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Zhao W, Wang YP, Tang X, Jiang Y, Xue Y, Wang Y, Ding Q, Chen H, Wang D, Cheng Y, Ge M, Zhou Q. Development and validation of LCMM prediction algorithms to estimate recovery pattern of postoperative AKI in type A aortic dissection: a retrospective study. Front Cardiovasc Med 2024; 11:1364332. [PMID: 38707890 PMCID: PMC11066321 DOI: 10.3389/fcvm.2024.1364332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 04/03/2024] [Indexed: 05/07/2024] Open
Abstract
Background Postoperative acute kidney injury (PO-AKI) is a prevalent complication among patients with acute type A aortic dissection (aTAAD) for which unrecognized trajectories of renal function recovery, and their heterogeneity, may underpin poor success in identifying effective therapies. Methods This was a retrospective, single-center cohort study in a regional Great Vessel Center including patients undergoing aortic dissection surgery. Estimated glomerular filtration rate (eGFR) recovery trajectories of PO-AKI were defined through the unsupervised latent class mixture modeling (LCMM), with an assessment of patient and procedural characteristics, complications, and early-term survival. Internal validation was performed by resampling. Results A total of 1,295 aTAAD patients underwent surgery and 645 (49.8%) developed PO-AKI. Among the PO-AKI cohort, the LCMM identified two distinct eGFR trajectories: early recovery (ER-AKI, 51.8% of patients) and late or no recovery (LNR-AKI, 48.2% of patients). Binary logistic regression identified five critical determinants regarding poor renal recovery, including chronic kidney disease (CKD) history, renal hypoperfusion, circulation arrest time, intraoperative urine, and myoglobin. LNR-AKI was associated with increased mortality, continuous renal replacement therapies, mechanical ventilation, ICU stay, and hospital stay. The assessment of the predictive model was good, with an area under the curve (AUC) of 0.73 (95% CI: 0.69-0.76), sensitivity of 61.74%, and specificity of 75.15%. The internal validation derived a consistent average AUC of 0.73. The nomogram was constructed for clinicians' convenience. Conclusion Our study explored the PO-AKI recovery patterns among surgical aTAAD patients and identified critical determinants that help to predict individuals at risk of poor recovery of renal function.
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Affiliation(s)
- Weiwei Zhao
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Ya-peng Wang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, Jiangsu, China
| | - Xinlong Tang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Yi Jiang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, Jiangsu, China
| | - Yunxing Xue
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Yali Wang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Qiuju Ding
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Huimei Chen
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore, Singapore
| | - Dongjin Wang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - YongQing Cheng
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Min Ge
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Qing Zhou
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
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Kang Y, Soehartono NA, Choi JW, Kim KH, Hwang HY, Kim JB, Kim HR, Lee SH, Cho YH. Recent Outcomes of Surgical Redo Aortic Valve Replacement in Prosthetic Valve Failure. Thorac Cardiovasc Surg 2024. [PMID: 38442916 DOI: 10.1055/a-2281-1897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
BACKGROUND As redo surgical aortic valve replacement (AVR) is relatively high risk, valve-in-valve transcatheter AVR has emerged as an alternative for failed prostheses. However, the majority of studies are outdated. This study assessed the current clinical outcomes of redo AVR. METHODS AND RESULTS This study enrolled 324 patients who underwent redo AVR due to prosthetic valve failure from 2010 to 2021 in four tertiary centers. The primary outcome was operative mortality. The secondary outcomes were overall survival, cardiac death, and aortic valve-related events. Logistic regression analysis, clustered Cox proportional hazards models, and competing risk analysis were used to evaluate the independent risk factors. Redo AVR was performed in 242 patients without endocarditis and 82 patients with endocarditis. Overall operative mortality was 4.6% (15 deaths). Excluding patients with endocarditis, the operative mortality of redo AVR decreased to 2.5%. Multivariate analyses demonstrated that endocarditis (hazard ratio [HR]: 3.990, p = 0.014), longer cardiopulmonary bypass time (HR: 1.006, p = 0.037), and lower left ventricular ejection fraction (LVEF) (HR: 0.956, p = 0.034) were risk factors of operative mortality. Endocarditis and lower LVEF were independent predictors of overall survival. CONCLUSION The relatively high risk of redo AVR was due to reoperation for prosthetic valve endocarditis. The outcomes of redo AVR for nonendocarditis are excellent. Our findings suggest that patients without endocarditis, especially with acceptable LVEF, can be treated safely with redo AVR.
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Affiliation(s)
- Yoonjin Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Nazla Amanda Soehartono
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Jongno-gu, Seoul, Republic of Korea
| | - Jae Woong Choi
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung Hwan Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho Young Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hong Rae Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung Hyun Lee
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Heart Stroke Vascular Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Muenster S, Zarragoikoetxea I, Moscatelli A, Balcells J, Gaudard P, Pouard P, Marczin N, Janssens SP. Inhaled NO at a crossroads in cardiac surgery: current need to improve mechanistic understanding, clinical trial design and scientific evidence. Front Cardiovasc Med 2024; 11:1374635. [PMID: 38646153 PMCID: PMC11027901 DOI: 10.3389/fcvm.2024.1374635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/27/2024] [Indexed: 04/23/2024] Open
Abstract
Inhaled nitric oxide (NO) has been used in pediatric and adult perioperative cardiac intensive care for over three decades. NO is a cellular signaling molecule that induces smooth muscle relaxation in the mammalian vasculature. Inhaled NO has the unique ability to exert its vasodilatory effects in the pulmonary vasculature without any hypotensive side-effects in the systemic circulation. In patients undergoing cardiac surgery, NO has been reported in numerous studies to exert beneficial effects on acutely lowering pulmonary artery pressure and reversing right ventricular dysfunction and/or failure. Yet, various investigations failed to demonstrate significant differences in long-term clinical outcomes. The authors, serving as an advisory board of international experts in the field of inhaled NO within pediatric and adult cardiac surgery, will discuss how the existing scientific evidence can be further improved. We will summarize the basic mechanisms underlying the clinical applications of inhaled NO and how this translates into the mandate for inhaled NO in cardiac surgery. We will move on to the popular use of inhaled NO and will talk about the evidence base of the use of this selective pulmonary vasodilator. This review will elucidate what kind of clinical and biological barriers and gaps in knowledge need to be solved and how this has impacted in the development of clinical trials. The authors will elaborate on how the optimization of inhaled NO therapy, the development of biomarkers to identify the target population and the definition of response can improve the design of future large clinical trials. We will explain why it is mandatory to gain an international consensus for the state of the art of NO therapy far beyond this expert advisory board by including the different major players in the field, such as the different medical societies and the pharma industry to improve our understanding of the real-life effects of inhaled NO in large scale observational studies. The design for future innovative randomized controlled trials on inhaled NO therapy in cardiac surgery, adequately powered and based on enhanced biological phenotyping, will be crucial to eventually provide scientific evidence of its clinical efficacy beyond its beneficial hemodynamic properties.
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Affiliation(s)
- Stefan Muenster
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Iratxe Zarragoikoetxea
- Department of Anesthesiology and Intensive Care Medicine, Hospital Universitari I Politècnic Fe, Valencia, Spain
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Joan Balcells
- Pediatric Intensive Care Unit, Vall d’Hebron Barcelona Campus Hospitalari, Universitari Vall d'Hebron, Barcelona, Spain
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine Arnaud de Villeneuve, CHU Montpellier, University of Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France
| | - Philippe Pouard
- Department of Anesthesiology and Critical Care, Assistance Publique-Hopitaux de Paris, Hopital Necker-Enfants Malades, Paris, France
| | - Nandor Marczin
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Stefan P. Janssens
- Cardiac Intensive Care, Department of Cardiovascular Diseases, University Hospital Leuven, Leuven, Belgium
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Milne B, Gilbey T, De Somer F, Kunst G. Adverse renal effects associated with cardiopulmonary bypass. Perfusion 2024; 39:452-468. [PMID: 36794518 PMCID: PMC10943608 DOI: 10.1177/02676591231157055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Cardiac surgery on cardiopulmonary bypass (CPB) is associated with postoperative renal dysfunction, one of the most common complications of this surgical cohort. Acute kidney injury (AKI) is associated with increased short-term morbidity and mortality and has been the focus of much research. There is increasing recognition of the role of AKI as the key pathophysiological state leading to the disease entities acute and chronic kidney disease (AKD and CKD). In this narrative review, we will consider the epidemiology of renal dysfunction after cardiac surgery on CPB and the clinical manifestations across the spectrum of disease. We will discuss the transition between different states of injury and dysfunction, and, importantly, the relevance to clinicians. The specific facets of kidney injury on extracorporeal circulation will be described and the current evidence evaluated for the use of perfusion-based techniques to reduce the incidence and mitigate the complications of renal dysfunction after cardiac surgery.
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Affiliation(s)
- Benjamin Milne
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Tom Gilbey
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
- Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, UK
| | - Filip De Somer
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium
| | - Gudrun Kunst
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular and Metabolic Medicine and Sciences, King’s College London British Heart Foundation Centre of Excellence, London, UK
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5
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Garg S, Govindaraj V, Dwivedi DP, Raja K, Theerthar EP. Postoperative pulmonary complications in patients undergoing upper abdominal surgery: risk factors and predictive models. Monaldi Arch Chest Dis 2024. [PMID: 38526466 DOI: 10.4081/monaldi.2024.2915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/13/2024] [Indexed: 03/26/2024] Open
Abstract
Postoperative pulmonary complications (PPCs) are unexpected disorders that occur up to 30 days after surgery, affecting the patient's clinical status and requiring therapeutic intervention. Therefore, it becomes important to assess the patient preoperatively, as many of these complications can be minimized with proper perioperative strategies following a thorough preoperative checkup. Herein, we describe the PPCs and risk factors associated with developing PPCs in patients undergoing upper abdominal surgery. Additionally, we compared the accuracy of the American Society of Anaesthesiologists (ASA) score, the Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score, the 6-Minute Walk Test (6MWT), and spirometry in predicting PPCs. Consenting patients (>18 years) undergoing elective upper abdominal surgery were recruited from November 2021 to April 2023. Clinical history was noted. Spirometry and 6MWT were both performed. Pre-operative ASA and ARISCAT scores were recorded. Postoperative follow-up was conducted to assess respiratory symptoms and the occurrence of PPC. PPC was defined as per EPCO guidelines. A total of 133 patients were recruited, predominantly male. A total of 27 (20.3%) patients developed PPCs. A total of 14 (10.5%) patients had more than one PPC. The most common PPCs developed were pleural effusion (11.3%), respiratory failure (7.5%), and pneumonia (4.5%). We obtained ten statistically significant associated variables on univariable analysis, viz obstructive airway disease (p=0.002), airflow limitation (p=0.043), chest radiography (p<0.001), albumin (p=0.30), blood urea nitrogen (BUN) (p=0.029), aspartate aminotransferase (p=0.019), alanine aminotransferase (p=0.009), forced expiratory volume in one second/forced vital capacity ratio (p=0.006), duration of surgery (p<0.001), and ASA score (p=0.012). On multivariable regression analysis, abnormal chest radiograph [odds ratio: 8.26; (95% confidence interval: 2.58-25.43), p<0.001], BUN [1.05; (1.00-1.09), p=0.033], and duration of surgery [1.44; (1.18-1.76), p<0.001] were found to be independently associated with PPC. The ASA score was found to have better predictive power for the development of PPCs compared to the ARISCAT score but is of poor clinical significance. Additionally, 6MWD and spirometry results were found to lack any meaningful predictive power for PPC. To conclude, preoperative evaluation of the chest radiograph, BUN, and duration of surgery are independently associated with developing PPCs. The ASA score performs better than the ARISCAT score in identifying patients at a higher risk of developing PPCs and implementing preventive measures.
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Affiliation(s)
- Shivam Garg
- Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry.
| | - Vishnukanth Govindaraj
- Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry.
| | - Dharm Prakash Dwivedi
- Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry.
| | - Kalayarasan Raja
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry.
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Kellum JA, Goldstein SL. Do Novel Biomarkers Have Utility in the Diagnosis and Prognosis of AKI? PRO. KIDNEY360 2023; 4:1663-1666. [PMID: 37287099 PMCID: PMC10758504 DOI: 10.34067/kid.0000000000000189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 06/09/2023]
Affiliation(s)
- John A. Kellum
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Stuart L. Goldstein
- Cincinnati Children's Hospital Medical Center, Cinncinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Bertini P, Guarracino F. Pro: Pulsatile Flow During Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2023; 37:2370-2373. [PMID: 37258366 DOI: 10.1053/j.jvca.2023.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/11/2023] [Accepted: 04/25/2023] [Indexed: 06/02/2023]
Affiliation(s)
- Pietro Bertini
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
| | - Fabio Guarracino
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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Rasmussen SB, Boyko Y, Ranucci M, de Somer F, Ravn HB. Cardiac surgery-Associated acute kidney injury - A narrative review. Perfusion 2023:2676591231211503. [PMID: 37905794 DOI: 10.1177/02676591231211503] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Cardiac Surgery-Associated Acute Kidney Injury (CSA-AKI) is a serious complication seen in approximately 20-30% of cardiac surgery patients. The underlying pathophysiology is complex, often involving both patient- and procedure related risk factors. In contrast to AKI occurring after other types of major surgery, the use of cardiopulmonary bypass comprises both additional advantages and challenges, including non-pulsatile flow, targeted blood flow and pressure as well as the ability to manipulate central venous pressure (congestion). With an increasing focus on the impact of CSA-AKI on both short and long-term mortality, early identification and management of high-risk patients for CSA-AKI has evolved. The present narrative review gives an up-to-date summary on definition, diagnosis, underlying pathophysiology, monitoring and implications of CSA-AKI, including potential preventive interventions. The review will provide the reader with an in-depth understanding of how to identify, support and provide a more personalized and tailored perioperative management to avoid development of CSA-AKI.
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Affiliation(s)
- Sebastian Buhl Rasmussen
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Yuliya Boyko
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesiology and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | | | - Hanne Berg Ravn
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Drăgan A, Sinescu I. AKI3-Risk Predictors and Scores in Radical Nephrectomy with High Thrombectomy under Extracorporeal Circulation for Renal Cell Carcinoma with Supradiaphragmatic Inferior Vena Cava/Right Atrial Thrombus: A Single-Centre Retrospective Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020386. [PMID: 36837587 PMCID: PMC9962973 DOI: 10.3390/medicina59020386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/10/2023] [Accepted: 02/15/2023] [Indexed: 02/19/2023]
Abstract
Background and Objectives: The recommended therapeutic management in renal cell carcinoma (RCC) with supradiaphragmatic inferior vena cava/right atrial thrombus (IVC/RA) is surgery. Extracorporeal circulation is required. Acute kidney injury (AKI), a frequent complication after nephrectomy and cardiac surgery is associated with long-term kidney disease. This study aims to identify the risk factors involved in the occurrence of the severe postoperative AKI (AKI3) and to analyse various preoperative validated risk scores from cardiac and noncardiac surgery in predicting this endpoint. Materials and Methods: The medical data of all patients with RCC with supradiaphragmatic IVC/RA thrombus who underwent radical nephrectomy with high thrombectomy, using extracorporeal circulation, between 2004-2018 in the Prof. C. C. Iliescu Emergency Institute for Cardiovascular Diseases, Bucharest, were retrospectively analysed. The patients who died intraoperatively were excluded from the study. The predefined study endpoint was the postoperative AKI3. Preoperative, intraoperative and postoperative data were collected according to the stratification of study population in two subgroups: AKI3-present and AKI3- absent patients. EuroSCORE, EuroSCORE II, Logistic EuroSCORE, NSQIP any-complications and NSQIP serious-complications were analysed. Results: We reviewed 30 patients who underwent this complex surgery between 2004-2018 in our institute. Two patients died intraoperatively. Nine patients (32.14%) presented postoperative AKI3. Age (OR 1.151, CI 95%: 1.009-1.312), preoperative creatinine clearance (OR 1.066, CI 95%: 1.010-1.123) and intraoperative arterial hypotension (OR 13.125, CI 95%: 1.924-89.515) were risk factors for AKI3 (univariable analysis). Intraoperative arterial hypotension emerged as the only independent risk factor in multivariable analysis (OR 11.66, CI 95%: 1.400-97.190). Logistic EuroSCORE (ROC analysis: AUC = 0.813, p = 0.008, CI 95%: 0.633-0.993) best predicted the endpoint. Conclusions: An integrated team effort is essential to avoid intraoperative arterial hypotension, the only independent risk factor of AKI3 in this highly complex surgery. Some risk scores can predict this complication. Further studies are needed.
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Affiliation(s)
- Anca Drăgan
- Department of Cardiovascular Anaesthesiology and Intensive Care, Prof. C. C. Iliescu Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania
- Correspondence:
| | - Ioanel Sinescu
- Department of Urological Surgery, Dialysis and Kidney Transplantation, Fundeni Clinical Institute, 258 Fundeni Road, 022328 Bucharest, Romania
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
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