Serum glypican-4 (GPC4) has been identified as an insulin-sensitizing adipokine serving as a marker for body mass index and insulin resistance in humans. The association of circulating GPC4 with kidney function is to date largely unexplored. Therefore, we aimed to evaluate the association between serum GPC4 and prevalent as well future kidney function in a prospective cohort study. The study included 456 Caucasian coronary angiography patients. After a median follow up period of 3.4 years, data on kidney function was reassessed in all patients. Chronic kidney disease (CKD) was defined by decreased estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m 2 or albuminuria. At baseline, serum GPC4 was significantly associated with decreased eGFR (adjusted odds ratio (OR) per standard deviation = 4.75 [2.66–8.48]; P < 0.001), albuminuria (OR = 1.49 [1.15–1.92]; P = 0.002), and, accordingly, with CKD (OR = 1.75 [1.35–2.26]; P < 0.001). GPC4 levels also significantly and independently predicted the incidence of newly diagnosed decreased eGFR (OR = 2.74 [1.82–4.14]; P < 0.001, albuminuria (OR = 1.58 [1.01–2.46]; P = 0.043, and CKD (OR = 2.16 [1.45–3.23]; P < 0.001). ROC analysis indicated an additional predictive value of GPC4 to a basic prediction model for newly diagnosed CKD and eGFR < 60 mL/min/1.73 m 2 . Our study, therefore, indicates that high serum GPC4 is associated with decreased prevalent and future kidney function.

Intraoperatively administered hydroxyethyl starch could be a risk indicator for postoperative acute kidney injury (AKI) in vascular surgical patients. In a single-center retrospective cohort analysis, we assessed the impact of hydroxyethyl starch and other risk indicators on AKI and mortality in 1095 patients undergoing elective open abdominal aneurysm repair (AAA-OR) or endovascular aortic repair (EVAR). We established logistic regression models to determine the effect of various risk indicators, including hydroxyethyl starch, on AKI, as well as Cox proportional hazard models to assess the effect on mortality. The use of intravenous hydroxyethyl starch was not associated with an increased risk of AKI or mortality. Patients undergoing EVAR were less likely to develop AKI (4% vs 18%). Multivariate risk indicators associated for AKI included suprarenal or pararenal aortic cross-clamp [odds ratio (OR), 4.44; 95% confidence interval (95% CI), 2.538-7.784; P<.001] and procedure length (OR, 1.005; 95% CI, 1.003-1.007; P<.001), and favored EVAR (OR, 0.351; 95% CI, 0.118-0.654; P<.01). Main multivariate risk indicators associated with mortality included patients needing an urgent procedure [hazard ratio (HR), 2.294; 95% CI, 1.541-3.413; P<.001], those with suprarenal or pararenal aortic cross-clamp (HR, 1.756; 95% CI, 1.247-2.472; P<.01), and patients undergoing EVAR (HR, 1.654; 95% CI, 1.292-2.118; P<.001). We found neither a benefit nor a negative effect of hydroxyethyl starch on the risk of AKI or mortality. Instead, other variables and comorbidities were found to be relevant for the development of postoperative AKI and survival. Nevertheless, clinicians should be aware of the high risk of postoperative AKI, particularly among those undergoing AAA-OR procedures.

Background: In patients with return of spontaneous circulation (ROSC) after resuscitation, the current gold standard for assessing acute cardiac function is cardiac echocardiography. However, its use may be limited in acute critically ill patients by delays, interobserver discrepancies or the varying priorities of radiographic examinations. We now report that standardised acute cardiac function in these patients can be assessed with triple rule out thoracic (TRO) computed tomography. Methods and patients: We retrospectively analysed cardiac function in all patients with ROSC after resuscitation and who underwent acute computed tomography between 01/2013 and 01/2015 with a new post processing software client after TRO- computed tomography angiography (n=15). The syngo-CT-cardiac-function-client (syngo.via VA 20, Siemens, Erlangen, Germany) was used to measure ejection fraction, myocardial mass, stroke volume, end systolic and end-diastolic volumes, as well as coronary morphology. Multivariate regression modelling and ROC analysis were used to control the independent associations between these parameters. Results: ROC curve analysis showed that right cardiac end systolic volume and left cardiac end systolic volume were associated with ROSC (AUC: 0.74 and AUC: 0.74, respectively). In these patients, we defined thresholds for right cardiac end systolic volume of 119 ml and for left cardiac end systolic volume of 48 ml. Conclusion: In combination with TRO computed tomography, the syngo-CT-cardiac-function-client provides a valuable, standardised tool to assess acute cardiac function in patients with ROSC after resuscitation.

Background Extended focused assessment with sonography for trauma (eFAST) has been shown to have moderate sensitivity for detection of pneumothorax in trauma. Little is known about the location or size of missed pneumothoraces or clinical predictors of pneumothoraces in patients with false-negative eFAST.Methods This retrospective cross-sectional study includes all patients with multiple blunt trauma diagnosed with pneumothorax who underwent both eFAST and CT performed in the ED of a level 1 trauma centre in Switzerland between 1 June 2012 and 30 September 2014. Sensitivity of eFAST for pneumothorax was determined using CT as the gold standard. Demographic and clinical characteristics of those who had a pneumothorax detected by eFAST and those who did not were compared using the Mann-Whitney U or Pearson's chi(2) tests. Univariate binary logistic regression models were used to identify predictors for pneumothoraces in patients with negative eFAST examination.Results The study included 109 patients. Overall sensitivity for pneumothorax on eFAST was 0.59 and 0.81 for pneumothoraces requiring treatment. Compared with those detected by eFAST, missed pneumothoraces were less likely to be ventral (30 (47.6%) vs 4 (9.3%), p < 0.001) and more likely to be apical and basal (7 (11.1%) vs 15 (34.9%), p=0.003; 11 (17.5%) vs 18 (41.9%), p=0.008, respectively). The missed pneumothoraces were smaller than the detected pneumothoraces (left side: 30.7 +/- 17.4 vs 12.1 +/- 13.9 mm; right side: 30.2 +/- 10.1 vs 6.9 +/- 10.2 mm, both p < 0.001). No clinical variables were identified which predicted pneumothoraces in falsely negative eFAST. Among those pneumothoraces missed by eFAST, 30% required tube thoracostomy compared with 88.9% of those detected with eFAST.Conclusion In our study, pneumothoraces missed by eFAST were smaller and in atypical locations compared with those detected by eFAST and needed thoracic drainage less often.

We appreciate the interest our manuscript has raised and respond to the comments abridgedly pointing at recent literature.

Hypoxic hepatitis (HH) is a frequent and potentially life-threatening event typically occurring in critically ill patients as a consequence of hemodynamic impairment. While acute kidney injury (AKI) has been well described in patients with acute liver failure, incidence and outcome of AKI accompanying HH are unclear. The aim of this study was to assess incidence, clinical implications and outcome of AKI and renal replacement therapy (RRT) in critically ill patients with HH.

Introduction Somnambulism is a state of dissociated consciousness, in which the affected person is partially asleep and partially awake. There is pervasive public opinion that sleepwalkers are protected from hurting themselves. There have been few scientific reports of trauma associated with somnambulism and no published investigations on the epidemiology or trauma patterns associated with somnambulism. Methods We included all emergency department (ED) admissions to University Hospital Inselspital, Berne, Switzerland, from January 1, 2000, until August 11, 2015, when the patient had suffered a trauma associated with somnambulism. Demographic data (age, gender, nationality) and medical data (mechanism of injury, final diagnosis, hospital admission, mortality and medication on admission) were included. Results Of 620,000 screened ED admissions, 11 were associated with trauma and sleepwalking. Two patients (18.2%) had a history of known non-rapid eye movement parasomnias. The leading cause of admission was falls. Four patients required hospital admission for orthopedic injuries needing further diagnostic testing and treatment (36.4%). These included two patients with multiple injuries (18.2%). None of the admitted patients died. Conclusion Although sleepwalking seems benign in the majority of cases and most of the few injured patients did not require hospitalization, major injuries are possible. When patients present with falls of unknown origin, the possibility should be evaluated that they were caused by somnambulism.

BACKGROUND:High sensitive cardiac troponin T (hs-TnT) found its way into everyday clinical routine to diagnose acute myocardial infarction (AMI). However, its levels vary considerably based on the underlying pathophysiology of the patients. Hence we sought to test the applicability of the currently only available hs-TnT assay (Roche Diagnostics, Switzerland) to diagnose acute myocardial infarction. METHODS AND PATIENTS:Retrospectively, we analyzed the hs-TnT results of 1573 patients admitted to a level A university hospital emergency department. Overall 323 patients had an acute cardiac event defined as Non-ST Elevated Myocardial Infarction (NSTEMI) and 286 patients had a ST-Elevated Myocardial Infarction (STEMI). 964 patients served as controls, consisting of patients with other cardiac and non-cardiac morbidity. RESULTS:The sensitivity of hs-TnT for detecting an acute cardiac event was more than 92% overall. The specificity varied around 35% depending on the respective patient cohort. ROC curve analysis of the initial hs-TnT results showed that the AUC in total cardiac events (STEMI and NSTEMI) was 0.81. Detailed analysis resulted in an AUC of 0.79 in NSTEMI and 0.84 in STEMI patients detected via the initial hs-TnT. We further tested the ESC algorithm for detecting NSTEMI and obtained a sensitivity of about 83%, while 43% of all non-NSTEMIs are classified as NSTEMIs. CONCLUSION:We show that the specificity of hs-TnT for AMI is very low and conclude that the current assay including its delta values represents myocardial damage of any origin. This damage alone does not substantiate an AMI diagnosis even when international algorithms are applied.

BACKGROUND:Patients with diuretic therapy are at risk for drug-induced adverse reactions. It is unknown if presence of diuretic therapy at hospital emergency room admission is associated with mortality. METHODS:In this cross sectional analysis, all emergency room patients 2010 and 2011 at the Inselspital Bern, Switzerland were included. A multivariable logistic regression model was performed to assess the association between pre-existing diuretic medication and 28 day mortality. RESULTS:Twenty-two thousand two hundred thirty-nine subjects were included in the analysis. A total of 8.5%, 2.5%, and 0.4% of patients used one, two, or three or more diuretics. In univariate analysis spironolactone, torasemide and chlortalidone use were associated with 28 day mortality (all p < 0.05). In a multivariate cox regression model no association with mortality was detectable (p > 0.05). No difference existed between patients with or without diuretic therapy (P > 0.05). Age and creatinine were independent risk factors for mortaliy (both p < 0.05). CONCLUSION:Use of diuretics is not associated with mortality in an unselected cohort of patients presenting in an emergency room.

Background Patients admitted to emergency departments with traumatic brain injury (TBI) are commonly being treated with oral anticoagulants. In contrast to patients without anticoagulant medication, no guidelines, scores or recommendations exist for the management of mild traumatic brain injury in these patients. We therefore tested whether age as one of the high risk factors of the Canadian head CT rule is applicable to a patient population on oral anticoagulants. Methods This cross-sectional analysis included all patients with mild TBI and concomitant oral anticoagulant therapy admitted to the Emergency Department, Inselspital Bern, Switzerland, from November 2009 to October 2014 ( n = 200). Using a logistic regression model, two groups of patients with mild TBI on oral anticoagulant therapy were compared — those with and those without intracranial haemorrhage. Results There was no significant difference in age between the patient groups with ( n = 86) and without ( n = 114) intracranial haemorrhage ( p = 0.078). In univariate logistic regression, GCS (OR = 0.419 (0.258; 0.680)) and thromboembolic event as reason for anticoagulant therapy (OR = 0.486 (0.257; 0.918)) were significantly associated with intracranial haemorrhage in patients with mild TBI and anticoagulation (all p < 0.05). However, there was no association with age ( p = 0.078, OR = 1.024 (0.997; 1.051)), the type of accident or additional medication with acetylsalicylic acid or clopidogrel ((both p > 0.05; 0.552 (0.139; 2.202) and 0.256 (0.029; 2.237), respectively). Conclusion Our study found no association between age and intracranial bleeding. Therefore, until further risk factors are identified, diagnostic imaging with CCT remains necessary for mild TBI patients on oral anticoagulation of all ages, especially those with therapeutic anticoagulation because of thromboembolic events.

Background: Sedation is a procedure required for many interventions in the Emergency department (ED) such as reductions, surgical procedures or cardioversions. However, especially under emergency conditions with high risk patients and rapidly changing interdisciplinary and interprofessional teams, the procedure caries important risks. It is thus vital but difficult to implement a standard operating procedure for sedation procedures in any ED. Reports on both, implementation strategies as well as their success are currently lacking. This study describes the development, implementation and clinical evaluation of an interprofessional and interdisciplinary simulation-based sedation training concept.Methods: All physicians and nurses with specialised training in emergency medicine at the Berne University Department of Emergency Medicine participated in a mandatory interdisciplinary and interprofessional simulation-based sedation training. The curriculum consisted of an individual self-learning module, an airway skill training course, three simulation-based team training cases, and a final practical learning course in the operating theatre. Before and after each training session, self-efficacy, awareness of emergency procedures, knowledge of sedation medication and crisis resource management were assessed with a questionnaire. Changes in these measures were compared via paired tests, separately for groups formed based on experience and profession. To assess the clinical effect of training, we collected patient and team satisfaction as well as duration and complications for all sedations in the ED within the year after implementation. We further compared time to beginning of procedure, time for duration of procedure and time until discharge after implementation with the one year period before the implementation. Cohen's d was calculated as effect size for all statistically significant tests.Results: Fifty staff members (26 nurses and 24 physicians) participated in the training. In all subgroups, there is a significant increase in self-efficacy and knowledge with high effect size (d(z) = 1.8). The learning is independent of profession and experience level. In the clinical evaluation after implementation, we found no major complications among the sedations performed. Time to procedure significantly improved after the introduction of the training (d = 0.88).Discussion: Learning is independent of previous working experience and equally effective in raising the self-efficacy and knowledge in all professional groups. Clinical outcome evaluation confirms the concepts safety and feasibility. Conclusion: An interprofessional and interdisciplinary simulation-based sedation training is an efficient way to implement a conscious sedation concept in an ED.

Background Phosphate imbalances or disorders have a high risk of morbidity and mortality in patients with chronic kidney disease. It is unknown if this finding extends to mortality in patients presenting at an emergency room with or without normal kidney function. Methods and Patients This cross sectional analysis included all emergency room patients between 2010 and 2011 at the Inselspital Bern, Switzerland. A multivariable cox regression model was applied to assess the association between phosphate levels and in-hospital mortality up to 28 days. Results 22,239 subjects were screened for the study. Plasma phosphate concentrations were measured in 2,390 patients on hospital admission and were included in the analysis. 3.5% of the 480 patients with hypophosphatemia and 10.7% of the 215 patients with hyperphosphatemia died. In univariate analysis, phosphate levels were associated with mortality, age, diuretic therapy and kidney function (all p<0.001). In a multivariate Cox regression model, hyperphosphatemia (OR 3.29, p<0.001) was a strong independent risk factor for mortality. Hypophosphatemia was not associated with mortality (p>0.05). Conclusion Hyperphosphatemia is associated with 28-day in-hospital mortality in an unselected cohort of patients presenting in an emergency room.

BackgroundThere has been little research on bathroom accidents. It is unknown whether the shower or bathtub are connected with special dangers in different age groups or whether there are specific risk factors for adverse outcomes.MethodsThis cross-sectional analysis included all direct admissions to the Emergency Department at the Inselspital Bern, Switzerland from 1 January 2000 to 28 February 2014 after accidents associated with the bathtub or shower. Time, age, location, mechanism and diagnosis were assessed and special risk factors were examined. Patient groups with and without intracranial bleeding were compared with the Mann-Whitney U test. The association of risk factors with intracranial bleeding was investigated using univariate analysis with Fisher's exact test or logistic regression. The effects of different variables on cerebral bleeding were analysed by multivariate logistic regression.ResultsTwo hundred and eighty (280) patients with accidents associated with the bathtub or shower were included in our study. Two hundred and thirty-five (235) patients suffered direct trauma by hitting an object (83.9%) and traumatic brain injury (TBI) was detected in 28 patients (10%). Eight (8) of the 27 patients with mild traumatic brain injuries (GCS 1315), (29.6%) exhibited intracranial haemorrhage. All patients with intracranial haemorrhage were older than 48 years and needed in-hospital treatment. Patients with intracranial haemorrhage were significantly older and had higher haemoglobin levels than the control group with TBI but without intracranial bleeding (p<0.05 for both). In univariate analysis, we found that intracranial haemorrhage in patients with TBI was associated with direct trauma in general and with age (both p<0.05), but not with the mechanism of the fall, its location (shower or bathtub) or the gender of the patient. Multivariate logistic regression analysis identified only age as a risk factor for cerebral bleeding (p<0.05; OR 1.09 (CI 1.01; 1.171))ConclusionIn patients with ED admissions associated with the bathtub or shower direct trauma and age are risk factors for intracranial haemorrhage. Additional effort in prevention should be considered, especially in the elderly.

BackgroundCalcium disorders are common in both intensive care units and in patients with chronic kidney disease and are associated with increased morbidity and mortality. It is unknown whether calcium abnormalities in unselected emergency department admissions have an impact on in-hospital mortality.MethodsThis cross-sectional analysis included all admissions to the Emergency Department at the Inselspital Bern, Switzerland from 2010 to 2011. For hyper- and hypocalcaemic patients with a Mann-Whitney U-test, the differences between subgroups divided by age, length of hospital stay, creatinine, sodium, chloride, phosphate, potassium and magnesium were compared. Associations between calcium disorders and 28-day in-hospital mortality were assessed using the Cox proportional hazard regression model.Results8,270 patients with calcium measurements were included in our study. Overall 264 (3.2%) patients died. 150 patients (6.13%) with hypocalcaemia and 7 patients with hypercalcaemia (6.19%) died, in contrast to 104 normocalcaemic patients (1.82%). In univariate analysis, calcium serum levels were associated with sex, mortality and pre-existing diuretic therapy (all p<0.05). In multivariate Cox regression analysis, hypocalcaemia and hypercalcaemia were independent risk factors for mortality (HR 2.00 and HR 1.88, respectively; both p<0.01).ConclusionBoth hypocalcaemia and hypercalcaemia are associated with increased 28-day in-hospital mortality in unselected emergency department admissions.

Intraoperative fluid management may influence postoperative outcome. (1) Vascular surgery patients have a raised risk for death and postoperative acute kidney injury (AKI). (2,3) Recent data demonstrated that the use of colloids is associated with higher mortality and higher rates of AKI. (4) In patients undergoing abdominal aortic aneurysm repair we investigated if colloids are an independent risk indicator for postoperative AKI using the RIFLE classification and their association with mortality. In a retrospective single centre analysis, 766 patients undergoing elective open abdominal aneurysm repair (AAA-OR) or endovascular aortic repair (EVAR) were selected. To determine the risk of AKI and the influence on thirty-day mortality and long-term mortality a 2 step procedure was applied for both outcomes. First we used the LASSO method to select risk indicators (RI) that are associated with the occurrence of AKI determined by RIFLE stages - on the basis of serum creatinine values. Then we calculated logistic regression models for thirty-day mortality and Cox proportional hazard models for long-term mortality with the selected subset of RI In total, 98 (13%) patients displayed symptoms of AKI. Overall, 25 (3%) patients died within thirty days. Risk indicators (RI) for a RIFLE stage were diabetes mellitus (OR 2.43), duration of anaesthesia (OR 1.14) and units of erythrocytes (OR 1.15) while higher weight and EVAR appeared to be protective (OR 0.98 and 0.33). Only univariate analysis showed associations of colloid use at any RIFLE stage (OR1.69). RI for thirty-day mortality were any RIFLE stage (OR 5.65). RI for long-term mortality were units of erythrocytes (OR 1.11) and EVAR (OR 2.11) while higher weight appeared to be protective (OR 0.98). RIFLE stages are the only RI in patients undergoing abdominal aortic repair for thirty-day mortality. The use of colloids in these patients was not associated with a higher risk for either AKI or mortality

For some people, winter snow shovelling is an unloved but necessary duty, especially in a country with high mountainous areas such as Switzerland. Not only environmental forces but also problems from physical exertion cause many admissions to emergency departments. In 2011, Watson et al described a representative sample of snow-shovelling emergencies in the USA [1]. They found an average annual rate of snow shovel-related emergencies of 4.15 per 100,000 in the American population. The cardiac effect of snow shovelling has also been described in other studies [2]. There are many case descriptions of snow shovelling-related myocardial infarctions [3, 4]. In 2012, Nichols et al demonstrated that a family history of premature cardiovascular disease and male gender were strong independent risk factors for suffering a snow shovelling-related acute cardiac event [5]. We speculated that shovelling appears to be some sort of physical exercise model to test coronary heart disease and, therefore, retrospectively analysed patient events throughout a 13-year period. In our database, patient data were analysed from 2001 to 2013. Medical records were screened for snow-shovelling incidents. Overall, approximately 350,000 cases were screened via a computer database. A total of 21 patients had documented snow shovelling-associated admissions. One patient was excluded, as the reason for admission was not related to snow shovelling. Our patients had a mean age of 62 ± 15 years. Fifteen subjects were male and five female. The leading causes of admission were: in 5 patients acute coronary events, in 11 patients orthopaedic ailments, in 2 patients neurological reasons and in 2 patients abdominal pain. None of the admitted patients died. Seven patients were managed in the outpatient setting; the rest required hospital admission. Three of our patients required surgery. Both neurological events were linked to intracranial haemorrhage and required surgical treatment. In all, 85% of outpatient cases (6/7) were admitted for orthopaedic problems. In contrast, all of the patients suffering cardiac events (23.8%; 5/21) required hospital treatment. It has been reported that low air temperature is associated with vasoconstriction and increased heart rate and blood pressure, as well as increased blood viscosity, fibrinogen and platelet counts [6–8]. Just recently in the USA, three deaths due to cardiac failure during snow shovelling were reported [9]. The combination of physical overstrain and inhalation of cold air may lead to cutaneous vasoconstriction and consequently to higher cardiac afterload; this could contribute to the reported cardiac events. These were the most serious events recorded in the rate of hospital admissions. Our results are consistent with samples in the USA reported by Watson et al. [1]. In contrast to the latter population, there was fortunately no in-hospital death in our database. In both studies, about 80% of cardiac events were associated with male sex [1]. In our study only one of the cardiac events showed an ST-segment elevation myocardial infarction; three were non-ST-segment elevation myocardial infarctions and one event was a cardiac syncope. The average annual rate of snow shovel-related emergencies was 4.15 per 100,000 in the American population in 1990–2006. In contrast, there were only 20 cases in 13 years (2001–2013) in our sample (ca. 0.004%) [1]. Moreover, only two of our documented cases occurred in the first 7 years of surveillance. Unfortunately no database exists for the whole of Switzerland and there is, therefore, no exact annual rate. As a limitation, we cannot exclude the possibility that some cases were missed, as data were analysed retrospectively and were based on the documentation of the respective physicians describing the aforementioned events in association with snow shovelling in the patients’ files. From our data, we firstly conclude that snow shovelling is quite unsuitable as a model for testing coronary heart disease in Switzerland. Secondly, the public service shovelling snow in Switzerland apparently protects people from the risk associated with this form of physical exercise, as compared with the USA. And finally, snow shovelling appears to be a form of exercise predominantly or more dangerously performed by men.

Background/Aims: The use of antihypertensive medicines has been shown to reduce proteinuria, morbidity, and mortality in patients with chronic kidney disease (CKD). A specific recommendation for a class of antihypertensive drugs is not available in this population, despite the pharmacodynamic differences. We have therefore analysed the association between antihypertensive medicines and survival of patients with chronic kidney disease. Methods: Out of 2687 consecutive patients undergoing kidney biopsy a cohort of 606 subjects with retrievable medical therapy was included into the analysis. Kidney function was assessed by glomerular filtration rate (GFR) estimation at the time point of kidney biopsy. Main outcome variable was death. Results: Overall 114 (18.7%) patients died. In univariate regression analysis the use of alpha-blockers and calcium channel antagonists, progression of disease, diabetes mellitus (DM) type 1 and 2, arterial hypertension, coronary heart disease, peripheral vascular disease, male sex and age were associated with mortality (all p<0.05). In a multivariate Cox regression model the use of calcium channel blockers (HR 1.89), age (HR 1.04), DM type 1 (HR 8.43) and DM type 2 (HR 2.17) and chronic obstructive pulmonary disease (HR 1.66) were associated with mortality (all p < 0.05). Conclusion: The use of calcium channel blockers but not of other antihypertensive medicines is associated with mortality in primarily GN patients with CKD.

Glomerular filtration rate (GFR) in patients with chronic kidney disease (CKD) identifies patients at risk for death or end-stage renal disease (ESRD). CKD staging by GFR should incorporate proteinuria to augment risk stratification. We therefore tested the predictive power of the combination of GFR with proteinuria in patients with different histologically-diagnosed types of glomerulonephritis (GN).

Background Physicians refer proteinuric patients to kidney biopsy in order to clarify the issue of underlying renal disease. We compared kidney biopsy results with classical outcome parameters in a large cohort of patients with biopsy proven glomerulonephritis (GN).Methods In a retrospective analysis, 2687 patients with different forms of GN from 123 Austrian centres were investigated. Patient characteristics, the diagnosis of GN and its respective subtype and clinical symptoms such as arterial hypertension, haematuria, amount of proteinuria and estimated glomerular filtration rate (eGFR) were tested for their association with all-cause mortality and progression to end-stage renal disease (ESRD).Results During a median follow-up of 129.9 months (IQR 89.6; 177.7), 688 patients (25.6%) died and 718 patients required dialysis (29.4%). In multivariate Cox's regression analysis age (HR 1.06), female sex (HR 0.71), eGFR (HR 0.74), the diagnosis of GN and its subtypes predicted patient survival (all P<0.01), whereas the amount of proteinuria was not associated with patient survival. The incidence of progression to ESRD was associated with female sex (HR 0.71), eGFR (HR 0.65), amount of proteinuria (HR 1.15) and the diagnosis of GN and its subtypes (all P<0.01). Nephrotic or nephritic syndromes were not associated with patient survival or progression to ESRD and did not add further predictive value to outcome of GN.Conclusions Our study demonstrates histological diagnosis of GN and its specific subtype predicts patient survival and dialysis incidence. Therefore, kidney biopsy should be an integral part of routine diagnostic assessment in patients with any forms of suspected GN.

Information on predisposing risk factors influencing long-term survival after extracorporeal membrane oxygenation (ECMO) support remains scarce. In critically ill patients chronic obstructive pulmonary disease (COPD) is an independent risk factor for mortality and morbidity. We assessed the influence of COPD on cardiovascular and all-cause mortality in patients undergoing ECMO therapy.We prospectively included 191 patients undergoing veno-arterial ECMO therapy following cardiovascular surgery at a university-affiliated tertiary care center into our registry.The median follow-up time was 51 months (IQR 34-71 months) corresponding to 4,197 overall months of follow-up. A total of 125 patients (65 %) died; 88 % of deaths were due to cardiovascular causes. Long-term survival was decreased in patients with COPD after 1 year (23 % vs. 44 %) and after 6 years (14 % vs. 35 %) compared to patients without COPD. COPD was independently associated with all-cause mortality with a hazard ratio of 4.22 (95 % CI 1.04-17.11, p = 0.04) and cardiovascular mortality with a hazard ratio of 5.87 (95 % CI 1.41-24.47, p = 0.02).We identified COPD as a strong and independent predictor of long-term all-cause mortality and cardiovascular mortality in patients undergoing ECMO therapy following cardiovascular surgery. The current study presents valuable information for a comprehensive decision-making process prior to ECMO implantation and helps to identify high-risk patients that may benefit from intensified treatment of co-morbidities and close check-ups after hospital discharge.