Background the introduction of transcatheter aortic valve replacement (TAVR) expanded definitive therapy of aortic stenosis to many high-risk patients, but it has not been fully evaluated in the dialysis population. Objectives We aimed to evaluate the current trend and in-hospital outcome of Surgical aortic valve replacement (SAVR) and TAVR in the dialysis population. Methods Severe aortic stenosis patients on maintenance dialysis who underwent SAVR or TAVR in the Nationwide Inpatient Sample database (NIS) from January 1, 2005, through December 31, 2014, were included in our comparative analysis. The trends of SAVR and TAVR were assessed. Inhospital mortality, rates of major adverse events, hospital length of stay, cost of care and intermediate care facility utilization were compared between the two groups using both unadjusted and propensity-matched data. Results Utilization of aortic valve replacement in dialysis patients increased 3-fold with a total of 2,531 dialysis patients who underwent either SAVR (n=2,264) or TAVR (n=267) between 2005–2014 were identified. Propensity score matching yielded 197 matched pairs. After matching, a twofold increase in in-hospital mortality was found with SAVR compared to TAVR 13.7% vs. 6.1% (p=0.021). Patients who underwent TAVR had more permanent pacemaker implantation (13.2% vs. 5.6%, p=0.012), but less blood transfusion (43.7% vs. 56.8% p=0.02). Rates of other key morbidities were similar. Hospital length of stay (19±16 vs. 11±11 days, P<0.001) and non-home discharges (44.7% vs. 31.5%, p=0.002) were significantly higher with SAVR. Cost of hospitalization was 25% less with TAVR. Conclusion TAVR is associated with lower hospital mortality, resource utilization, and cost in comparison with SAVR.

BackgroundThere is a paucity of contemporary data on the characteristics and outcomes of acute ischemic stroke (AIS) in patients on maintenance dialysis.Methods and ResultsWe used the nationwide inpatient sample to examine contemporary trends in the incidence, management patterns, and outcomes of AIS in dialysis patients. A total of 930 010 patients were admitted with AIS between 2003 and 2014, of whom 13 642 (1.5%) were on dialysis. Overall, the incidence of AIS among dialysis patients decreased significantly (P trend<0.001), while it remained stable in non‐dialysis patients (P trend=0.78). Compared with non‐dialysis patients, those on dialysis were younger (67±13 years versus 71±15 years, P<0.001), and had higher prevalence of major comorbidities. Black patients constituted 35.2% of dialysis patients admitted with AIS compared with 16.7% of patients in the non‐dialysis group (P<0.001). After propensity score matching, in‐hospital mortality was higher in the dialysis group (7.6% versus 5.2%, P<0.001), but this mortality gap narrowed overtime (P trend<0.001). Hemorrhagic conversion and gastrointestinal bleeding rates were similar, but blood transfusion was more common in the dialysis group. Rates of severe disability surrogates (tracheostomy, gastrostomy, mechanical ventilation and non‐home discharge) were also similar in both groups. However, dialysis patients had longer hospitalizations, and accrued a 25% higher total cost of acute care.ConclusionsDialysis patients have 8‐folds higher incidence of AIS compared withnon‐dialysis patients. They also have higher risk‐adjusted in‐hospital mortality, sepsis and blood transfusion, longer hospitalizations, and higher cost. There is a need to identify preventative strategies to reduce the risk of AIS in the dialysis population.

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Ogilvie's syndrome, or acute colonic pseudo-obstruction, is characterized by massive dilation of the colon without mechanical obstruction. Water and electrolytes often can be sequestered in the dilated intestinal loops resulting in profuse and watery diarrhea as well as hypokalemia. We report an anuric, end-stage renal disease (ESRD) patient undergoing peritoneal dialysis (PD) who developed acute colonic pseudo-obstruction causing a prolonged hospitalization. He also developed severe hypokalemia with a serum potassium (K+) as low as 2.4 mEq/L and required 180 - 240 mEq of potassium chloride per day for more than a month to correct it. While PD K+ losses often contribute to hypokalemia, the PD K+ loss was estimated to be only 39 mEq/day. Therefore, PD could only contribute modestly to the recalcitrant hypokalemia observed during the episode of pseudo-obstruction. It has been shown, however, that patients with colonic pseudo-obstruction have enhanced colonic K+ secretion. In addition, experimental studies in patients with chronic kidney disease (CKD) have demonstrated that colonic K+ excretion can be up to 3 times greater than in individuals with normal renal function. This increase may involve an upregulation of the large conductance K+ channel (maxi-K), also known as the BK channel, in the apical border of the colonocytes. We suggest that ESRD may have placed our patient at a greater risk of developing hypokalemia as his colon may have already adapted to secrete more K+. Clinicians should be aware of this extrarenal K+ wasting etiology in patients with colonic pseudo-obstruction, particularly in those with CKD where such a severe K+ deficit is not anticipated and, therefore, may inhibit more rigorous K+ replacement.

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