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Background and objectives: Hemodialysis patients (HD) display high rates of cardiac diseases and mortality. In chronic kidney disease, vascular injury leads to coronary artery disease, heart failure, and stroke. Carotid intima-media thickness (CIMT) measurements are currently widely used in randomized controlled trials (RCTs) to study the efficacy of interventions. An RCT was designed for the assessment of the safety and effectiveness of spironolactone to inhibit the progression of CIMT in HD patients as a primary outcome. Secondary outcomes included measurements of plasma potassium.Design, setting, participants, & measurements: HD patients were randomly assigned to receive 50 mg spironolactone or placebo thrice weekly after dialysis. In between dialysis sessions, plasma potassium concentrations were measured every month. Ultrasonographic measurements of CIMT were done at the beginning of the study and after 2 years.Results: Fifty-three age-and sex-adjusted patients (30 with drug and 23 with placebo) successfully completed the trial. There were no significant differences between the two groups in all profiles studied at baseline. Measurements of CIMT after 2 years showed a progression in the placebo group, whereas in the spironolactone group a significant decrease or even reversed CIMT was observed. Progression rates (mm/yr) were: common carotid, placebo: 0.06 ؎ 0.07, spironolactone: 0.01 ؎ 0.04; carotid bifurcation, placebo: 0.15 ؎ 0.27, spironolactone: 0.0001 ؎ 0.01; internal carotid, placebo: 0.10 ؎ 0.12, spironolactone: ؊0.10 ؎ 0.15. No episodes of hyperkalemia were observed, but a slight increase in plasma potassium was found in the spironolactone group.Conclusions: Fifty milligrams of spironolactone thrice weekly significantly reduced the progression of CIMT in HD patients.

At a Glance Commentary Scientific Knowledge on the SubjectExtracorporeal membrane oxygenation (ECMO) has been incorporated in the World Health Organization recommendations for the management of COVID-19-associated severe acute respiratory distress syndrome (ARDS). However, the incidence of ECMO use, its time course and outcomes are unknown at a nationwide level under the COVID-19 pandemic scenario. What This Study Adds to the FieldIn this nationwide study, all patients who received ECMO for severe ARDS during the first wave of COVID-19 pandemic in Chile were identified. The incidence and time course of ECMO use was similar to that observed in the 2009 influenza A(H1N1) pandemic in Australia/New Zealand.The mortality rate was comparable to that reported for other indications of extracorporeal respiratory support. The operation of a National Advisory Commission for Adult ECMO was key to assist patient eligibility, transportation and allocation in tertiary centers in a resource-limited and logistically complex pandemic scenario. These findings might be useful for future COVID-19 pandemic waves worldwide. Total word count: 3475Funding: This investigation had no funding or grant.

Patients with severe coronavirus disease (COVID-19) may have COVID-19–associated invasive mold infection (CAIMI) develop. We report 16 cases of CAIMI among 146 nonimmunocompromised patients with severe COVID-19 at an academic hospital in Santiago, Chile. These rates correspond to a CAIMI incidence of 11%; the mortality rate for these patients was 31.2%.

Background Persistent hyperlactatemia is particularly difficult to interpret in septic shock. Besides hypoperfusion, adrenergic-driven lactate production and impaired lactate clearance are important contributors. However, clinical recognition of different sources of hyperlactatemia is unfortunately not a common practice and patients are treated with the same strategy despite the risk of over-resuscitation in some. Indeed, pursuing additional resuscitation in non-hypoperfusion-related cases might lead to the toxicity of fluid overload and vasoactive drugs. We hypothesized that two different clinical patterns can be recognized in septic shock patients through a multimodal perfusion monitoring. Hyperlactatemic patients with a hypoperfusion context probably represent a more severe acute circulatory dysfunction, and the absence of a hypoperfusion context is eventually associated with a good outcome. We performed a retrospective analysis of a database of septic shock patients with persistent hyperlactatemia after initial resuscitation.ResultsWe defined hypoperfusion context by the presence of a ScvO2 < 70%, or a P(cv-a)CO2 ≥6 mmHg, or a CRT ≥4 s together with hyperlactatemia. Ninety patients were included, of whom seventy exhibited a hypoperfusion-related pattern and 20 did not. Although lactate values were comparable at baseline (4.8 ± 2.8 vs. 4.7 ± 3.7 mmol/L), patients with a hypoperfusion context exhibited a more severe circulatory dysfunction with higher vasopressor requirements, and a trend to longer mechanical ventilation days, ICU stay, and more rescue therapies. Only one of the 20 hyperlactatemic patients without a hypoperfusion context died (5%) compared to 11 of the 70 with hypoperfusion-related hyperlactatemia (16%).ConclusionsTwo different clinical patterns among hyperlactatemic septic shock patients may be identified according to hypoperfusion context. Patients with hyperlactatemia plus low ScvO2, or high P(cv-a)CO2, or high CRT values exhibited a more severe circulatory dysfunction. This provides a starting point to launch further prospective studies to confirm if this approach can lead to a more selective resuscitation strategy. Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-017-0253-x) contains supplementary material, which is available to authorized users.