左卡尼汀联合重组人促红素注射液治疗规律透析慢性肾功能衰竭合并贫血患者的临床效果

目的探究左卡尼汀联合重组人促红素注射液治疗规律透析慢性肾功能衰竭合并贫血患者的临床效果。方法选择2017年1月至2020年1月收治的100例规律透析慢性肾功能衰竭合并贫血患者,以计算机随机化法将其分为对照组和试验组,每组50例。对照组给予重组人促红素注射液治疗,试验组给予左卡尼汀与重组人促红素注射液联合治疗。比较两组患者的治疗效果。结果试验组的治疗总有效率为96.00%,高于对照组的80.00%(P<0.05);治疗后,两组患者的MCHC、MCH、MCV、SF、Hb、RBC水平均高于治疗前,且试验组高于对照组(P<0.05);两组患者的不良反应总发生率比较,差异无统计学意义(P>0.05)。结论规律透析慢性肾功能衰竭合并贫血患者接受左卡尼汀与重组人促红素注射液联合治疗,可获得较好的效果,改善贫血相关生化指标水平,且不良反应发生率低,安全有效。     

A multi-institutional analysis of Textbook Outcomes among patients undergoing cytoreductive surgery for peritoneal surface malignancies

BackgroundWhile recent studies have introduced the composite measure of a textbook outcome (TO) for measuring postoperative outcomes, the incidence of a TO has not been characterized among patients undergoing cytoreductive surgery (CRS) for peritoneal surface malignancies (PSM).Study designAll patients who underwent CRS ± hyperthermic intraperitoneal chemotherapy (HIPEC) between 1999 and 2017 from 12 institutions were included. A TO was defined as the absence of any of the following criteria: completeness of cytoreduction >1, reoperation within 90-days, readmission within 90-days, mortality within 90-days, any grade ≥2 complication, hospital stay >75th percentile, and non-home discharge.ResultsAmong 1904 patients who underwent CRS, only 30.9% achieved a TO while 69.1% failed to achieve a TO most commonly because of postoperative complications. On multivariable analysis, factors associated with achieving a TO were age <65 years (OR: 1.5), albumin ≥3.5 g/dl (OR: 5.7), receipt of HIPEC (OR: 4.5), PCI ≤14 (OR: 2.2), intravenous fluid volume ≤10,000 ml (OR: 2.1), blood loss ≤1000 ml (OR: 4.2) and operative time <7 h (OR: 1.9); while receipt of neoadjuvant therapy (OR: 0.7) and liver resection (OR: 0.4) were associated with not achieving a TO (all p < 0.05). TO was associated with improved overall survival (median 159 months vs 56 months, p < 0.01) even after controlling for confounders on Cox regression (hazard ratio: 2.5, p < 0.01).ConclusionAmong patients undergoing CRS ± HIPEC for PSM, failure to achieve a TO is common and independently associated with worse overall survival.     

胃癌腹膜转移病人腹腔化疗港并发症发生及危险因素分析

目的:分析腹腔化疗港并发症发生及相关危险因素。方法:回顾性分析我院323例放置腹腔化疗港病人的临床资料,纳入261例胃癌腹膜转移病人。分析腹腔化疗港在胃癌腹膜转移病人腹腔化疗时发生的并发症及其危险因素。结果:261例中59例(22.6%)发生化疗港相关并发症。其中,皮下积液(25例,42.4%)和化疗港感染(16例,27.1%)是发生较多的并发症。其他是港体倾斜翻转(9例,15.3%),化疗港局部切口裂开(7例,11.9%),导管堵塞(1例,1.7%),和皮下转移(1例,1.7%)。化疗港并发症发生的中位时间为化疗港放置后3.0个月。结合Clavien-Dindo分级方法,将化疗港发生的并发症分为1~4个等级。ECOG评分、血清白蛋白水平、置港流程优化及专业团队放置为化疗港并发症发生的独立危险因素(P<0.05)。ECOG评分为唯一影响并发症分级的关联因素(P<0.05)。结论:腹腔化疗港在胃癌腹膜转移病人腹腔化疗中的应用安全可行,发生并发症可控。ECOG评分、血清白蛋白水平、置港方式是否优化及是否专业团队放置为化疗港并发症发生的独立危险因素。     

Diffusion-weighted MRI and PET/CT reproducibility in epithelial ovarian cancers during neoadjuvant chemotherapy

PurposeTo investigate the reproducibility of diffusion-weighted (DW) MRI and ¹⁸F-Fluorodeoxyglucose (¹⁸F-FDG)-Positron emission tomography/CT (PET/CT) in monitoring response to neoadjuvant chemotherapy in epithelial ovarian cancer.Materials and methodsTen women (median age, 67 years; range: 41.8–77.3 years) with stage IIIC-IV epithelial ovarian cancers were included in this prospective trial (NCT02792959) between 2014 and 2016. All underwent initial laparoscopic staging, four cycles of carboplatine-paclitaxel-based chemotherapy and interval debulking surgery. PET/CT and DW-MRI were performed at baseline (C0), after one cycle (C1) and before surgery (C4). Two nuclear physicians and two radiologists assessed five anatomic sites for the presence of ≥ 1 lesion. Target lesions in each site were defined and their apparent diffusion coefficient (ADC), maximal standardized uptake value (SUV-max), SUV-mean, SUL-peak, metabolic tumor volume (MTV) and total lesion glycolysis (TLG) were monitored (i.e., 10 patients × 5 sites × 3 time-points). Their relative early and late changes were calculated. Intra/inter-observer reproducibilities of qualitative and quantitative analysis were estimated with Kappa and intra-class correlation coefficients (ICCs).ResultsFor both modalities, inter- and intra-observer agreement percentages were excellent for initial staging but declined later for DW-MRI, leading to lower Kappa values for inter- and intra-observer variability (0.949 and 1 at C0, vs. 0.633 and 0.643 at C4, respectively) while Kappa values remained > 0.8 for PET/CT. Inter- and intra-observer ICCs were > 0.75 for SUV-max, SUL-peak, SUV-mean and their change regardless the time-point. ADC showed lower ICCs (range: 0.013–0.811). ANOVA found significant influences of the evaluation time, the measurement used (ADC, SUV-max, SUV-mean, SUV-max, SUL-peak, MTV or TLG) and their interaction on ICC values (P = 0.0023, P< 0.0001 and P =0.0028, respectively).ConclusionWhile both modalities demonstrated high reproducibility at baseline, only SUV-max, SUL-peak, SUV-mean and their changes maintained high reproducibility during chemotherapy.     

Recent insights into the characteristics and role of peritoneal macrophages from ascites of cirrhotic patients

Macrophages are a diverse myeloid cell population involved in innate and adaptive immune responses, embryonic development, wound repair, and regulation of tissue homeostasis. These cells link the innate and adaptive immunities and are crucial in the development and sustainment of various inflammatory diseases. Macrophages are tissue-resident cells in steady-state conditions; however, they are also recruited from blood monocytes after local pathogen invasion or tissue injury. Peritoneal macrophages vary based on their cell complexity, phenotype, and functional capabilities. These cells regulate inflammation and control bacterial infections in the ascites of decompensated cirrhotic patients. Our recent work reported several phenotypic and functional characteristics of these cells under both healthy and pathological conditions. A direct association between cell size, CD14/CD16 expression, intracellular level of GATA-6, and expression of CD206 and HLA-DR activation/maturation markers, indicate that the large peritoneal macrophage CD14^highCD16^high subset constitutes the mature phenotype of human resident peritoneal macrophages during homeostasis. Moreover, elevated expression of CD14/CD16 is related to the phagocytic capacity. The novel large CD14^highCD16^high peritoneal subpopulation is increased in the ascites of cirrhotic patients and is highly sensitive to lipopolysaccharide (LPS)-induced activation, thereby exhibiting features of inflammatory priming. Thus, phosphorylation of ERK1/2, PKB/Akt, and c-Jun is remarkably increased in response to LPS in vitro, whereas that of p38 MAPK is reduced compared with the monocyte-derived macrophages from the blood of healthy controls. Furthermore, in vitro activated monocyte-derived macrophages from ascites of cirrhotic patients secreted significantly higher levels of IL-6, IL-10, and TNF-α and lower amounts of IL-1β and IL-12 than the corresponding cells from healthy donor’s blood. Based on these results, other authors have recently reported that the surface expression level of CD206 can be used to identify mature, resident, inflammatory peritoneal macrophages in patients with cirrhosis. Soluble CD206 is released from activated large peritoneal macrophages, and increased concentrations in patients with cirrhosis and spontaneous bacterial peritonitis (SBP) indicate reduced odds of survival for 90 d. Hence, the level of soluble CD206 in ascites might be used to identify patients with SBP at risk of death. In conclusion, peritoneal macrophages present in ascites of cirrhotic patients display multiple phenotypic modifications characterized by reduced ratio of cells expressing several membrane markers, together with an increase in the ratios of complex and intermediate subpopulations and a decrease in the classic-like subset. These modifications may lead to the identification of novel pharmaceutical targets for prevention and treatment of hepatic damage.     

改进Seldinger法经皮穿刺腹膜透析置管术在终末期肾病患者中的应用

目的:探讨改进Seldinger法经皮穿刺腹膜透析置管术在终末期肾病患者中的应用效果。方法:选取2019年12月~2020年12月于本院进行腹膜透析置管术的终末期肾病患者61例,随机分为观察组(31例)和对照组(30例),对照组患者采用常规开腹手术置管,观察组采用改进Seldinger法置管,比较两组患者完成置管手术的相关指标(手术时间、术后排气时间、切口长度、住院时间),术后3d、1个月患者并发症发生情况。结果:较对照组,观察组手术时间、术后排气时间均更短,腹部切口长度更短(P<0.05),两组患者住院时间比较(P>0.05),观察组穿刺成功率明显高于对照组(100.00%,80.00%,χ²=6.88,P=0.01)。较对照组,观察组患者术后3d并发症发生率明显低于对照组(22.58%,50.00%,χ²=4.97,P=0.03),观察组患者术后1个月并发症发生率明显低于对照组(19.35%,53.33%,χ²=7.05,P=0.01)。结论:对终末期肾病患者运用改进Seldinger法经皮穿刺腹膜透析置管术进行置管可有效缩短手术时间和术后排气时间,创口较小,患者术后早期、远期并发症较少,临床应用效果较好。     

Routine Laboratory Testing Every 4 Versus Every 6 Weeks for Patients on Maintenance Hemodialysis: A Quality Improvement Project

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Impacto del primer año de tratamiento sustitutivo renal en la hospitalización de una comunidad autónoma

Introduction and objectivesChronic kidney disease has a high prevalence and economic impact, and an increased risk of hospitalization. Although there are public regional and country registries, we have not found references to estimate the impact of renal replacement therapy (RRT) on hospital admissions.MethodsWe obtained authorization from the ethics committee and health authorities to integrate the REMER [Madrid Kidney Disease Registry] (2013-2014) and Minimum Basic Data Set (2013-2015) databases and to analyze the admissions during the first year of RRT.Results767 patients started RRT in all the hospitals of our region across all RRT modalities. More than a third of the patients start dialysis during a hospital admission. This unplanned start, more common in HD than PD, shows relevant differences in patient profile or admission characteristics.Without considering this initial episode, almost 60% of patients were admitted during their first year. The hospitalization rate was 1.2 admissions/patient, higher in HD than in TX or PD; the mean length of stay was 8.6 days.The estimated cost of admissions during the first year is €12,006/patient. Our analysis ensures the exhaustive inclusion of all episodes and accurate estimation based on the discharge form.ConclusionThe impact of RRT on hospitals has been underestimated and is very relevant when calculating the total cost of RRT. Results from other countries cannot be extrapolated due to differences in the health system and patient profile. The integration of clinical databases could open up an opportunity that needs only institutional support for its development.