI, 2.59-31.49]) after AKI vs no AKI were significantly associated with increased risk of 2-year mortality.Conclusion
The mortality rate increased for all patients with AKI undergoing TAVR. A reverse correlation existed for progressively higher risk of death and the extent of AKI recovery.Item Open Access The comparison of the commonly used surrogates for baseline renal function in acute kidney injury diagnosis and staging.(BMC nephrology, 2016-01) Thongprayoon, Charat; Cheungpasitporn, Wisit; Harrison, Andrew M; Kittanamongkolchai, Wonngarm; Ungprasert, Patompong; Srivali, Narat; Akhoundi, Abbasali; Kashani, Kianoush BBackground
Baseline serum creatinine (SCr) level is frequently not measured in clinical practice. The aim of this study was to investigate the effect of various methods of baseline SCr determination measurement on accuracy of acute kidney injury (AKI) diagnosis in critically ill patients.Methods
This was a retrospective cohort study. All adult intensive care unit (ICU) patients admitted at a tertiary referral hospital from January 1, 2011 through December 31, 2011, with at least one measured SCr value during ICU stay, were included in this study. The baseline SCr was considered either an admission SCr (SCrADM) or an estimated SCr, using MDRD formula, based on an assumed glomerular filtration rate (GFR) of 75 ml/min/1.73 m(2) (SCrGFR-75). Determination of AKI was based on the KDIGO SCr criterion. Propensity score to predict the likelihood of missing SCr was used to generate a simulated cohort of 3566 patients with baseline outpatient SCr, who had similar characteristics with patients whose outpatient SCr was not available.Results
Of 7772 patients, 3504 (45.1 %) did not have baseline outpatient SCr. Among patients without baseline outpatient SCr, AKI was detected in 571 (16.3 %) using the SCrADM and 997 (28.4 %) using SCrGFR-75 (p < .001). Compared with non-AKI patients, patients who met AKI only by SCrADM, but not SCrGFR-75, were significantly associated with 60-day mortality (OR 2.90; 95 % CI 1.66-4.87), whereas patients who met AKI only by SCrGFR-75, but not SCrADM, had a non-significant increase in 60-day mortality risk (OR 1.33; 95 % CI 0.94-1.88). In a simulated cohort of patients with baseline outpatient SCr, SCrGFR-75 yielded a higher sensitivity (77.2 vs. 50.5 %) and lower specificity (87.8 vs. 94.8 %) for the AKI diagnosis in comparison with SCrADM.Conclusions
When baseline outpatient SCr was not available, using SCrGFR-75 as surrogate for baseline SCr was found to be more sensitive but less specific for AKI diagnosis compared with using SCrADM. This resulted in higher incidence of AKI with larger likelihood of false-positive cases.Item Open Access Transapical versus transfemoral approach and risk of acute kidney injury following transcatheter aortic valve replacement: a propensity-adjusted analysis.(Renal failure, 2017-11) Thongprayoon, Charat; Cheungpasitporn, Wisit; Srivali, Narat; Harrison, Andrew M; Kittanamongkolchai, Wonngarm; Greason, Kevin L; Kashani, Kianoush BBackground
The aim of this study was to compare the incidence of post-procedural acute kidney injury (AKI) and other renal outcomes in patients undergoing transapical (TA) and transfemoral (TF) approaches for transcatheter aortic valve replacement (TAVR).Methods
All consecutive adult patients undergoing TAVR for aortic stenosis from 1 January 2008 to 30 June 2014 at a tertiary referral hospital were included. AKI was defined based on Kidney Disease Improving Global Outcomes (KDIGO) criteria. Logistic regression adjustment, propensity score stratification, and propensity matching were performed to assess the independent association between procedural approach and AKI.Results
Of 366 included patients, 171 (47%) underwent TAVR via a TA approach. AKI occurrence in this group was significantly higher compared to the TF group (38% vs. 18%, p < .01). The TA approach remained significantly associated with increased risk of AKI after logistic regression (OR 3.20; CI 1.68-4.36) and propensity score adjustment: OR 2.83 (CI 1.66-4.80) for stratification and 3.82 (CI 2.04-7.44) for matching. Nonetheless, there was no statistically significant difference among the TA and TF groups with respect to major adverse kidney events (MAKE) or estimated glomerular filtration rate (eGFR) at six months post-procedure.Conclusion
In a cohort of patients undergoing TAVR for aortic stenosis, a TA approach significantly increases the AKI risk compared with a TF approach. However, the TAVR approach did not affect severe renal outcomes or long-term renal function.