Serum endocan and circadian heart rate variability in non-dialysis stage 5 chronic kidney disease patients

Background

Chronic kidney disease (CKD) is very common now and is associated with high overall and cardiovascular mortality. Numerous studies have reported that elevated heart rate (HR) is a risk factor for cardiovascular mortality. We investigated the link between serum endocan and circadian heart rate variability in non-dialysis stage 5 CKD patients.

Methods

In a cross-sectional study, we enrolled 54 prevalent n non-dialysis stage 5 CKD patients (32 males, aged 48.2?±?14.92 years). HR was measured with an automatic system. Serum endocan level was analyzed by ELISA.

Results

Night/day HR ratio was independently predicted by serum endocan level (P?<?0.01) and hypertension history (P?<?0.05). Adjusted R² of the model was 0.222.

Conclusion

Increased serum endocan is significantly associated with circadian heart rate variability in non-dialysis stage 5 CKD patients. Further investigation is needed to explore the potential benefits of serum endocan lowering therapy in this patient group.

     

Perioperative Complications are Associated With Adverse Long-Term Prognosis and Affect the Cause of Death After General Surgery

Background

It is unclear how mortality and causes of death vary between patients and surgical procedures and how occurrence of postoperative complications is associated with prognosis. This study describes long-term mortality rates and causes of death in a general surgical population. Furthermore, we explore the effect of postoperative complications on mortality.

Methods

A single-centre analysis of postoperative complications, with mortality as primary endpoint, was conducted in 4479 patients undergoing surgery. We applied univariate and multivariable regression models to analyse the effect of risk factors, including surgical risk and postoperative complications, on mortality. Causes of death were also explored.

Results

75 patients (1.7 %) died within 30 days after surgery and 730 patients (16.3 %) died during a median follow-up of 6.3 years (IQR 5.8–6.8). Significant differences in long-term mortality were observed with worst outcome for patients undergoing high-risk vascular surgery (HR 1.5; 95 % CI 1.2–1.9). When looking at causes of death, high-risk surgery was associated with a twofold higher risk of cardiovascular death (HR 1.9; 95 % CI 1.2–3.1), whereas the intermediate-risk group had a higher risk of dying from cancer-related causes (HR 1.5; 95 % CI 1.1–2.0). Occurrence of complications—particularly of cardiovascular nature— was associated with worse survival (HR 1.9; 95 % CI 1.3–2.7).

Conclusion

High-risk vascular surgery and occurrence of postoperative complications are important predictors of late mortality. Further focus on these groups of patients can contribute to reduced morbidity. Improvement in quality of care should be aimed at preventing postoperative complications and thus a better outcome in a general surgical population.

     

Vitamin D and prostate cancer prognosis: a Mendelian randomization study

Purpose

Decreased vitamin D levels have been associated with prostate cancer, but it is unclear whether this association is causal. A functional single-nucleotide polymorphism (SNP) in the group-specific component (GC) gene (T > G, rs2282679) has been associated with 25-hydroxy (25-OH) vitamin D and 1.25 dihydroxy (1.25-OH2) vitamin D levels.

Methods

To examine the hypothesized inverse relationship between vitamin D status and prostate cancer, we studied the association between this SNP and prostate cancer outcome in the prospective PROCAGENE study comprising 702 prostate cancer patients with a median follow-up of 82 months.

Results

GC rs2282679 genotypes were not associated with biochemical recurrence [hazard ratios (HR) 0.91, 95 % confidence interval (CI) 0.73–1.12; p = 0.36], development of metastases (HR 1.20, 95 % CI 0.88–1.63; p = 0.25) or overall survival (HR 1.10; 95 % CI 0.84–1.43; p = 0.50).

Conclusions

A causal role of vitamin D status, as reflected by GC rs2282679 genotype, in disease progression and mortality in prostate cancer patients is unlikely.

     

Simple scoring system for prediction of mortality in Fournier’s gangrene

Purpose

To create new scoring system for prediction of hospital mortality for patients with Fournier’s gangrene(FG).

Material and method

In total, 84 patients with FG were enrolled into this study. The demographic and clinical characteristics of patients were analyzed retrospectively.

Results

The mortality rate was 11.9 %. On multivariate analyses, age >60 years, BUN >40 mg/dl, RDW >14.95 %, albumin level <20 mg/dl and presence of sepsis were significant and independent predictors of mortality. The predictive value of our score for mortality was 95.1 %.

Conclusion

Our scoring system shows adequate discriminatory function for prediction of mortality in patients with FG. Further larger scale studies can improve the performance of our score.

     

RIFLE classification in geriatric patients with acute kidney injury in the intensive care unit

Background

The RIFLE classification is widely used to assess the severity of acute kidney injury (AKI), but its application to geriatric AKI patients complicated by medical problems has not been reported.

Methods

We investigated 256 geriatric patients (≥65 years old; mean age, 74.4 ± 6.3 years) who developed AKI in the intensive care unit (ICU) according to the RIFLE classification. Etiologic, clinical, and prognostic variables were analyzed.

Results

They were categorized into RIFLE-R (n = 53), RIFLE-I (n = 102), and RIFLE-F (n = 101) groups. The overall in-hospital mortality was 39.8 %. There were no significant differences in RIFLE category between survivors and non-survivors. Survivors had significantly less needs for a ventilator and vasopressor, and lower number of failing organs. Survivors had higher systolic blood pressure, hemoglobin level, and serum albumin levels. We performed a logistic regression analysis to identify the independent predictors of in-hospital mortality. In a univariate analysis, hypertension, chronic kidney disease, RIFLE classification, number of failing organs, need for a ventilator and vasopressor, systolic blood pressure, hemoglobin level, and serum albumin levels were identified as prognostic factors of in-hospital mortality. However, in a multivariate analysis, hypertension, chronic kidney disease, number of failing organs, and serum albumin levels were independent risk factors, with no significant difference for in-hospital mortality with the RIFLE classification.

Conclusion

The RIFLE classification might not be associated with mortality in geriatric AKI patients in the ICU. In geriatric patients with AKI, various factors besides severity of AKI should be considered to predict mortality.

     

Long-Term Mortality in Patients Operated for Perforated Peptic Ulcer: Factors Limiting Longevity are Dominated by Older Age,Comorbidity Burden and Severe Postoperative Complications

Background

Perforated peptic ulcer (PPU) is a surgical emergency associated with high short-term mortality. However, studies on long-term outcomes are scarce. Our aim was to investigate long-term survival after surgery for PPU.

Materials and Methods

A population-based, consecutive cohort of patients who underwent surgery for PPU between 2001 and 2014 was reviewed, and the long-term mortality was assessed. Survival was investigated by univariate analysis (log-rank test) and displayed using Kaplan–Meier survival curves. Multivariable analysis of risk factors for long-term mortality was assessed by Cox proportional hazards regression and reported as hazard ratio (HR) with 95 % confidence intervals (CI).

Results

A total of 234 patients were available for the calculation of ninety-day, one-year and two-year mortality, and the results showed rates of 19.2 % (45/234), 22.6 % (53/234) and 24.8 % (58/234), respectively. At the end of follow-up, a total of 109 of the 234 patients (46.6 %) had died. Excluding 37 (15.2 %) patients who died within 30 days of surgery, 197 patients had long-term follow-up (median 57 months, range 1–168) of which 36 % (71/197) died during the follow-up period. In multivariable analyses, age >60 years (HR 3.95, 95 % CI 1.81–8.65), active cancer (HR 3.49, 95 % CI 1.73–7.04), hypoalbuminemia (HR 1.65, 95 % CI 0.99–2.73), pulmonary disease (HR 2.06, 95 % CI 1.14–3.71), cardiovascular disease (HR 1.67, 95 % CI 1.01–2.79) and severe postoperative complications (HR 1.76, 95 % CI 1.07–2.89) during the initial stay for PPU were all independently associated with an increased risk of long-term mortality. Cause of long-term mortality was most frequently (18 of 71; 25 %) attributed to new onset sepsis and/or multiorgan failure.

Conclusion

The long-term mortality after surgery for PPU is high. One in every three patients died during follow-up. Older age, comorbidity and severe postoperative complications were risk factors for long-term mortality.

     

Cardiac troponin T elevation at dialysis initiation is associated with all-cause and cardiovascular mortality on dialysis in patients without diabetic nephropathy

Background

It is not known whether asymptomatic cardiac troponin T (cTnT) elevation is associated with all-cause or cardiovascular mortality in non-diabetic and advanced chronic kidney disease (CKD) patients.

Methods

We measured cTnT in 248 consecutive patients at 1–2 weeks before dialysis initiation between March 2005 and August 2010 and followed them prospectively. A Cox proportional hazard model was used to investigate the relationship between cTnT and all-cause and cardiovascular mortality on dialysis.

Results

The median age of the patients was 67 years (male 59.3 %), and the prevalence of diabetic nephropathy (DN) was 38.3 %. Asymptomatic cTnT elevation (>0.01 ng/mL) was observed in 196 (79 %) and 111 (73 %) patients among the overall patients and among patients without DN, respectively. A total of 51 patients died during a median follow-up period of 31.6 months. The cTnT level was associated with all-cause [hazard ratio (HR) 1.453; 95 % confidence interval (CI) 1.093–1.931; P = 0.010] and cardiovascular mortality [HR 1.973; 95 % CI 1.127–3.454; P = 0.017] on dialysis after extensive adjustment in the overall patient population. Patients without DN showed similar associations as those for the overall patient population (all-cause mortality: HR 1.566; 95 % CI 1.048–2.339; P = 0.029 and cardiovascular mortality: HR 2.657; 95 % CI 1.115–6.328; P = 0.027).

Conclusion

Asymptomatic cTnT elevation might be strongly associated with all-cause and cardiovascular mortality in patients without DN, as well as in the overall advanced CKD patients. We suggest that cardiovascular risk in patients with pre-dialysis CKD should be stratified according to cTnT levels.

     

Predictors of hypofibrinogenemia in blunt trauma patients on admission

Purpose

Massive bleeding usually leads to critically low levels of clotting factors, including fibrinogen. Although reduced fibrinogen levels correlate with increased mortality, predictors of hypofibrinogenemia have remained poorly understood. We investigated whether findings available on admission can be used as predictors of hypofibrinogenemia.

Methods

We retrospectively reviewed serum fibrinogen levels tested on arrival in 290 blunt trauma patients transported to a level I trauma center during a 3-year period. The primary outcome was prehospital predictors for hypofibrinogenemia. Covariates included age, sex, prehospital fluid therapy, prehospital anatomical and physiological scores, time from injury, base excess, and lactate on arrival. All variables with values of p < 0.10 in univariate analysis were included in a multivariate logistic regression model. The relationships between the variables and the 7-day mortality rate were evaluated in a Cox proportional hazards model.

Results

Patient’s age [odds ratio (OR): 0.97, p < 0.001], Triage Revised Trauma Score (T-RTS) (OR: 0.81, p = 0.003), and prehospital fluid therapy (OR: 2.54, p = 0.01) were detected as independent predictors for hypofibrinogenemia in multivariate logistic regression analysis. Serum fibrinogen level [hazard ratio (HR): 0.99, p = 0.01] and T-RTS (HR: 0.77, p < 0.01) were associated with the 7-day mortality rate.

Conclusion

T-RTS is considered to play an important role in predicting hypofibrinogenemia and 7-day mortality in blunt trauma patients.

     

No difference in flexion power despite iliopsoas fatty degeneration in healed hip fractures with large lesser trochanter displacement

Objective

To evaluate iliopsoas atrophy and loss of function after displaced lesser trochanter fracture of the hip.

Design

Cohort study.

Setting

District hospital.

Patients

Twenty consecutive patients with pertrochanteric fracture and displacement of the lesser trochanter of?>?20 mm.

Intervention

Fracture fixation with either an intramedullary nail or a plate.

Outcome measurements

Clinical scores (Harris hip, WOMAC), hip flexion strength measurements, and magnetic resonance imaging findings.

Results

Compared with the contralateral non-operated side, the affected side showed no difference in hip flexion force in the supine upright neutral position and at 30° of flexion (205.4 N vs 221.7 N and 178.9 N vs. 192.1 N at 0° and 30° flexion, respectively). However, the affected side showed a significantly greater degree of fatty infiltration compared with the contralateral side (global fatty degeneration index 1.085 vs 0.784), predominantly within the psoas and iliacus muscles.

Conclusion

Severe displacement of the lesser trochanter (>?20 mm) in pertrochanteric fractures did not reduce hip flexion strength compared with the contralateral side. Displacement of the lesser trochanter in such cases can lead to fatty infiltration of the iliopsoas muscle unit. The amount of displacement of the lesser trochanter did not affect the degree of fatty infiltration.

Level of evidence

II.

     

Risk factors associated with relapse or infectious complications in Japanese patients with microscopic polyangiitis

Background

The prevention of relapse and infection complications during remission maintenance therapy is required to improve the prognosis of patients with microscopic polyangiitis (MPA) showing rapidly progressive glomerulonephritis (RPGN). The clinicopathological characteristics of patients with ANCA-positive MPA were examined to determine the risk factors for relapse or infectious complications after remission induction therapy.

Patients and methods

The study population consisted of 52 patients diagnosed as ANCA-positive MPA showing RPGN from 2002 to 2012, after publication of the Japanese guideline for RPGN. The clinicopathological findings were examined between the presence and absence of relapse or infectious complications.

Results

The value of vasculitis damage index (VDI) was high for the relapse group and VDI value was identified as the leading factor associated with relapse [hazard ratio (HR) 3.36, 95 % confidence interval (CI) 1.58–7.12, P < 0.01]. On the other hand, the values of Birmingham Vasculitis Activity Score, clinical grade category of RPGN at diagnosis, and VDI at remission were high in the infectious group. Furthermore, clinical grade category of RPGN was the leading factor associated with infectious complications (HR 5.30, 95 % CI 1.41–19.9, P = 0.01).

Conclusion

The disease activity at diagnosis and severity of organ damage at remission were associated with relapse and infectious complications during remission maintenance therapy and infectious complication affected kidney survival and all-cause mortality in patients with ANCA-positive MPA exhibiting RPGN.

     

Home Return After Surgery in Patients Aged over 85 Years is Associated with Preoperative Albumin Levels,the Type of Surgery,and APACHE II Score

Background

Owing to an aging society, both the number of operations for patients aged >85 years and the average age of patients admitted to the intensive care unit (ICU) are rapidly increasing. However, mortality is not an appropriate outcome measurement in patients aged >85 years; a more important outcome is home return (HR), because quality of life is valuable to these patients. We identified predictors for HR of patients aged >85 years admitted to the ICU after surgery.

Methods

Retrospective analysis of medical records was conducted at a university hospital. Patients aged > 85 years, admitted to the ICU after surgery from March 2006 to June 2015 (n = 187), were divided into a HR group (patients who returned home after discharge) and non-HR group (deceased or transferred to nursing facilities). Perioperative data and outcome were assessed and compared. Multivariate logistic regression analysis was conducted to identify independent predictors.

Results

The average age of patients was 88 years. HR occurred in 61% of patients, and mortality was 9%. The HR group had higher preoperative albumin level than did the non-HR group. More patients in the non-HR group experienced hip surgery than in the HR group (51 vs. 12%, P < 0.001). APACHE II score was higher (P < 0.001) in the non-HR group. In multivariate analysis, preoperative albumin, hip surgery, and APACHE II score were independent predictors of HR.

Conclusion

Predictors of HR of surgical critically ill elderly patients included preoperative albumin level, hip surgery, and APACHE II score on ICU admission.

     

Preoperative serum lactate cannot predict in-hospital mortality after decompressive craniectomy in traumatic brain injury

Purpose

Despite the utility of serum lactate for predicting clinical courses, little information is available on the topic after decompressive craniectomy. This study was conducted to determine the ability of perioperative serum lactate levels to predict in-hospital mortality in traumatic brain-injury patients who received emergency or urgent decompressive craniectomy.

Methods

The medical records of 586 consecutive patients who underwent emergency or urgent decompressive craniectomy due to traumatic brain injuries from January 2007 to December 2014 were retrospectively analyzed. Pre- and intraoperative serum lactate levels and base deficits were obtained from arterial blood gas analysis results.

Results

The overall mortality rate after decompressive craniectomy was 26.1 %. Mean preoperative serum lactate was significantly higher in the non-survivors (P = 0.034) than the survivors but had no significance for predicting in-hospital mortality in the multivariate regression analysis (P = 0.386). Rather, preoperative Glasgow Coma Score was a significant predictor for in-hospital mortality (hazard ratio 0.796, 95 % confidence interval 0.755–0.836, P < 0.001).

Conclusion

Preoperative lactate level is not an independent predictor of in-hospital mortality after decompressive craniectomy in traumatic brain-injury patients.

     

Addition of Surgery After Radiation Significantly Improves Survival in Stage IIIB Non-small Cell Lung Cancer: A Population-Based Analysis

Objectives

Limited work, either retrospective or prospective, has been done to investigate whether or not there is a cause-specific mortality (CSM) or all-cause mortality (ACM) benefit to adding surgery following neoadjuvant treatment for Stage IIIB NSCLC.

Methods

We extracted patients with Stage IIIB NSCLC from the Survival, Epidemiology, and End Results Program (SEER) database treated from 2004 to 2012 with either radiation alone or radiation followed by surgery. Other variables extracted were age, sex, race, and tumor location. The impact of patient and treatment variables on CSM and ACM was explored using Cox multivariable regression analysis.

Results

A total of 14,065 patients were extracted from the SEER database. On multivariable analysis, even after adjustment for age, gender, race, and site, radiation followed by surgery was associated with a reduction in cause-specific mortality compared to radiation alone (adjusted HR 0.46; 95 % CI 0.41, 0.52; p < 0.0001). Median overall survival was 11 months in the radiotherapy alone arm versus 29 months in the radiotherapy plus surgery arm (p < 0.0001 by log-rank test). After adjustment for these same factors, radiation followed by surgery was also associated with a reduction in all-cause mortality compared with radiation alone (adjusted HR 0.47; 95 % CI 0.42, 0.52; p < 0.0001). Median cause-specific survival was 12 months in the radiotherapy alone arm versus 33 months in the radiotherapy plus surgery arm (p < 0.0001 by log-rank test).

Discussion

In the SEER database, there appears to be both a CSM and ACM benefit to adding surgery following radiation for Stage IIIB NSCLC.

     

Total arch replacement versus debranching thoracic endovascular aortic repair for aortic arch aneurysm: what indicates a high-risk patient for arch repair in octogenarians?

Objectives

This study aimed to reveal the differences in intermediate outcomes between TAR and d-TEVAR in octogenarians and to identify risk factors for adverse events after aortic arch repair in octogenarians.

Methods

We reviewed medical records of 125 patients aged?>?80 years who underwent surgical intervention for aortic aneurysm between 2008 and 2016. Of these, 60 underwent conventional TAR (43 men; age, 82?±?2.2 years) and 65 underwent d-TEVAR (49 men; age, 84?±?3.4 years).

Results

Freedom from all causes of mortality at 2 and 4 years was similar (80 and 66% in TAR, 80 and 51% in d-TEVAR, p?=?0.17). Freedom from aortic death at 2 and 4 years was similar (88 and 88% in TAR, 87 and 76% in d-TEVAR, p?=?0.86). Using Cox regression analysis, chronic obstructive pulmonary disease (COPD) [hazard ratio (HR), 6.0; p?=?0.008], malignancy (HR, 8.8; p?=?0.004), previous cardiac and thoracic aortic surgery (required median sternotomy) (HR, 65.9; p?=?0.012), perioperative stroke (HR, 12.6; p?=?0.012), and postoperative pneumonia (HR, 5.8; p?=?0.026) were identified as independent positive predictors of overall postoperative mortality for TAR, whereas neurological dysfunction (HR, 3.0; p?=?0.016) and perioperative stroke (HR, 12.1; p?=?0.023) were identified for d-TEVAR.

Conclusions

TAR in octogenarians with COPD and/or malignancy showed higher mortality rates; d-TEVAR is more appropriate in these situations. The prevention of perioperative stroke, which is related with poor prognosis in both the groups, is critical.

     

Physical function at the time of dialysis initiation is associated with subsequent mortality

Background

In dialysis patients, physical function is associated with mortality. However, the association between physical function at the time of dialysis initiation and subsequent mortality remains unknown.

Methods

A total of 1496 patients with chronic kidney disease who initiated dialysis at 17 centers participating in the Aichi Cohort Study of the Prognosis in Patients Newly Initiated into Dialysis, a multicenter prospective cohort study, were included. The patients were divided into the high (H)-, middle (M)-, and low (L)-score groups according to Barthel index (BI) at the time of dialysis initiation, and the all-cause, cardiovascular disease (CVD)-related, and infection-related mortality rates were compared. Moreover, factors affecting all-cause mortality were investigated. The effects of BI on mortality were assessed in the patients stratified by age, sex, and history of CVD or cerebral infarction.

Results

A log-rank test for the Kaplan–Meier survival curve showed significant differences between the three groups in all-cause, CVD-related, and infection-related mortality rates (p < 0.001). Cox proportional hazard regression analysis with the step-wise method showed a significantly higher risk of all-cause mortality in the M and L groups than in the H group (M group: HR 1.612, 95 % CI 1.075–2.417; L group: HR 1.994, 95 % CI 1.468–2.709). Regardless of the age categories and the history of CVD, the risk of all-cause mortality was significantly higher in the L group than in the H group.

Conclusion

Physical function assessed by BI at the time of dialysis initiation was found to be associated with subsequent mortality.

     

Hip fracture,mortality risk,and cause of death over two decades

Summary

Men and women with hip fracture have higher short-term mortality. This study investigated mortality risk over two decades post-fracture; excess mortality remained high in women up to 10 years and in men up to 20 years. Cardiovascular disease (CVD) and pneumonia were leading causes of death with a long-term doubling of risk.

Introduction

Hip fractures are associated with increased mortality, particularly short term. In this study with a two-decade follow-up, we examined mortality and cause of death compared to the background population.

Methods

We followed 1013 hip fracture patients and 2026 matched community controls for 22 years. Mortality, excess mortality, and cause of death were analyzed and stratified for age and sex. Hazard ratio (HR) was estimated by Cox regression. A competing risk model was fitted to estimate HR for common causes of death (CVD, cancer, pneumonia) in the short and long term (>1 year).

Results

For both sexes and at all ages, mortality was higher in hip fracture patients across the observation period with men losing most life years (p?<?0.001). Mortality risk was higher for up to 15 years (women (risk ratio (RR) 1.9 [95 % confidence interval (CI) 1.7–2.1]); men (RR 2.8 [2.2–3.5])) and until end of follow-up ((RR 1.8 [1.6–2.0]); (RR 2.7 [2.1–3.3])). Excess mortality by time intervals, censored for the first year, was evident in women (<80 years, up to 10 years; >80 years, for 5 years) and in men <80 years throughout. CVD and pneumonia were predominant causes of death in men and women with an associated higher risk in all age groups. Pneumonia caused excess mortality in men over the entire observation period.

Conclusion

In a remaining lifetime perspective, all-cause and excess mortality after hip fracture was higher even over two decades of follow-up. CVD and pneumonia reduce life expectancy for the remaining lifetime and highlights the need to further improve post-fracture management.

     

Low serum intact parathyroid hormone level is an independent risk factor for overall mortality and major adverse cardiac and cerebrovascular events in incident dialysis patients

Summary

Abnormal bone dynamics is a major risk factor for cardiovascular disease in patients with chronic kidney disease. The level of serum intact parathyroid hormone (iPTH) is widely used as a bone dynamic marker. We investigated the effect of the mean level of serum iPTH on overall mortality and cardiovascular outcomes in incident dialysis patients.

Purpose

Chronic kidney disease–mineral bone disorder (CKD–MBD) is a major risk factor for cardiovascular disease (CVD) in patients with end-stage renal disease (ESRD). CKD–MBD is classified as low- or high-turnover bone disease according to the bone dynamics; both are related to vascular calcification in ESRD. To evaluate the prognostic value of abnormal serum parathyroid hormone (PTH) levels on ESRD patients, we investigated the effects of time-averaged serum intact PTH (TA-iPTH) levels on overall mortality and major adverse cardiac and cerebrovascular events (MACCEs) in incident dialysis patients.

Methods

Four hundred thirteen patients who started dialysis between January 2009 and September 2013 at Yonsei University Health System were enrolled. The patients were divided into three groups according to TA-iPTH levels during the 12 months after the initiation of dialysis: group 1, <65 pg/ml; group 2, 65–300 pg/ml; and group 3, >300 pg/ml. Cox regression analyses were performed to determine the prognostic value of TA-iPTH for overall mortality and MACCEs.

Results

The mean age of the patients was 57?±?15 years, and 222 patients (54 %) were men. During the median follow-up of 40.8?±?29.3 months, 49 patients (12 %) died, and MACCEs occurred in 55 patients (13 %). The multivariate Cox regression analyses demonstrated that a low TA-iPTH level was an independent risk factor for both overall mortality (group 2 as reference; group 1: hazard ratio (HR)?=?2.06, 95 % confidence interval (CI)?=?1.11–3.83, P?=?0.023) and MACCEs (HR?=?1.82, 95 % CI?=?1.04–3.20, P?=?0.036) in incident dialysis patients after adjustment for confounding factors.

Conclusion

Low serum TA-iPTH is a useful clinical marker of both overall mortality and MACCEs in patients undergoing incident dialysis, mediated by vascular calcification.

     

Remedial operations for failed endovascular therapy of 32 renal artery stenoses in 24 children

Background

Percutaneous transluminal angioplasty (PTA) for the treatment of pediatric renovascular hypertension (RVH) in contemporary practice is accompanied with ill-defined complications. This study examines the mode of pediatric renal PTA failures and the results of their surgical management.

Methods

Twenty-four children underwent remedial operations at the University of Michigan from 1996 to 2014 for failures of renal PTA. Their clinical courses were retrospectively reviewed and results analyzed.

Results

Renal PTA of 32 arteries, including 13 with stenting, was performed for severe RVH in 12 boys and 12 girls, having a mean age of 9.3 years. Developmental ostial stenoses affected 22 children. PTA failures included: 27 restenoses and five thromboses. Remedial operations included: 13 renal artery-aortic reimplantations, one segmental renal artery—main renal artery reimplantation, ten aortorenal bypasses, one arterioplasty, one iliorenal bypass, and six nephrectomies for unreconstructable arteries; the latter all in children younger than 10 years. Follow-up averaged 2.1 years. Postoperatively, hypertension was cured, improved, or unchanged in 25, 54, and 21 %, respectively. There was no perioperative renal failure or mortality.

Conclusions

Renal PTA for the treatment of pediatric RVH due to ostial disease may be complicated by failures requiring complex remedial operations or nephrectomy, the latter usually affecting younger children.