Mild gentamicin nephrotoxicity reduces the progression of chronic adriamycin nephrosis

The effect of mild acute tubular injury on the progression of tubulointerstitial fibrosis was studied in pair-fed uninephrectomized male Wistar rats with established adriamycin nephrosis ( n =34). Rats were stratified into three groups according to endogenous creatinine clearance (CrCl), proteinuria (Upr) and body weight (BW): (i) group 1 (Fe, n =12) received a single intraperitoneal injection of ferric nitrilotriacetate (5 mg Fe/kg BW); (ii) group 2 (G, n =10) three daily subcutaneous injections of gentamicin (60 mg/kg BW) and; (iii) group 3 (C, n =12) saline injections. Serial CrCl (day 2, day 5, weeks 2, 4, 6 and 8) and renal histology (week 8) were examined following administration of nephrotoxin. CrCl was reduced on d2 (Fe: 0.78±0.23 mL/min; mean±SD) and day 5 (G: 0.91±0.36 mL/min) as compared with C (1.22±0.12 mL/min; P <0.05). There was no change in the serum creatinine and functional recovery occurred by d5 (Fe) and week 2 (G). Upr decreased transiently in G at week 2 (G: 482±208 mg/day vs C: 716±233; P =0.05) despite similar food intake, baseline Upr and CrCl. At week 8, CrCl in Fe (0.84±0.40 mL/min) was similar to C (0.84±0.58 mL/min), whereas in G it remained stable (1.27±0.39 mL/min; P <0.05). By morphometric analysis, mean relative interstitial volume (RIV) and glomerulosclerosis (GS) in Fe (RIV: 28.5±13.4%; GS: 10.3±12.3%) was no different to C (RIV: 24.5±12.5%; GS: 20.9±20.0%), whereas both parameters were reduced in G (RIV: 14.1±8.1%; GS: 4.0±4.8%; P <0.05). Mild gentamicin nephrotoxicity therefore reduced the progression of adriamycin nephrosis. The mechanism of this finding is unclear, but it may relate to altered glomerular and tubular cell handling of protein.     

Reasons for non-use of recovered kidneys: the effect of donor glomerulosclerosis and creatinine clearance on graft survival

BACKGROUND: In 2000, the United Network for Organ Sharing/Organ Procurement and Transplantation Network Registry reported 540 recovered kidneys were discarded because of biopsy results, and 210 were discarded because of poor organ function. We compared the percentage of glomerulosclerosis (GS) and creatinine clearance (CrCl) of both discarded and transplanted cadaveric kidneys and examined their effect on graft survival and function. METHODS: The cohort consisted of all cadaveric kidneys (n= 3,444) with reported biopsy results between October 25, 1999 and December 31, 2001. Graft survival was calculated by univariate and multivariate models. RESULTS: Fifty-one percent of discarded kidneys had GS of less than 20%, 27% had a CrCl greater than 80 mL/min, and 15% (129 kidneys) had both GS less than 20% and a CrCl of greater than 80 mL/min. Univariate analyses of kidneys with less than or equal to 20% GS revealed no difference in 1-year graft survival when the CrCl was greater than or less than or equal to 80 mL/min. When GS was greater than 20%, 1-year graft survival of kidneys with a CrCl of greater than 80 mL/min was significantly greater than that of kidneys with a CrCl of less than or equal to 80 mL/min. Multivariate results showed no significant difference in relative risk of graft loss with GS greater than 20% versus less than or equal to 20% when the CrCl was either 50 or 80 mL/min. With both GS less than or equal to 20% and greater than 20%, serum creatinine at 1 year was significantly lower in kidneys with CrCl greater 80 mL/min. CONCLUSIONS: Calculated donor CrCl does, and percentage GS on donor kidney biopsies does not, correlate well with 1-year graft survival and function, and percentage GS should not be used as the sole criterion for discarding recovered cadaveric kidneys.     

Influence of pancreas transplantation alone on native renal function

Pancreas transplantation alone (PTA) has become an accepted treatment of nonuremic diabetic patients, when the risks of secondary complications of diabetes mellitus are greater than those of the surgical procedure and the posttransplant immunosuppression. As a decrease in native renal function is expected, we followed this parameter among patients who underwent PTA. From January 1997 through January 2005, we performed 69 PTA in 66 patients. All patients showed glucose hyperlability with hypoglycemic unawareness, or two or more diabetic complications as well as creatinine clearance (CrCl) > or = 45 mL/min. Immunosuppression was based on tacrolimus, mycophenolate mofetil and prednisone. Twenty-four hour CrCl were performed after all successful PTA. We divided patients in two groups according to the pretransplant CrCl: group 1, CrCl < or = 70 mL/min (n = 20) and group 2, CrCl > 70 mL/min (n = 25). The data were analyzed using Student's t-test (P < or = .05 was considered significant). Twenty-one patients were excluded from the analysis because of death (n = 5) or graft loss (n = 8) during the first year or follow-up shorter than 1 year (n = 8). The mean value of CrCl decreased 28.8% (85.0 +/- 31 versus 60.5 +/- 36 mL/min; P < .001). There was also a 39.3% reduction among group 1 subjects (P = .003), including 10 who displayed CrCl < or = 30 mL/min. There was also a 24.4% reduction among group 2 (P = .008), but no patient developed end-stage renal disease. In conclusion, native renal function decreased significantly after PTA, but was well tolerated among patients with CrCl > 70 mL/min. Patients with CrCl < 70 mL/min show a significant risk of worsened renal function.     

Immunosuppression With Low-Dose Daclizumab in Liver Transplant Recipients With Impaired Kidney Function: A Single-Center Experience

Background

Nephrotoxicity of calcineurin inhibitors (CNI) may exert detrimental effects, particularly in orthotopic liver transplantation (OLT) patients with impaired kidney function. Immunosuppression with daclizumab permits delayed introduction of CNI, and may be preferred for patients with kidney dysfunction. This retrospective analysis of our experience using daclizumab was performed among patients who underwent transplantation with impaired kidney function.

Methods

We analyzed 168 patients. A serum creatinine (Cr) level >1.5 mg/dL was the indication for a protocol with low-dose daclizumab (50 mg intravenous [IV], day 0 and day 4), mycophenolate mofetil (MMF; 500 mg twice daily IV/orally), and tapering doses of prednisolone from day 0 after OLT. CNI were introduced at day 4-15 after OLT. Patients with a Cr level <1.5 mg/dL received immunosuppression with CNI+MMF+steroids or CNI+steroids.

Results

Fourteen patients fulfilled the criterion for daclizumab immunosupression. Their Cr and creatinine clearance (CrCl) values at OLT were 2.85 ± 1.22 mg/dL and 19 ± 11 mL/min, respectively. In the remaining 154 patients, Cr and CrCl results were 0.88 ± 0.3 mg/dL and 107 ± 82 mL/min, respectively. At discharge, the daclizumab group showed Cr and CrCl estimates of 0.97 ± 0.45 mg/dL and 86 ± 34 mL/min (P < .0001 for both, when compared with prior to OLT). Both Cr and CrCl levels at discharge were not different from those values of patients who underwent transplantation with normal kidney function. The incidence of acuterejection was 14% in the daclizumab group and 18% in the other recipients (P = not significant [NS]).

Conclusions

Immunosuppression with low-dose daclizumab and delayed introduction of CNI was safe and did not increase the risk of an acute rejection episode, thus offerring an excellent therapeutic option for patients who undergo transplantation with impaired kidney function.     

The impact of aortic endografts on renal function

OBJECTIVE: To determine the impact on late postoperative renal function of suprarenal and infrarenal fixation of endografts used to treat infrarenal abdominal aortic aneurysm (AAA). METHODS: Retrospective analysis of 277 patients treated from 2000 to 2003 with three different endografts at two clinical centers. Five patients on dialysis for preoperative chronic renal failure were excluded. Group IF of 135 patients treated with an infrarenal device (Medtronic AneuRx) was compared with group SF of 137 patients treated with a suprarenal device (106 Cook Zenith and 31 Medtronic Talent). Renal function was evaluated by calculating preoperative and latest postoperative creatinine clearance (CrCl) using the Cockcroft formula. Patients who developed a >20% decrease in CrCl were considered to have significantly impaired renal function. RESULTS: There were no significant differences in patient age, sex, aneurysm size, preoperative risk factors, dose of intra- and postoperative contrast, or baseline CrCl (IF: 69.3 mL/min, SF: 71.7 mL/min, P = .4). Follow-up time of 12.2 months was the same in both groups. CrCl decreased significantly during the follow-up period in both groups (IF: 69.3 mL/min to 61.7 mL/min, P < .01; SF: 71.7 mL/min to 64.9 mL/min, P < .03). Postoperative CrCl (IF: 61.7 mL/min, SF: 64.9 mL/min, P = .3), and the rate of CrCl decrease during the follow-up period (IF: -10.9%, SF: -9.5%, P = .2) was not different between the two groups. The number of patients with a >20% decrease in CrCl was not different between the two groups (IF: n = 35 [25.9%], SF: n = 41 [29.9%], P = .46). However, the magnitude of decrease in CrCl in patients with renal impairment was greater in patients treated with suprarenal fixation endografts (SF: -39%) compared with those treated with infrarenal endografts (IF: -31%, P = .005). This greater degree of renal impairment was not due to identifiable differences in preoperative risk factors, age, or baseline CrCl. No patients in these series required dialysis. CONCLUSIONS: Regardless the type of endograft used, there is a 10% decrease in CrCl in the first year after endovascular aneurysm repair. Suprarenal fixation does not seem to increase the likelihood of postoperative renal impairment. Decline in renal function over time after endovascular aortic repair is probably due to multiple factors, and measures known to be effective in protecting kidneys should be considered for these patients. Long-term follow-up with measurement of CrCl, along with renal imaging and regular blood pressure measurements, should be performed to detect possible late renal dysfunction. Prospective studies comparing suprarenal versus infrarenal fixation are needed to confirm those results.     

Impact of statin treatment on 1-year functional and histologic renal allograft outcome

BACKGROUND: Statins are antilipidemic agents that exhibit a variety of cellular effects independent of their lipid-lowering action. A retrospective study was undertaken to establish the impact of statins on graft outcome in the first year posttransplantation. METHODS: Data from patients with uniform immunosuppression (cyclosporine, mycophenolate mofetil, and prednisolone) who underwent transplantation at the authors' unit from 1997 to 2002 were reviewed. Patients prescribed statins were compared with those not on a statin. Mean change in creatinine clearance (CrCl) from 3 to 12 months posttransplantation was calculated. Histomorphometric analysis was used to quantify fractional interstitial area and collagen III deposition in matched preperfusion and 12-month protocol biopsy specimens. RESULTS: Seventy-seven patients met study criteria: statin, n=44 patients; nonstatin, n=33 patients. Median time to commencing a statin was 5 weeks. At 3 months, CrCl (+/-SEM) was similar: 51.6+/-2.9 mL/min (statin) versus 51.3+/-1 mL/min (nonstatin). At 12 months, the mean change in CrCl was 4.1+/-1 mL/min (statin) compared with -2.0+/-1.8 mL/min (nonstatin), resulting in a difference of 6.13 mL/min at 12 months (P<0.005). Mean preperfusion fractional interstitial areas were similar (23.9+/-1.6%; P=not significant [NS]). On 12-month biopsy specimens, the fractional interstitial area had increased to 34+/-3.2% in the nonstatin group (P<0.005), with no change in the statin group. Interstitial collagen III deposition was similar in preperfusion biopsy specimens (10.4+/-1%; P=NS), but at 12 months it was significantly greater in the nonstatin group (17.6+/-1%; P<0.05) CONCLUSIONS: Early introduction of statins may be associated with improved 1-year graft outcome.     

Experience of iron saccharate supplementation in haemodialysis patients treated with erythropoietin

SUMMARY: We assessed the efficacy of intravenous (i.v.) iron saccharate (VENOFER) vs oral iron supplementation in haemodialysis patients treated with low-dose erythropoietin (EPO). Twenty haemodialysis patients with serum ferritin >200 ng/mL and transferrin saturation >30% were assigned to one of the two groups. In Group 1, 10 were given i.v. iron saccharate (100 mg i.v. twice weekly) post dialysis. In Group 2, oral ferrous sulphate 200 mg was given thrice daily. In both groups, subcutaneous EPO 25 units/kg body weight (BW) was started simultaneously, twice weekly. After 3 months (study completion) the mean haemoglobin and haematocrit was significantly increased in Group 1 than in Group 2 (Hb 11.60 ± 0.64 G/ dL vs 10.5 G/dL ± 1.14 P <0.01). the final mean EPO dose was 25% lower in Group 1 than in Group 2 (3400 ± 1356 U/week vs 4600 ± 1356 U/week P =0.10) and the mean serum ferritin was higher in the i.v. iron group than the oral group (671 ng/mL ± 388 vs 367 ng/mL ± 238 P =NS). the same was also observed with transferrin saturation (44.6%± 19.8 in Group 1 vs. 29%± 11.0 in Group 2 P =NS). No adverse effects were seen during the study. In conclusion, we observed that regular use of i.v. iron had a significantly enhanced haemoglobin response, better maintained serum ferritin and lower EPO dosage requirement than the oral iron group.     

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??Approaches of exposing recurrent laryngeal nerve in total thyroidectomy: A randomized controlled study HU Ji-sheng??KONG Rui??YANG Gang??et al. Department of Pancreatic and Biliary Surgery??the First Affiliated Hospital??Harbin Medical University??Harbin 150001??China
Corresponding author??WU Lin-feng??E-mail: wulinfeng1020@126.com
Abstract Objective To investigate the clinical effect of three surgical approaches (entering point approach?? tracheoesophageal groove approach??inferior thyroid artery approach??to exposure of recurrent laryngeal nerve (RLN) in total thyroidectomy. Methods A randomnized, prospective study was conducted among 286 patients who were confirmed diagnosed or highly suspected with malignant thyroid diseases, bilateral multinodular goiter, toxic multinodular goiter and Graves disease. All patients were performed thyroidectomy totally from March 2014 to March 2015 in Department of Pancreatic and Biliary Surgery, the First Affiliated Hospital of Harbin Medical University. The enrolled patients were randomly divided into three groups, Group A (entering point of RLN approach, n=97), Group B (tracheoesophageal groove approach, n=96) and Group C (inferior thyroid artery approach, n=93). The postoperative effects were compared among three groups. Results There was no statistical difference in RLN injury (Group A vs. Group B vs. Group C: 1.0% vs. 2.1% vs. 5.4%??P =0.158) and postoperative hospital stay [??2.6±0.5??d vs. ??2.5±0.7??d vs. ??2.6±0.5??d??F=0.724??P=0.486??]among three groups. The volume of blood loss of Group A and B was less than Group C [??10.1±7.2??mL vs.??12.0±10.0??mL vs.??8.3±7.5??mL] and significance was only observed between Group B and Group C (P<0.05). The operating time of both Group A and B were significantly shorter than Group C [??97.5±16.6??min vs.??93.2±13.3??min vs.??103.9±15.0??min??P<0.05]. Conclusion The incidences of RLN injury of three surgical approaches were similar. The tracheoesophageal groove approach is considered as a better choice for its advantage of less intraoperative blood loss.     

Estimation of glomerular filtration rate in South Asian healthy adult kidney donors

Aim:   We evaluated the performance of serum creatinine based equations to estimate glomerular filtration rate (GFR) in South Asian healthy renal donors.
Methods:   GFR by 99mTc-diethylenetriamine pentaacetic acid (DTPA) renogram (mGFR) in 599 renal donors was measured. GFR was estimated using a six variable modification of diet in renal disease formula (MDRD1), a four variable MDRD formula (MDRD2), Cockcroft-Gault creatinine clearance (CG CrCl), Cockcroft-Gault glomerular filtration rate (CG GFR) and the Mayo Clinic formula (Mayo GFR). The performance of various prediction equations was compared for global bias, precision (R²) and accuracy (percentage of estimated GFR (eGFR) falling within 15% and 30% of mGFR).
Results:   The mean age was 37.4 ± 11 years and 48.2% were male. The mGFR was 95.5 ± 11.6 mL/min per 1.73 m². The bias (mL/min per 1.73 m²) was 7.5 ± 0.9, −9.0 ± 0.75, 13.1 ± 0.9, 7.5 ± 0.9 and 23.4 ± 0.76 for CG CrCl, CG GFR, MDRD1, MDRD2 and Mayo GFR, respectively. R² was 0.082 for CG CrCl and MDRD1, 0.081 for CG GFR and MDRD2 and 0.045 for Mayo GFR. The percentages of eGFR falling within 15% and 30% of mGFR were 50.5 and 80.1 for CG CrCl, 65.8 and 84 for CG GFR, 50 and 74 for MDRD1, 54.3 and 80.1 for MDRD2 and 32 and 63.4 for Mayo GFR. Overall CG GFR performed better in estimating GFR in all subjects.
Conclusion:   The CG GFR equation was better than other equations to estimate GFR in South Asian healthy renal donors. We propose a new equation derived from the regression model in our study population to estimate GFR in a South Asian healthy adult population.     

Endothoracic Injection of Room Air for Internal Mammary Artery Harvest

Abstract   Background : Arterial spasm is described as an event occurring after internal mammary artery (IMA) harvesting. Endothoracic papaverine and carbon dioxide application have been used to prevent IMA spasm before surgical dissection. This technique may make harvest quicker and easier. The aim of this study is to evaluate the effect of room air injection into the endothoracic fascia on IMA blood flow and harvest time. Methods: Eighty-four consecutive ischemic patients were randomly assigned to four groups: group 1 (n = 21, no treatment), group 2 (n = 21, papaverine), group 3 (n = 21, air), group 4 (n = 21, air and papaverine). The room air was injected with a blunt needle through the endothoracic fascia before harvest. Each dissection time was recorded and the flows were measured before cardiopulmonary bypass. Results: Mean blood flows and harvest time were: group 1 = 65.7 ± 16.3 mL/min, 37.2 ± 8.5 minutes; group 2 = 86.6 ± 16.4 mL/min, 25.6 ± 5.5 minutes; group 3 = 85.7 ± 13.1 mL/min, 22.4 ± 4.8 minutes; and group 4 = 90.2 ± 16.4 mL/min, 21.7 ± 5.7 minutes. IMA flow and harvest time in groups 2, 3, and 4 were different than the control group (p < 0.001), but there was no significant statistical difference between treatment groups (2, 3, and 4) (p > 0.05). Conclusions: Injection of room air beneath the endothoracic fascia before IMA dissection may prevent spasm and shorten harvest time, which avoids any risk of intimal injury.     

甲状腺全切除术中显露喉返神经入路随机对照研究

目的 探讨甲状腺全切除术中3种显露喉返神经方法（入喉点入路、气管食管旁沟入路、甲状腺下动脉入路）的临床疗效。方法 随机选择2014年3月至2015年3月哈尔滨医科大学附属第一医院胰胆外科收治的行双侧甲状腺全切除术病人286例,术前通过细针穿刺明确或超声检查高度怀疑甲状腺恶性疾病、累及双侧腺叶的多发性结节性甲状腺肿、结节性甲状腺肿继发甲状腺功能亢进及Graves病。采用随机数字法将病人分为A组（入喉点入路,97例）、B组（气管食管旁沟入路,96例）、C组（甲状腺下动脉入路,93例）。比较3组病人术后疗效。结果 3组喉返神经损伤发生率［A组 vs. B组vs. C组：1.0% vs. 2.1% vs. 5.4%（下同）,P=0.158］及术后住院时间［（2.6±0.5）d vs. （2.5±0.7）d vs. （2.6±0.5）d,F=0.724,P=0.486］差异无统计学意义。在术中出血量方面,A、B组少于C组［（10.1±7.2）mL vs.（12.0±10.0）mL vs.（8.3±7.5）mL］,其中B、C组间差异有统计学意义（P<0.05）;在手术时间方面,A、B组均短于C组,且差异均有统计学意义［（97.5±16.6）min vs.（93.2±13.3）min vs.（103.9±15.0）min,P<0.05］。 结论 入喉点入路、气管食管旁沟入路、甲状腺下动脉入路的喉返神经损伤发生率相近,但气管食管旁沟入路在术中出血量及手术时间上均存在优势,可优先考虑选择。     

Temporary Epicardial Ventricular Stimulation in Patients with Atrial Fibrillation: Acute Effects of Ventricular Pacing Site on Bypass Graft Flows

Abstract   Objective: Data on coronary artery bypass grafts flows in patients with atrial fibrillation (AF) requiring epicardial ventricular pacing is lacking. This study aimed to evaluate the optimal epicardial ventricular pacing site in patients with AF following coronary artery bypass surgery (CABG). Methods: In 23 consecutive patients (mean age = 69.2 ± 1.9 years, gender = 62% male, ejection fraction [EF]= 50.4 ± 2.1%) monoventricular stimulations (VVI) were tested with a constant pacing rate of 100 bpm. The impact of ventricular pacing on bypass graft flow (transit-time flow probe) and pulsatility index (PI) were measured after lead placement on the mid paraseptal region of the right (RVPS) and the left (LVPS) ventricle, on the right inferior wall (RVIW), and on the right ventricular outflow tract (RVOT). In addition, hemodynamic parameters were measured. Patients served as their own control. Results: Comparison of all tested pacing locations revealed that RVOT stimulation provided the highest bypass grafts flows (59.9 ± 6.1 mL/min) and PI (2.2 ± 0.1) when compared with RVPS (51.3 ± 4.7 mL/min, PI = 2.6 ± 0.2), RVIW (54.0 ± 5.1 mL/m; PI = 2.4 ± 0.2), and LVPS (53.1 ± 4.5 mL/min; PI = 2.3 ± 0.1), respectively (p < 0.05). When analyzing patients according to their preoperative LV function (group I = EF > 50%; group II = EF < 50%), higher bypass graft flows were observed with RVOT pacing in patients with lower EF (p = n.s.). Conclusions: Temporary RVOT pacing facilitates optimal bypass graft flows when compared with other ventricular pacing sites and should be the preferred method of temporary pacing in cardiac surgery patients with AF. Especially in patients with low EF following CABG, RVOT pacing may improve myocardial oxygen conditions for the ischemic myocardium and enhance graft patency in the early postoperative period.     

Superior Flow Pattern of Internal Thoracic Artery over Saphenous Vein Grafts during OPCAB Procedures

Abstract   Background: The advantages of the use of the internal thoracic artery (ITA) over that of the saphenous vein (SV) for revascularization of the circumflex (Cx) or right coronary artery (RCA) are still debated. Methods: Serial intraoperative flow measurements were carried out in 306 consecutive patients (mean age 64 years, mean Euroscore 5.1) undergoing off-pump coronary artery bypass grafting (OPCAB). The LAD was grafted in 302 patients [293 ITA (97%), 9 SV], the Cx in 252 patients [117 ITA (46%), 135 SV], and the RCA in 260 patients [36 ITA (14%), 224 SV]. Results: Averages of 3.7 ± 1.0 distal anastomoses/patient were constructed. Mean pulsatile index (PI) was significantly better for the single ITA/Cx-grafts (2.8 ± 1.9, n = 92) than for the single SV/Cx-grafts (3.3 ± 1.7, n = 43, p < 0.05), whereas the mean flow did not differ (28 ± 22 and 31 ± 25 mL/min respectively, p = ns). Accordingly, the mean PI was significantly better for the single ITA/RCA-grafts (2.2 ± 1.2, n = 36) than for the single SV/RCA-grafts (3.4 ± 2.6, n = 178, p < 0.01), whereas the mean flow did not differ (30 ± 16 and 32 ± 22 mL/min respectively, p = ns). The incidence of perioperative myocardial infarction tended to be lower in patients receiving an ITA to either the Cx or the RCA than in those receiving a SV, but the difference did not reach statistical significance [2/92 of ITA/Cx (2.2%) vs. 2/43 of SV/Cx (4.6%), 1/36 of ITA/RCA (2.8%) vs. 8/178 of SV/RCA (4.5%)]. Conclusion: The internal thoracic artery provides superior flow properties than the SV to the Cx and RCA regions with reduced perioperative ischemia. Whether this advantage persists after adjusting for the grade of the proximal coronary stenosis needs further studies.     

Multiple Renal Cystic Lesions and Acute Renal Failure in Non-Hodgkin's Testicular Lymphoma—A Case Report

To evaluate renal function after the use of a low-osmolality radiological contrast medium (CM), we prospectively analyzed 39 patients submitted to the following examinations: arteriography (n = 32), phlebography (n = 3), computed tomography (n = 3), angioplasty (n = 1), and retrograde pyelography (n = 1). The patients were divided into three groups: group 1, control, formed by renal donors (CT, n = 11 and 11 exams); group 2, hypertensive patients (HYPT, n = 15 and 16 exams): and group 3, patients with diseases of multiple etiologies (MIX, n = 13 patients and 13 exams). Additionally, the patients were divided according to their renal function into: group 4, with a moderate deficit of renal function, creatinine clearance (CrCl) 25 to 60 mL/min (n = 15 patients and 15 exams); and group 5, with a mild deficit of renal function, CrCl ≥ 60 mL/min (n = 14 patients and 14 exams). The CM utilized was ioxaglic acid (Hexabrix) the incidence of acute renal failure (ARF) among the patients studied was 12.5% (5/40), and CrCl was the best parameter to monitor the alterations in renal function, which occurred in 35% of the patients, although the changes were mild, reversible, and did not need any therapeutic interventions. The triggering of ARF in these patients may have been due to multiple factors presented at time of CM examination. Thus, it is not possible to identify a single risk factor. However, it is probable that previous important impairment of renal function was the most expressive risk factor.     

髋关节置换术中碘伏冲洗对患者甲状腺功能的影响

目的探讨髋关节置换术术中使用碘伏冲洗消毒对患者术后甲状腺功能的影响。 方法2017年1月至2017年9月将诊于上海长海医院关节外科拟行髋关节置换术的50名患者(无甲状腺疾病及髋关节感染患者),随机分为两组：实验组(术中于假体置入后应用碘伏冲洗、浸泡消毒5 min)25例,对照组(使用生理盐水冲洗、浸泡5 min)25例。两组术后采用相同的康复训练方案。采集所有患者术前、术后第1天,第1周以及第1个月促甲状腺素(TSH)、游离三碘甲状腺原氨酸(FT₃)、游离甲状腺素(FT₄)以及尿碘的结果,评估术后以及术后1 d、1周及1个月与术前相比变化的程度。各时间点的组间差异采用配对样本t检验。 结果50名患者均顺利完成手术,且术后至少随访1个月。实验组FT₃术前为(4.4±0.8)pmol/L,术后第1天、1周、1个月分别为(1.7±0.3)、(4.7±0.7)、(4.3±1.0)pmol/L,对照组术前为(4.2±0.7)pmol/L,术后1 d,1周、1个月分别为(2.9±0.5)、(3.8±0.8)、(4.5±0.9)pmol/L;实验组FT₄术前为(15.4±3.6)pmol/L,术后第1天、1周、1个月分别为(10.7±2.5)、(12.1±2.7)、(15.3±3.5)pmol/L,对照组术前为(15.1±3.8)pmol/L,术后1 d,1周、1个月分别为(13.9±2.7)、(14.6±2.3)、(15.7±3.1)pmol/L;实验组TSH术前为(2.6±1.3)mIU/L,术后1 d、1周、1个月分别为(1.3±0.3)、(3.1±1.0)、(2.36±1.9)mIU/L,对照组术前为(2.6±1.0)mIU/L,术后1 d,1周、1个月分别为(1.3±0.3)、(2.0±1.1)、(2.5±1.5)mIU/L;实验组术前尿碘(251±97)μg/L,术后1 d、1周、1个月为(919± 224)、(453± 106)、(253±112)μg/L,对照组术前为(254±98)μg/L,术后1 d,1周、1个月分别为(262±215)、(255±107)、(244±94)μg/L。两组组间相比术后1 d及1周TSH、FT₃、FT₄以及尿碘值比较差异有统计学意义(术后1 d TSH：t＝0. 892,术后1 d FT₃：t＝7.165,术后1 d FT₄：t＝3.296,术后1 d尿碘值：t＝8.184,均为P <0.05;术后1周TSH：t＝2.691,术后1周FT₃：t＝3.339,术后1周FT₄：t＝2.754,术后1周尿碘值：t＝5.092;均为P <0.05),而术后1个月TSH、FT₃、FT₄以及尿碘值比较差异无统计学意义(均为P>0.05)。 结论术中使用碘伏冲洗对患者甲状腺功能有一过性影响,在术后第1天影响最大,1周后逐渐恢复,1个月后几无影响。     

Experience of iron saccharate supplementation in haemodialysis patients treated with erythropoietin

We assessed the efficacy of intravenous (i.v.) iron saccharate (VENOFER) vs oral iron supplementation in haemodialysis patients treated with low-dose erythropoietin (EPO). Twenty haemodialysis patients with serum ferritin >200 ng/mL and transferrin saturation >30% were assigned to one of the two groups. In Group 1, 10 were given i.v. iron saccharate (100 mg i.v. twice weekly) post dialysis. In Group 2, oral ferrous sulphate 200 mg was given thrice daily. In both groups, subcutaneous EPO 25 units/kg body weight (BW) was started simultaneously, twice weekly. After 3 months (study completion) the mean haemoglobin and haematocrit was significantly increased in Group 1 than in Group 2 (Hb 11.60±0.64 G/dL vs 10.5 G/dL±1.14 P <0.01). The final mean EPO dose was 25% lower in Group 1 than in Group 2 (3400±1356 U/week vs 4600±1356 U/week P =0.10) and the mean serum ferritin was higher in the i.v. iron group than the oral group (671 ng/mL±388 vs 367 ng/mL±238 P =NS). The same was also observed with transferrin saturation (44.6%±19.8 in Group 1 vs. 29%±11.0 in Group 2 P =NS). No adverse effects were seen during the study. In conclusion, we observed that regular use of i.v. iron had a significantly enhanced haemoglobin response, better maintained serum ferritin and lower EPO dosage requirement than the oral iron group.     

Solitary renal allografts from pediatric cadaver donors less than 2 years of age transplanted into adult recipients

BACKGROUND: Transplantation of solitary pediatric renal allografts from donors 2 years of age or younger into adult recipients is controversial. METHODS: Between 1998 and 2001, 15 solitary renal allografts from pediatric donors 2 years of age or younger were transplanted into adult recipients. Thirty-three en bloc renal allografts transplanted between 1994 and 2001 were used for comparison. En bloc kidneys were considered for separation if they measured greater than or equal to 6 cm in length. Renal function (creatinine clearance [CrCl]) was estimated using the Cockroft-Gault formula. RESULTS: Two-year graft survival for the solitary and en bloc groups were 93% and 77%, respectively (P =0.405). Five grafts were lost because of arterial thrombosis (four en bloc and one solitary). Ureteral complications occurred in three grafts in the en bloc group. One-year postoperative CrCl of the surviving solitary (n=14) and en bloc (n=26) grafts were 51.4+/-26.2 mL/min and 55.1+/-27.5 mL/min (P >0.05), respectively. Donor weight and kidney length were greater in the solitary group (14.3+/-3.5 kg and 6.3+/-0.4 cm, respectively) compared with the en bloc group (10.8+/-2.6 kg and 5.9+/-0.3 cm, respectively) (P =0.001 and P <0.001). CONCLUSIONS: Separation of en bloc pairs into solitary allografts can be considered when the graft measures greater than or equal to 6 cm in length and donor weight is greater than or equal to 14 kg. The transplantation of solitary pediatric kidneys into adult recipients is successful, and the majority of pediatric en bloc allografts can be separated before transplantation.     

How long should initiation of calcineurin inhibitors be delayed to protect renal function in liver transplantation?

Background and aim

Delayed introduction of calcineurin inhibitors (CNI) in liver transplantation (OLT) seeks to protect renal function, although the optimal length of the delay is not well established. The aim of this study was to analyze the effects on renal function of CNI initiation on different days after OLT.

Methods

We reviewed the charts of 260 OLT recipients. Group D1-a (n = 36) underwent the standard initial immunosuppression at our center: namely, CNI introduction on day 1 with further daily administration to achieve target levels of 8 to 15 ng/mL for tacrolimus or 150 to 300 ng/mL for cyclosporine. Due to renal concerns, 126 patients (group D1-b) had CNI introduced on day 1 either not daily or at doses to achieve less than the target on at least two occasions. In 43 patients (group D2), CNI were introduced on day 2 in 23 on day 3 (group D3), in 12 on day 4 (group D4), and at least at day 5 in 20 others (group D5). In periods without CNI treatment, patients received mycophenolate mofetil. Steroids were administered to all patients. The study period included the first 3 months post-OLT. Renal function was estimated as creatinine clearance (CrCl) using the Cockcroft-Gault equation.

Results

Changes in CrCl from pre-OLT to month 3 were −19% ± 28% in group D1-a; −27% ± 19% in group D1-b; −29% ± 19% in group D2; −23% ± 26% in group D3; −4% ± 38% in group D4, and +4% ± 33% in group D5 (P < .05 vs groups D1-a, D1-b, D2, and D3). On multivariate analysis, CNI introduction at day ≥5 was protective for kidneys when adjusted for other variables that potentially influence renal function.

Conclusion

CNI should be introduced at day 5 after OLT to protect renal function.     

三重带袢钢板技术治疗新鲜Rockwood Ⅲ型肩锁关节脱位手术创伤与临床疗效相关性研究

目的对比AO锁骨钩钢板和三重带袢钢板技术治疗新鲜RockwoodⅢ型肩锁关节脱位患者手术创伤和临床疗效指标，并进一步在优势组中行相关性分析，探究优势组中影响临床疗效相关因素，为此类疾病手术治疗改进提供借鉴。 方法回顾性分析惠州市第一人民医院自2018年1月至2020年5月符合新鲜Rockwood Ⅲ型肩锁关节脱位患者72例，根据手术方式不同分为AO组（A组）和三重Endobutton带袢钢板组（B组）。其中A组（n=37，F/M=12/25），平均年龄（41.30±1.02）岁；B组（n=35，F/M=13/22），平均年龄（43.36±1.15）岁。所有患者术后1 d、1周、1个月、3个月、1年均行X线检查。X线中测量喙锁间距、肩锁间距评估手术复位，视觉模拟评分（visual analogue scale/score,VAS）和Constant-Murley肩关节功能评分评估临床疗效。通过Graphpad Prism 7软件进行数据分析。年龄、返工时间、受伤至手术花费时间、手术持续时间、手术切口长度、术中出血量、VAS评分、Constant-Murley肩关节功能评分、喙锁间距和肩锁间距采用 ±s表示；性别、受伤位侧采用数量表示。计量资料组间比较用t检验分析，计数资料组间用卡方检验分析，相关性分析均采用Pearson相关性分析，P<0.05为差异具有统计学意义，r>0为正相关。 结果72例患者依据12个月随访，Constant-Murley肩关节功能评分结果：A组术后1 d（46.60±0.41）分、术后1周（65.22±0.45）分和B组术后1 d（51.30±0.39）分、术后1周（75.07±0.35）分相比较，术后1 d和术后1周A组分数均明显小于B组，差异具有统计学意义（P<0.05）。VAS结果提示：A组术后1 d（6.71±0.07）分、术后1周（5.45±0.09）分、术后1个月（3.70±0.11）分和B组术后1 d（5.70±0.10）分、术后1周（3.60±0.14）分、术后1个月（2.00±0.10）分相比较，A组分数均明显大于B组，差异具有统计学意义（P<0.05）。返工时间结果示：A组（7.64±0.10）周明显长与B组（6.01±0.17）周，差异有统计学意义（P<0.05）。相关性提示：B组手术切口长度与术后1 dVAS评分（r= 0.73，P<0.05）和术后1周VAS评分（r= 0.68，P<0.05）均呈正相关。 结论带袢钢板和锁骨钩钢板技术治疗肩锁关节脱位远期疗效相当，但相较于锁骨钩钢板内固定术而言，带袢钢板具有手术切口小、出血量少、伤口外观更好，并且在早期恢复中疼痛缓解、肩关节功能恢复更快等优势，在术后早期恢复中，带袢钢板技术通过减小手术创伤缩短患者术后疼痛时间，临床值得推广。     

How pregnancy influences renal function in nephropathic type 1 diabetic women depends on their pre-conceptional creatinine clearance

Pregnancy in type 1 diabetic women with overt nephropathy can lead to a further deterioration in renal function but it is not clear at what level of pre-conceptional GFR the risk for worsening of renal function begins to increase. Therefore we investigated the influence of pregnancy on renal function in 12 women (14 pregnancies) with pre-conceptional macroproteinuria and near-normal creatinine clearance (range 37-93 ml/min/1.73m2). S-creatinine, creatinine clearance (CrCL), HbA1c and blood pressure (BP) were measured before conception, during each trimester (12th and 24th week of gestation and last week before delivery) and three and six months post-partum. In five diabetic women with six pregnancies (group A) there was a physiological increase in CrCl of 36% up until the 24th week of gestation; their pre-conceptional mean CrCl was 80 (range 70-93) ml/min/1.73m2. In seven women with eight pregnancies (group B) CrCl decreased by 16% during the first two trimesters; the mean CrCl before conception was 61 (37-73) ml/min/1.73m2. In the last week before delivery CrCl worsened transiently in three cases in group A and four in group B, due to pre-eclampsia. Three months post-partum the mean CrCl in group A was 78 (70-91) ml/min/1.73m2, approximately the same as before pregnancy. In group B the mean CrCl was 39 (22-68) ml/min/1.73m2 at this same time; this was 36% lower than the pre-conceptional clearance. Mean HbA1c in both groups were approximately the same, but mean BP tended to be higher during pregnancy in group B, especially in the week before delivery (p<0.05). We conclude that in a high percentage of nephropathic diabetic women with significantly low CrCl before conception, renal function worsens during and after pregnancy. Inadequate antihypertensive therapy may contribute to this.