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1.
Micah R. Chan Bharvi Oza-Gajera Kevin Chapla Arjang X. Djamali Brenda L. Muth Jennifer Turk Maureen Wakeen Alexander S. Yevzlin Brad C. Astor 《Clinical journal of the American Society of Nephrology》2014,9(7):1225-1231
Background and objectives
Permanent hemodialysis vascular access is crucial for RRT in ESRD patients and patients with failed renal transplants, because central venous catheters are associated with greater risk of infection and mortality than arteriovenous fistulae or arteriovenous grafts. The objective of this study was to determine the types of vascular access used by patients initiating hemodialysis after a failed renal transplant.Design, setting, participants, & measurements
Data from the US Renal Data System database on 16,728 patients with a failed renal transplant and 509,643 patients with native kidney failure who initiated dialysis between January 1, 2006, and September 30, 2011 were examined.Results
At initiation of dialysis, of patients with a failed transplant, 27.7% (n=4636) used an arteriovenous fistula, 6.9% (n=1146) used an arteriovenous graft, and 65.4% (n=10,946) used a central venous catheter. Conversely, 80.8% (n=411,997) of patients with native kidney failure initiated dialysis with a central venous catheter (P<0.001). Among patients with a failed transplant, predictors of central venous catheter use included women (adjusted odds ratio, 1.75; 95% confidence interval, 1.63 to 1.87), lack of referral to a nephrologist (odds ratio, 2.00; 95% confidence interval, 1.72 to 2.33), diabetes (odds ratio, 1.14; 95% confidence interval, 1.06 to 1.22), peripheral vascular disease (odds ratio, 1.31; 95% confidence interval, 1.16 to 1.48), and being institutionalized (odds ratio, 1.53; 95% confidence interval, 1.23 to 1.89). Factors associated with lower odds of central venous catheter use included older age (odds ratio, 0.85 per 10 years; 95% confidence interval, 0.83 to 0.87), public insurance (odds ratio, 0.74; 95% confidence interval, 0.68 to 0.80), and current employment (odds ratio, 0.87; 95% confidence interval, 0.80 to 0.95).Conclusions
Central venous catheters are used in nearly two thirds of failed renal transplant patients. These patients are usually followed closely by transplant physicians before developing ESRD after a failed transplant, but the relatively low prevalence of arteriovenous fistulae/arteriovenous grafts in this group at initiation of dialysis needs to be investigated more thoroughly. 相似文献2.
Mariana Murea Kimone M. James Greg B. Russell Graham V. Byrum III James E. Yates Nicholas S. Tuttle Anthony J. Bleyer John M. Burkart Barry I. Freedman 《Clinical journal of the American Society of Nephrology》2014,9(4):764-770
Background and objectives
Elderly patients require tunneled central vein dialysis catheters more often than younger patients. Little is known about the risk of catheter-related bloodstream infection in this population.Design, setting, participants, & measurements
This study identified 464 patients on hemodialysis with tunneled central vein dialysis catheters between 2005 and 2007 and excluded patients who accrued <21 catheter-days during this period. Outpatient and inpatient catheter-related bloodstream infection data were collected. A Cox proportional hazards regression analysis adjusting for sex, ancestry, comorbidites, dialysis vintage, dialysis unit, immunosuppression, initial catheter site, and first antimicrobial catheter lock solution was performed for risk of catheter-related bloodstream infection between nonelderly (18–74 years) and elderly (≥75 years) patients.Results
In total, 374 nonelderly and 90 elderly patients with mean (SD) ages of 54.8 (12.3) and 81.3 (4.9) years and dialysis vintages of 1.8 (3.3) and 1.5 (2.9) years (P=0.47), respectively, were identified. Mean at-risk catheter-days were 272 (243) in nonelderly and 318 (240) in elderly patients. Between age groups, there were no significant differences in initial catheter site, type of catheter lock solution, or microbiology results. A total of 208 catheter-related bloodstream infection events occurred (190 events in nonelderly and 18 events in elderly patients), with a catheter-related bloodstream infection incidence per 1000 catheter-days of 1.97 (4.6) in nonelderly and 0.55 (1.6) in elderly patients (P<0.001). Relative to nonelderly patients, the hazard ratio for catheter-related bloodstream infection in the elderly was 0.33 (95% confidence interval, 0.20 to 0.55; P<0.001) after multivariate analysis.Conclusion
Elderly patients on hemodialysis using tunneled central vein dialysis catheters are at lower risk of catheter-related bloodstream infection than their younger counterparts. For some elderly patients, tunneled central vein dialysis catheters may represent a suitable dialysis access option in the setting of nonmaturing arteriovenous fistulae or poorly functioning synthetic grafts. 相似文献3.
Maria Elisa Mancuso Luisa Berardinelli Claudio Beretta Mauro Raiteri Ermanno Pozzoli Elena Santagostino 《Haematologica》2009,94(5):687-692
Background
An easy and stable venous access is essential in hemophilic children who receive regular prophylaxis or immune tolerance induction treatment. Central venous access devices improve treatment feasibility, but their use is complicated by infection and/or thrombosis. Arteriovenous fistula (AVF) has been evaluated as an alternative to central venous access devices in hemophilic children since 1999.Design and Methods
This study provides results obtained in a large series after seven years of follow-up.Results
From 1999 to 2008, 43 procedures were performed in 38 children (median age: 2.7 years). Thirty-five AVFs (81%) achieved maturation after a median of 58 days and were used for a median of five years (range: 0.4–8.5). A brachial artery caliber larger than 1.2 mm was associated with successful maturation (p<0.05). Complications with some impact on arteriovenous fistula use or duration were observed in 14/43 procedures (32%) and in 13/38 children (34%). Age at arteriovenous fistula creation was younger in children who lost arteriovenous fistula patency (p<0.05) and aneurysms were more frequent in children who were on daily treatment regimen and thus had a greater cumulative number of arteriovenous fistula accesses (p<0.05). At the end of the follow-up period, 22 AVFs were still in use and 9 had been surgically dismantled. Arteriovenous fistula use allowed long-term prophylaxis (up to 8.5 years) in 11 children and the completion of immune tolerance induction without interruptions in 18 children.Conclusions
This study confirms the feasibility of arteriovenous fistula with an acceptable rate of complications and suggests that its use is particularly favorable in children with inhibitors in whom it should be considered as first-choice venous access. 相似文献4.
Steven Wu Iftikhar Ahmad Sohail Qayyum Stephan Wicky Sanjeeva P. Kalva 《Clinical journal of the American Society of Nephrology》2011,6(6):1333-1336
Summary
Background and objectives
The safety of percutaneous endovascular declotting procedures for thrombosed hemodialysis fistulae/grafts is well described in the general population; however, its safety in the presence of a patent foramen ovale (PFO) is not known. The objective of this study is to assess the incidence of symptomatic paradoxical embolic events associated with declotting procedure of thrombosed arteriovenous (AV) graft or fistula in patients with documented PFO.Design, setting, participants, & measurements
This was a retrospective study in a hospital-based, academic practice. It included 23 patients (10 men; mean age, 65) with PFO and thrombosed hemodialysis graft/fistula who underwent a standardized declotting procedure with 2 mg of Alteplase and balloon thrombectomy. Twenty patients (87%) had AV grafts, and three (13%) had AV fistulae. The PFO shunt was right to left in two (9%), left to right in eight (34%), and bidirectional in ten (44%). The shunt direction was not specified in three patients (13%). The technical success of the declotting procedure and the frequency of clinically manifested paradoxical embolic events in this patient population were calculated.Results
Fifty declotting procedures were performed on 23 patients with a technical success rate of 96% (48 of 50, 96%). No symptomatic paradoxical embolic events were found in any of the 23 patients with PFO.Conclusions
Symptomatic paradoxical embolic events after percutaneous endovascular declotting procedures of thrombosed AV grafts and fistulae in patients with documented PFO are rare. This procedure appears to be safe in patients with a PFO. 相似文献5.
Eduardo Lacson Jr Weiling Wang J. Michael Lazarus Raymond M. Hakim 《Clinical journal of the American Society of Nephrology》2010,5(11):1996-2003
Background and objectives: Conversion from central venous catheters to a graft or a fistula is associated with lower mortality risk in long-term hemodialysis (HD) patients; however, a similar association with hospitalization risk remains to be elucidated.Design, setting, participants, & measurements: We conducted a prospective observational study all maintenance in-center HD patients who were treated in Fresenius Medical Care, North America legacy facilities; were alive on January 1, 2007; and had baseline laboratory data from December 2006. Access conversion (particularly from a catheter to a fistula or a graft) during the 4-month period from January 1 through April 30, 2007, was linked using Cox models to hospitalization risk during the succeeding 1-year follow-up period (until April 30, 2008).Results: The cohort (N = 79,545) on January 1, 2007 had 43% fistulas, 29% catheters, and 27% grafts. By April 30, 2007, 70,852 patients were still on HD, and among 19,792 catheters initially, only 10.3% (2045 patients) converted to either a graft or a fistula. With catheters as reference, patients who converted to grafts/fistulas had similar adjusted hazard ratios (0.69) as patients on fistulas (0.71), while patients with fistulas/grafts who converted to catheters did worse (1.22), all P < 0.0001.Conclusions: Catheters remain associated with the greatest hospitalization risk. Conversion from a catheter to either graft or fistula had significantly lower hospitalization risk relative to keeping the catheter. Prospective studies are needed to determine whether programs that reduce catheters will decrease hospitalization risk in HD patients.In long-term hemodialysis (HD) patients, an arteriovenous fistula is preferred over arteriovenous grafts and central venous catheters (1–3). Within the campaign to increase fistulas, our group and others have expressed concern over the alarming rates of catheter use, the access type with the worst associated outcomes (4–8). Data derived from the Hemodialysis (HEMO) Study indicated substantial reduction in death risk associated with conversion from catheters to fistulas or grafts in prevalent HD patients who had survived for 1 year (9). Recently, a report from the Dialysis Outcomes and Practice Patterns Study (DOPPS) also showed an association of improved survival with conversion from initial catheter accesses to either fistulas or grafts for incident HD patients, with 30% lower adjusted mortality risk compared with patients who were maintained on catheter access (10). Of note, the survival advantage that was associated with catheter removal was similar, whether patients converted to fistulas or grafts.We recently reported a similar reduction of death risk associated with conversion from catheters to grafts or fistulas in a cohort of 79,545 prevalent HD patients whose access types were tracked during a 4-month baseline period, with mortality monitored for the remainder of the year (11). As a follow-up to this study, we used the same large prevalent cohort of HD patients to test the hypothesis that conversion from a catheter to either a fistula or a graft during a 4-month period may be associated with lower hospitalization risk in the succeeding year, compared with patients with continuous catheter use. To frame this hypothesis in context, we initially determined the association between baseline access type and hospitalization risk. 相似文献
6.
Martins PN Chang S Mahadevapa B Martins AB Sheiner P 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2011,13(3):212-220
Background
There is a general concern that aged organs are more susceptible to ischaemia. In the light of recent proposals to change the liver allocation system by expanding regional sharing, it is feared that increased cold ischaemia time of grafts from older donors may reduce graft survival. The aim of this study was to correlate donor age and the patterns of ischaemia reperfusion injury and synthetic function early after liver transplantation.Methods
We performed a retrospective study of first transplants using a single-centre electronic database. Patterns of liver injury (based on transaminases and post-reperfusion biopsy), synthetic function (international normalized ratio [INR]), and graft and patient survival in recipients receiving liver grafts from donors aged ≥65 years (group 1, n= 50) were compared with equivalent patterns in a matched cohort of recipients transplanted with grafts from donors aged <65 years (group 2, n= 50).Results
There was no significant difference in transaminase levels from day 0 to day 6 after transplantation. When groups 1 and 2 were subdivided into two subgroups based on the duration of graft cold ischaemia time (<8 h and ≥8 h), there was no statistical difference in transaminase levels during the first 7 days. There were two cases (4%) of primary non-function in group 1 and one (2%) in group 2. Initial poor function did not differ significantly between the groups (26% vs. 24%; P= 0.81). In addition, there was no difference in histological changes in post-reperfusion biopsies (21% vs. 34%; P= 0.078) and rate of acute rejection episodes in the first year (30% vs. 32%; P= 0.99). There was no significant difference between groups 1 and 2 in 1-year patient and graft survivals (78% vs. 90% [P= 0.17]; 88% vs. 94% [P= 0.48], respectively).Conclusions
Judiciously selected livers from aged donors are not associated with major increased susceptibility to ischaemia reperfusion injury. 相似文献7.
Zisun Kim Min Joo Kim Jung Hoon Kim So Young Jin Yong Bae Kim Daekwan Seo Dongho Choi Kyung Yul Hur Jae Joon Kim Min Hyuk Lee Chul Moon 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2009,11(3):215-221
Background:
Post-operative pancreatic fistula (POPF) is one of the most fearful complications which may occur after pancreaticoduodenectomy (PD). The methods used to predict POPF pre-operatively have not been studied in great detail. We analyzed correlation between various parameters related to PD including pre-operative magnetic resonance imaging (MRI) signal intensity (SI), pathology of pancreatic fibrosis and occurrence rates of POPF, and verified that MRI SI results could be the determining values for pre-operative prediction of POPF.Methods:
From January 2005 to August 2006, we retrospectively examined 43 cases of PDs by reviewing abdominal MRI findings, degree of fibrosis of remnant pancreatic stump, and other surgery-related parameters.Results:
POPF encountered in PD were 11 cases (25.6%). Operation time and degree of fibrosis of remnant pancreatic cut surface were related to POPF (P= 0.030, P= 0.010). The pancreas–liver SI ratio (PLSI) between fistula group and no fistula group was −0.0009 ± 0.2 and −0.1297 ± 0.2, respectively (P= 0.0004). The pancreas–spleen SI ratio (PSSI) in each group was 0.423 ± 0.25 and 0.288 ± 0.32, respectively (P= 0.014). Using quantitative analysis, the SI ratios were 1.27 and 0.66 in each group (P= 0.013).Conclusions:
When analyzing the results of POPF in 43 patients who underwent PD, PLSI, PSSI and qualitative analysis, fistula group differed significantly from no fistula group. Using these results, it will be helpful for us to predict the occurrence of POPF pre-operatively using MRI in PD patients. 相似文献8.
Fu-Bao Liu Jiang-Ming Chen Wei Geng Sheng-Xue Xie Yi-Jun Zhao Li-Quan Yu Xiao-Ping Geng 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2015,17(2):123-130
Objectives
This study aimed to compare pancreaticojejunostomy (PJ) with pancreaticogastrostomy (PG) after pancreaticoduodenectomy (PD).Methods
A literature search of PubMed and the Cochrane Central Register of Controlled Trials for studies comparing PJ with PG after PD was conducted. The primary outcome for meta-analysis was pancreatic fistula. Secondary outcomes were morbidity, mortality, biliary fistula, intra-abdominal fluid collection, hospital length of stay (LoS), postoperative haemorrhage and reoperation. Outcome measures were odds ratios (ORs) and mean differences with 95% confidence intervals (CIs).Results
Seven recent RCTs encompassing 1121 patients (559 PJ and 562 PG cases) were involved in this meta-analysis. Incidences of pancreatic fistula (10.6% versus 18.5%; OR 0.52, 95% CI 0.37–0.74; P = 0.0002), biliary fistula (2.3% versus 5.7%; OR 0.42, 95% CI 0.03–3.15; P = 0.03) and intra-abdominal fluid collection (8.0% versus 14.7%; OR 0.50, 95% CI 0.34–0.74; P = 0.0005) were significantly lower in the PG than the PJ group, as was hospital LoS (weighted mean difference: −1.85, 95% CI −3.23 to −0.47; P = 0.008). Subgroup analysis indicated that severe pancreatic fistula (grades B or C) occurred less frequently in the PG than the PJ group (8.3% versus 20.5%; OR 0.37, 95% CI 0.23–0.59; P < 0.00001). However, there was no significant difference in morbidity (48.9% versus 51.0%; OR 0.90, 95% CI 0.70–1.16; P = 0.41), mortality (3.2% versus 3.5%; OR 0.82, 95% CI 0.43–1.58; P = 0.56), delayed gastric emptying (16.6% versus 14.7%; relative risk: 1.02, 95% CI 0.62–1.68; P = 0.94), postoperative haemorrhage (9.6% versus 11.1%; OR 0.82, 95% CI 0.54–1.24; P = 0.35) or reoperation (9.9% versus 9.8%; OR 0.93, 95% CI 0.60–1.43; P = 0.73).Conclusions
Pancreaticogastrostomy provides benefits over PJ after PD, including in the incidences of pancreatic fistula, biliary fistula and intra-abdominal fluid collection and in hospital LoS. Therefore, PG is recommended as a safer and more reasonable alternative to PJ reconstruction after PD. 相似文献9.
Manju D Chandrasegaram Guy D Eslick Wayne Lee Mark E Brooke-Smith Rob Padbury Christopher S Worthley John W Chen John A Windsor 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2014,16(8):691-698
Background
Portal vein (PV) resection is used increasingly in pancreatic resections. There is no agreed policy regarding anticoagulation.Methods
A systematic review was performed to compare studies with an anticoagulation policy (AC+) to no anticoagulation policy (AC−) after venous resection.Results
There were eight AC+ studies (n = 266) and five AC− studies (n = 95). The AC+ studies included aspirin, clopidogrel, heparin or warfarin. Only 50% of patients in the AC+ group received anticoagulation. There were more prosthetic grafts in the AC+ group (30 versus 2, Fisher''s exact P < 0.001). The overall morbidity and mortality was similar in both groups. Early PV thrombosis (EPVT) was similar in the AC+ group and the AC− group (7%, versus 3%, Fisher''s exact P = 0.270) and was associated with a high mortality (8/20, 40%). When prosthetic grafts were excluded there was no difference in the incidence of EPVT between both groups (1% vs 2%, Fisher''s exact test P = 0.621).Conclusion
There is significant heterogeneity in the use of anticoagulation after PV resection. Overall morbidity, mortality and EPVT in both groups were similar. EPVT has a high associated mortality. While we have been unable to demonstrate a benefit for anticoagulation, the incidence of EPVT is low in the absence of prosthetic grafts. 相似文献10.
Nissreen Elfadawy Stuart M. Flechner Jesse D. Schold Titte R. Srinivas Emilio Poggio Richard Fatica Robin Avery Sherif B. Mossad 《Clinical journal of the American Society of Nephrology》2014,9(3):553-561
Background and objectives
The objective was to study the long-term impact of transient versus persistent BK viremia on kidney transplant outcomes.Design, setting, participants, & measurements
In total, 609 recipients who underwent kidney transplant from 2007 to 2011 were screened at months 1–12 for the occurrence of polyomavirus BK viremia; 130 patients (21.7%) developed BK viremia during the first year post-transplant. BK viremia patients were classified according to duration of infection (more or less than 3 months), and BK viral loads (more or less than 10,000 copies/ml) were classified as transient low viremia (n=42), transient high viremia (n=18), persistent low viremia (n=23), and persistent high viremia (n=47). All patients were followed a median of 36 (3–66) months. The rates of BK polyomavirus–associated nephropathy, acute rejection, and 1-year graft function were compared with the polyomavirus BK–negative control group.Results
Patient and graft survival were not significantly different among the groups. Graft function (creatinine; milligrams per deciliter) at 1 year was significantly worse in the persistent high viremia (1.75±0.6) and transient high viremia (1.85±0.7) groups compared with aviremic controls (1.47±0.4; P=0.01 and P=0.01, respectively). The incidence of BK polyomavirus–associated nephropathy was limited to the persistent high viremia group (1.3%, P<0.001). The transient high viremia (50%) and persistent high viremia (34%) groups showed significantly (P=0.01) increased incidence of acute rejection versus aviremic controls (21.5%), transient low viremia (19%), or persistent low viremia (17.3%) groups.Conclusion
Low viral load BK viremia, either transient or persistent, was not associated with long-term transplant outcomes. Persistent high viremia was associated with a greater risk for BK polyomavirus–associated nephropathy and subsequent graft dysfunction. Although transient high viremia was not associated with BK polyomavirus–associated nephropathy, it was associated with worse graft function. These data support the role of surveillance for BK viremia after transplant. 相似文献11.
Geun Dong Lee Hyeong Ryul Kim Se Hoon Choi Yong-Hee Kim Dong Kwan Kim Seung-Il Park 《Journal of thoracic disease》2016,8(1):61-67
Background
We aimed to assess graft patency in patients undergoing prosthetic graft interposition of the brachiocephalic veins (BCVs) or the superior vena cava (SVC) combined with resection of malignant tumours.Methods
A retrospective analysis was conducted on 16 patients who underwent prosthetic graft interposition of the BCVs or the SVC between 1998 and 2012.Results
Among a total of 20 grafts in 16 patients (unilateral graft interposition in 12, bilateral graft interposition in 4), 8 grafts were occluded in 8 patients. Overall graft patency rate was 64.6%, 42.4% at the 2- and 5-year follow-up. Graft patency rate of the left BCV was significantly lower than that of the right BCV or the SVC (2-year patency, 38.1% vs. 81.8%, P=0.024). In univariate analysis, the superior anastomosis site [left BCV vs. right BCV; hazard ratio (HR) =2.312; 95% confidence interval (CI), 1.015–5.265; P=0.046], the inferior anastomosis site (right atrial appendage vs. SVC; HR =2.409; 95% CI, 1.124–5.161; P=0.024), and interruption of warfarin (HR =5.015; 95% CI, 1.106–22.734; P=0.037) were significant risk factors for graft occlusion. Graft occlusive symptoms were identified in 4 patients who underwent unilateral graft interposition.Conclusions
Prosthetic graft interposition between the left BCV and the right atrial appendage resulted in a significant rate of graft occlusion. Prosthetic graft interposition of the bilateral BCVs and long-term warfarin therapy may be necessary to prevent graft occlusive symptoms. 相似文献12.
Luca Viganò Alexis Laurent Claude Tayar Jean-Claude Merle Jean-Yves Lauzet Monica Hurtova Thomas Decaens Christophe Duvoux Daniel Cherqui 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2010,12(3):195-203
Background:
The split-liver technique provides a good left lateral graft in children, but its results in adults remain controversial.Methods:
From 1992 to 2007, 37 patients received 38 cadaveric right-sided grafts. Donors and recipients were selected for good quality grafts and elective indications; the latter included a high proportion of tumour cases and primary sclerosing cholangitis. Grafts included 31 extended right grafts (ERGs; segments IV–VIII and I and the inferior vena cava [IVC]) and seven right grafts (RGs; segments V–VIII) including five without the IVC and middle hepatic vein (MHV).Results:
Mortality was 5% (two patients). There were four retransplantations (11%) for arterial thrombosis (1), portal vein thrombosis (2) and primary non-function (1). The retransplantation rate was higher in RG than in ERG (three vs. one patient; P= 0.015). Of the five patients without MHV, three were retransplanted and one had small-for-size syndrome leading to late death. After a mean follow-up of 5 years, 1-, 3- and 5-year graft and patient survival rates were 84%, 80% and 71%, and 91%, 88% and 78%, respectively. One-year patient and graft survival rates after ERG transplantation were 96% and 92%, respectively.Conclusions:
Split-liver transplantation is a safe alternative to whole organ transplantation when an ERG is carried out. Right graft is associated with increased risk of graft loss, especially if the MHV is omitted. Split-liver transplantation with an ERG offers excellent outcomes and should be encouraged when good quality grafts are available. 相似文献13.
Shin-E. Wang Shih-Chin Chen Bor-Uei Shyr Yi-Ming Shyr 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2016,18(3):229-235
Background
The aim of this study was to compare perioperative outcomes after Blumgart pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) for pancreatic-enteric reconstruction following pancreaticoduodenectomy.Methods
Data of patients undergoing Blumgart PJ and PG were retrieved from prospectively-collected database. Matched patients in each surgical groups were included based on the Callery risk scoring system for clinically relevant postoperative pancreatic fistula (CR-POPF) (grades B and C). Surgical parameters and risks were compared between these two groups.Results
A total of 206 patients undergoing PD were included. Blumgart PJ was associated with shorter postoperative hospital stay (median (range) 25 (10–99) vs. 27 (10–97) days, P = 0.022). There was no surgical mortality in the Blumgart PJ group, but a 4.9% perioperative mortality in the PG, P = 0.030. The CR-POPF by Blumgrt PG is significantly lower than that by PG for overall patients (7% vs. 20%, P = 0.007), especially for those in intermediate fistula risk zone (6% vs. 21%, P = 0.048) and high fistula risk zone (14% vs. 47%, P = 0.038).Conclusions
Blumgart PJ is superior to PG in terms of pancreatic leakage and surgical mortality. Blumgart PJ can be recommended for pancreatic reconstruction after PD for all pancreatic remnant subtypes. 相似文献14.
Carol L. Moore Anatole Besarab Marie Ajluni Vivek Soi Edward L. Peterson Laura E. Johnson Marcus J. Zervos Elizabeth Adams Jerry Yee 《Clinical journal of the American Society of Nephrology》2014,9(7):1232-1239
Background and objectives
Infection is the second leading cause of death in hemodialysis patients. Catheter-related bloodstream infection and infection-related mortality have not improved in this population over the past two decades. This study evaluated the impact of a prophylactic antibiotic lock solution on the incidence of catheter-related bloodstream infection and mortality.Design, setting, participants, & measurements
This prospective, multicenter, observational cohort study compared the effectiveness of two catheter locking solutions (gentamicin/citrate versus heparin) in 555 hemodialysis patients dialyzing with a tunneled cuffed catheter between 2008 and 2011. The groups were not mutually exclusive. Rates of catheter-related bloodstream infection and mortality hazards were compared between groups.Results
The study population (n=555 and 1350 catheters) had a median age of 62 years (interquartile range=41–83 years), with 50% men and 71% black. There were 427 patients evaluable in the heparin period (84,326 days) and 322 patients evaluable in the antibiotic lock period (71,192 days). Catheter-related bloodstream infection in the antibiotic lock period (0.45/1000 catheter days) was 73% lower than the heparin period (1.68/1000 catheter days; P=0.001). Antibiotic lock use was associated with a decreased risk of catheter-related bloodstream infection compared with heparin (risk ratio, 0.23; 95% confidence interval, 0.13 to 0.38 after multivariate adjustment). Cox proportional hazards modeling found that antibiotic lock was associated with a reduction in mortality (hazard ratio, 0.36; 95% confidence interval, 0.22 to 0.58 in unadjusted analyses; hazard ratio, 0.32; 95% confidence interval, 0.14 to 0.75 after multivariate adjustment). The rate of gentamicin-resistant organisms decreased (0.40/1000 person-years to 0.22/1000 person-years) in the antibiotic lock period (P=0.01).Conclusions
The results of this study show that the use of a prophylactic, gentamicin/citrate lock was associated with a substantial reduction in catheter-related bloodstream infection and is the first to report a survival advantage of antibiotic lock in a population at high risk of infection-related morbidity and mortality. 相似文献15.
Guofen Yan Alfred K. Cheung Jennie Z. Ma Alison J. Yu Tom Greene M. Norman Oliver Wei Yu Keith C. Norris 《Clinical journal of the American Society of Nephrology》2013,8(4):610-618
Background and objectives
Pre-ESRD care is an important predictor of outcomes in patients undergoing long-term dialysis. This study examined the extent of variation in receiving pre-ESRD care and black-white disparities across urban and rural counties.Design, setting, participants, & measurements
Participants were 404,622 non-Hispanic white and black patients aged >18 years who began dialysis between 2005 and 2010 and resided in 3076 counties from the U.S. Renal Data System. The counties were grouped into large metropolitan, medium/small metropolitan, suburban, and rural counties. Pre-ESRD care indicators included receipt of nephrologist care at least 6 or 12 months before ESRD, dietitian care, use of arteriovenous fistula at first outpatient dialysis session, and use of erythropoiesis-stimulating agents (ESAs) in patients with hemoglobin level < 10 g/dl.Results
Large metropolitan and rural counties had lower percentages of patients who received pre-ESRD nephrologist care (25.7% and 26.9% for nephrologist care > 12 months), compared with the higher percentage in medium/small metropolitan counties (31.6%; both P<0.001). For both races, nonmetropolitan patients had poorer access to dietitian care and lower ESA use than metropolitan patients. Consistently in all four geographic areas, black patients received less care than their white counterparts. The unadjusted odds ratios of black versus white patients in receiving nephrologist care for >12 months before ESRD were 0.66 (95% confidence interval [CI], 0.61–0.72) in large metropolitan counties and 0.79 (95% CI, 0.69–0.90) in rural counties. The patterns remained, albeit attenuated, after adjustment for patient factors.Conclusions
The receipt of pre-ESRD care, with blacks receiving less care, varies among geographic areas defined by urban/rural characteristics. 相似文献16.
Knowles B Welsh FK Chandrakumaran K John TG Rees M 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2012,14(5):298-309
Background
Neoadjuvant chemotherapy for colorectal liver metastases (CRLM) reduces the accuracy of liver imaging which may understage patients pre-operatively. Retrospective review of a prospective database to determine whether liver-specific magnetic resonance imaging (MRI) prior to pre-operative chemotherapy affects intra-hepatic recurrence and long-term outcome after hepatectomy.Patients and methods
Between 2003 and 2009, 242 patients with CRLM underwent a hepatectomy after ≥3 cycles of oxaliplatin or irinotecan-based chemotherapy. All had a liver-specific MRI immediately pre-operatively. The outcome of patients who had a liver-specific MRI prior to chemotherapy (PCI group, n = 92) was compared with those who did not (non-PCI group, n = 150).Results
A liver-specific MRI pre-chemotherapy changed the staging in 56% of patients. At a median (range) follow-up of 55 (6–94) months, there was a higher incidence of intra-hepatic recurrence at a new site in the non-PCI group (65% vs. 48% in the PCI group, P = 0.041) and an increased rate of recurrence in patients with the same number of lesions pre- and post-chemotherapy [hazard ratio (HR) 2.02, 1:10–3.37, P = 0.024]. The non-PCI group underwent more repeat hepatectomies than the PCI group (24.7% vs. 13%, P = 0.034), achieving similar long-term survival.Conclusions
A liver-specific MRI prior to chemotherapy reduces intra-hepatic recurrence and avoids a repeat hepatectomy. 相似文献17.
Van Arendonk KJ James NT Locke JE Montgomery RA Colombani PM Segev DL 《Clinical journal of the American Society of Nephrology》2011,6(11):2705-2711
Summary
Background and objectives
Kidney transplantation from donors after cardiac death (DCD) provides similar graft survival to donors after brain death (DBD) in adult recipients. However, outcomes of DCD kidneys in pediatric recipients remain unclear, primarily because of limited sample sizes.Design, setting, participants, & measurements
We identified 137 pediatric (<18 years old) recipients of DCD kidneys between 1994 and 2010 using Scientific Registry of Transplant Recipients data and compared outcomes with 6059 pediatric recipients of DBD kidneys during the same time period, accounting for donor, recipient, and transplant characteristics using time-varying Cox regression and matched controls. Long-term follow-up (4 years or beyond) was available for 31 DCD recipients.Results
Pediatric recipients of DCD kidneys experienced a significantly higher rate of delayed graft function (22.0% versus 12.3%; P = 0.001), although lower than reported delayed graft function rates of DCD grafts in adults. Although DCD and DBD graft survival was equal in the early postoperative period, graft loss among pediatric recipients of DCD kidneys exceeded their DBD counterparts starting 4 years after transplantation. This effect was statistically significant in a multivariate Cox model (hazard ratio = 2.03; 95% confidence interval, 1.21 to 3.39; P = 0.007) and matched-controls analysis (hazard ratio = 2.36; 95% confidence interval, 1.11 to 5.03; P = 0.03).Conclusions
A significant increase in DCD graft loss starting 4 years after transplantation motivates a cautious approach to the use of DCD kidneys in children, in whom long-term graft survival is of utmost importance. 相似文献18.
Louiza Lioni Konstantinos P. Letsas Michael Efremidis Konstantinos Vlachos Georgios Giannopoulos Vasileios Kareliotis Spyridon Deftereos Antonios Sideris 《老年心脏病学杂志》2014,11(4):291-295
Background Atrial fibrillation (AF) catheter ablation has emerged as a promising treatment strategy for AF, but has not been widely adopted in the elderly population. The present study aimed to determine the safety and efficacy of AF catheter ablation in the elderly popula-tion. Methods and Results The study population consisted of 316 patients with paroxysmal AF who underwent left atrial ablation. Ninety-five patients were≥65 years (48 males, mean age 68.9 ± 3.0 years old) and 221 patients were〈65 years old (130 males, mean age 52.5 ± 10.4 years old). After a mean follow-up period of 34.0 ± 15.1 months, 55 (57.9%) patients in the elderly group were free from ar-rhythmia recurrence compared with 149 (67.4%) patients in the younger group (P=0.169). Procedural complications were uncommon in both study groups. In logistic regression analysis, left atrial diameter (P=0.003), hypertension (P=0.001), dyslipidemia (P=0.039), and coronary artery disease (P=0.018) were independent predictors of AF recurrence in the elderly population. Conclusions Catheter ablation of AF is safe and effective in older patients. Invasive strategies should be considered as an alternative choice in symptomatic elderly patients with AF. 相似文献
19.
Pietro Addeo Jean Robert Delpero Francois Paye Elie Oussoultzoglou Pascal R Fuchshuber Alain Sauvanet Antonio Sa Cunha Yves Patrice Le Treut Mustapha Adham Jean-Yves Mabrut Laurence Chiche Philippe Bachellier The French Surgical Association 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2014,16(1):46-55
Backgrounds
A pancreatic fistula (PF) is the most relevant complication after a pancreaticoduodenectomy (PD). This retrospective multicentric study attempts to elucidate the risk factors and complications of a PF in a large cohort of patients undergoing a PD for ductal adenocarcinoma.Methods
Using a survey tool, clinical data of 1325 patients undergoing a PD for ductal adenocarcinoma at 37 institutions, between January 2004 and December 2009, were collected. Peri-operative risk factors associated with PF and its association with morbidity and mortality were assessed. Morbidity and PF were graded according to the ISGPF (International Study group for pancreatic fistula) definition and the Dindo–Clavien classification.Results
Overall PF, mortality, morbidity and relaparotomy rates were 14.3%, 3.8%, 54.4% and 11.7%, respectively. PF occurred more frequently after a pancreaticojejunostomy (PJ) compared with a pancreaticogastrostomy (PG) (16.8% vs. 10.4%; P = 0.0012). Independent risk factors for PF by multivariate analysis were absence of pre-operative diabetes (P = 0.0014), PJ reconstruction (P = 0.0035), soft pancreatic parenchyma (P < 0.0001) and low-volume centre (P = 0.0286). Clinically relevant PF (grade B and C) and severe complications (Dindo–Clavien grade IIIB, IV, V) were significantly more frequent after PJ than PG (71.6% vs. 28.3%; P = 0.030 and 24.8% vs. 19.1%; P = 0.015, respectively). Overall mortality and relaparotomy rates were similar after PG and PJ.Conclusions
A soft pancreatic parenchyma, the absence of pre-operative diabetes, PJ and low-volume centre are independent risk factors for PF after PD for ductal adenocarcinoma. A significantly higher incidence and clinical severity of PF are associated with PJ. 相似文献20.
Xue-Sen Cao Jun Chen Jian-Zhou Zou Yi-Hong Zhong Jie Teng Jun Ji Zhang-Wei Chen Zhong-Hua Liu Bo Shen Yu-Xin Nie Wen-Lv Lv Fang-Fang Xiang Xiao Tan Xiao-Qiang Ding 《Clinical journal of the American Society of Nephrology》2015,10(1):111-119