Prednisone in the treatment of tubulointerstitial nephritis in children

Background

Patients with tubulointerstitial nephritis (TIN) may develop permanent renal impairment. However, there are no prospective studies available on the treatment of TIN.

Methods

The effect of prednisone in the treatment of TIN was evaluated in a total of 17 patients who received prednisone or who were followed up without medication. The patient group was subdivided based on the initial plasma creatinine (PCr), below or above 150 μmol/l.

Results

All prednisone-treated patients had normal plasma creatinine (PCr) after 1 month of treatment (median 59.1 [45–85] μmol/l) whereas only 50 % of patients in the non-treatment group had normal creatinine (median 81.0 [42–123] μmol/l) at the same time point (p?=?0.025). During 6 months’ follow-up, PCr decreased in all patient groups; however, it decreased significantly only in prednisone-treated patients with baseline PCr >150 μmol/l (p?<?0.001). At the end of follow-up, no difference in PCr, glomerular filtration rate (GFR), or low molecular weight (LMW) proteinuria could be found between the study groups. A considerable number of patients in both groups had subnormal GFR and/or persistent LMW proteinuria at the 6-month follow-up visit. Eighty-two percent of the patients had uveitis.

Conclusions

Prednisone speeds up the recovery from renal symptoms of TIN, especially in patients with severe nephritis. The renal function did not differ significantly between prednisone and control patients after 6 months’ follow-up.     

Cyanid-Intoxikationen

Introduction

Cyanide is important as a component of smoke, as an industrial chemical and as a potential chemical weapon. In cases of inhalational exposure to high cyanide concentrations the poisoning is fulminant. Poisoning can also occur after ingestion of organic compounds with nitrile groups. As cyanide is released metabolically, the symptoms may develop after a latency period of several hours. Cyanide acts through a blockade of cytochrome oxidases and leads to internal suffocation.

Material and methods

In addition to nonspecific life support an antidote treatment is indicated. Dimethylaminophenol (DMAP) induces the formation of methemoglobin which binds cyanide ions because of its trivalent iron ion and thus reduces the burden on the respiratory chain (3–4 mg/kg body weight forming about 30?% methemoglobin). However, DMAP should only be given in cases of severe poisoning to unconscious patients. Alternatively, hydroxocobalamin (vitamin B12) may be administered at high doses (70 mg/kg) as it binds and inactivates cyanide. After inhalation of incendiary smoke, concomitant carbon monoxide poisoning with reduced oxygen-carrying capacity of the blood must be taken into account. In case the percentage of carboxyhemoglobin in blood cannot be determined, hydroxocobalamin, if available, or DMAP at reduced doses (1–2 mg/kg) should be given. In addition sodium thiosulphate (0.1 g/kg i.v.) should be administered to accelerate the detoxification of cyanide. In cases of mild poisoning the administration of sodium thiosulphate alone is sufficient. Fire smoke also contains irritant gases and the risk of pulmonary edema must be considered. Besides the metabolic release of cyanide, organic compounds with nitrile groups often cause non-specific central nervous disorders and many volatile compounds are also irritant gases. Moreover, these organic nitriles may have additional substance-specific toxic effects, so that it is highly advisable to contact a poison control center.     

The value of an artificial neural network in the decision-making for prostate biopsies

Purpose

In majority of patients who are subjected to prostate biopsies, no prostate cancer (PCa) is found. It is important to prevent unnecessary biopsies since serious complications may occur. An artificial neural network (ANN) may be able to predict the risk of the presence of PCa.

Methods

Included were all patients, who underwent transrectal ultrasound-guided prostate biopsies between June 2006 and June 2007 with a total PSA (tPSA) level between 2 and 20 μg/l. The patients were divided into two groups according to their tPSA level (2–10 μg/l and 10–20 μg/l). The ANN Prostataclass of the Universitätsklinikum Charité in Berlin was used. The predictions of the ANN were compared to the pathology results of the biopsies.

Results

Overall 165 patients were included. PCa was diagnosed in 53 patients, whereas the ANN predicted “no risk” in 19 of these patients (36%). The ANN output receiver operator characteristic (ROC) plots for the range of tPSA 2–10 μg/l and tPSA 10–20 μg/l showed an area under the curve (AUC) of 63 and 88% for the initial biopsy group, versus 69 and 57%, respectively, for the repeat biopsy group.

Conclusions

The ANN resulted in a false negative rate of 36%, missing PCa in 19 patients. For use in an outpatient-clinical setting, this ANN is insufficient to predict the risk of presence of PCa reliably.     

DHEA(S)—a novel marker in Cushing’s disease

Introduction

Dehydroepiandrosterone sulfate (DHEA(S)) is a multi-functional steroid implicated in a broad range of biological effects, including obesity, diabetes, bone metabolism, neuroprotection, and anti-tumorigenesis. It has not yet undergone wider research in the context of Cushing’s disease. The objective of this study was to determine if perioperative blood levels of DHEA(S) correlate with levels of ACTH and cortisol, and therefore may be useful as a new, additional marker for the early definition of cure in patients suffering from Cushing’s disease.

Methods

Forty-two consecutive patients undergoing transsphenoidal surgery for Cushing’s disease from September 2009 to September 2010 were perioperatively monitored for ACTH, cortisol, and DHEA(S).

Results

Pre-operative blood samples revealed ACTH levels of median 65 ng/l (range 11–1,183 ng/l, standard deviation 183.76), cortisol of median 257 μg/l (range 93–803 μg/l, standard deviation 140.88), and DHEA(S) of median 2.22 mg/l (range 0.44–7.79 mg/l, standard deviation 1.82) according to the pathology of Cushing’s disease. Postoperative blood samples drawn over a 7-day time span showed a drop in median ACTH to just 14.5 % (median: 9 ng/l, range 2–44, standard deviation 12.75) of its median preoperative figure. Median cortisol levels were reduced to 6.9 % (median: 18 μg/l, range 10–190 μg/l, standard deviation 38.04) of their preoperative values and DHEA(S) levels decreased to 17 % (median: 0.38 mg/l, range 0.05–2.29, standard deviation 0.51). In persistent disease, no patient showed a drop in DHEA(S) below 38 % of its preoperative figures.

Conclusions

DHEA(S) shows the potential to become an additional marker in the diagnosis and follow-up of patients. However, it needs to be examined further, including whether DHEA(S) may also be a useful predictor of recovery of the HPA-axis after successful surgery.     

S100B,intraoperative neuromonitoring findings and their relation to clinical outcome in surgically treated intradural spinal lesions

Background

Neurophysiological monitoring (IOM) consisting of somatosensory (SEPs), muscle (MEPs) and spinal motor evoked (D-wave; spinal MEPs) potentials is used to indicate injury related to surgical treatment of intradural and intramedullary lesions. Combining spinal and muscle MEPs reliably predicts long-term motor deficit. If spinal MEPs recording is not possible, additional markers—e.g. S100B, a serum marker for glial injury—may be a helpful adjunct. Thus, serial serum S100B measurements were related to both the intraoperative IOM recordings and the long-term neurological outcome in patients surgically treated for cervical and thoracic intradural lesions.

Methods

In 33 patients (9 men, 24 women, 54?±?17 years) during intramedullary (8) or intradural (25) cervical or thoracic spinal surgeries significant intraoperative SEP-amplitude decrement >50 % or MEP loss and serial S100B serum concentration (perioperative days 0, 1-3, 5) were related to outcome (>1 year after discharge, grouped into improved and unchanged/altered neurological symptoms).

Results

Differences in S100B levels between patients with improved and unchanged/altered neurological outcome were significantly on postoperative days 2 (0.085?±?0.08 μg/l vs 0.206?±?0.07 μg/l, p?=?0.005) and 3 (0.076?±?0.03 μg/l vs 0.12?±?0.05 μg/l, p?=?0.007). All patients with permanent altered neurological symptoms developed S100B levels >0.08 μg/l (0.09–0.35 μg/l). Eighty-one percent of patients with improved neurological symptoms presented with S100B levels ≤0.08 μg/l (0.02–0.08 μg/l). Nine out of ten patients (90 %) without changes in EP and S100B had an improved long-term outcome, whereas 9/13 patients (69 %) with changes in EP and S100B had altered neurological symptoms in long-term outcome.

Conclusion

Intraoperative stable EPs and S100B?≤0.08 μg/l may be used as a marker to predict long-term neurological improvement, whereas EP-changes and elevated S100B levels on the 3rd postoperative day may be useful as a marker to predict long-term neurological alteration. In summary, the combined use of S100B and EPs might be helpful in the prediction of the severity of adverse spinal cord affection following surgery and guidance of patients.     

The risk of atherosclerosis in patients with chronic kidney disease

Background

Chronic kidney disease (CKD) is becoming a serious health problem; the number of people with impaired renal function is rapidly rising, especially in industrialized countries. A major complication of CKD is cardiovascular disease. Accelerated atherosclerosis has been observed in early stages of renal dysfunction. The purpose of this study was to examine the relationship between the degree of renal insufficiency and both the prevalence and intensity of coronary artery disease (assessed on the basis of number of vessels with stenosis).

Methods

446 individuals with both serum creatinine >120 μmol/l (men) or >96 μmol/l (women) and acute coronary syndrome were included in the study. All patients included in this analysis underwent urgent coronarography. Data concerning glomerular filtration rate (GFR), number of vessels with stenosis, hypertension, lipid disorders, creatinine concentration, C-reactive protein, glucose and lipid profile were analyzed.

Results

This study confirmed that moderate to severe renal impairment is associated with accelerated atherosclerosis. Moreover, patients with GFR values below 60 ml/min/1.73 m² are predisposed to accelerated, multivessel cardiovascular disease.

Conclusions

GFR seems to be an independent risk factor for multivessel cardiovascular disease. Due to the fact that patients with renal dysfunction are at high risk of cardiovascular events, they should obtain optimal treatment resulting not only in kidney protection but also in the elimination of cardiovascular risk factors.     

An algorithm using the early changes in PINP to predict the future BMD response for patients treated with daily teriparatide

Summary

About two thirds of patients with a procollagen type I N-terminal propeptide (PINP) increase of >80 μg/l at 1 month after starting teriparatide therapy showed a ≥10 % increase in lumbar spine (LS) bone mineral density (BMD) from baseline at 12 months. We recommend this algorithm as an aid in the clinical management of patients treated with daily teriparatide.

Introduction

An algorithm using PINP is provided in osteoporotic patients with teriparatide treatment. The correlations between the early changes in PINP and the subsequent BMD changes after daily teriparatide therapy were studied to develop an algorithm to monitor patients.

Methods

We evaluated whether early changes in PINP correlated with the changes in BMD at 12 months and developed an algorithm using the early changes in PINP to predict the upcoming BMD increases.

Results

The highest correlation coefficient for the relationship between PINP and LS BMD response was determined for the absolute change in PINP at 1 month and the percent change in LS BMD at 12 months (r?=?0.36, p <0.01). Using a receiver operator curve analysis, we determined that an 80 μg/l increase in PINP was the most convenient predictor of a 10 % increase in LS BMD from baseline (area under curve?=?0.72). Using a cut-off value of 80 μg/l, the positive predictive value for predicting a 10 % increase in LS BMD from baseline to 12 months was 65 %.

Conclusion

Greater short-term changes in PINP with teriparatide therapy are associated with greater 12-month increases in LS BMD. About two thirds of patients with a PINP increase of >80 μg/l at 1 month after starting treatment showed a ≥10 % increase in LS BMD from baseline at 12 months. We recommend this algorithm as an aid in the clinical management of patients treated with teriparatide.     

Small renal size in newborns with spina bifida: possible causes

Background

Previous studies reported that children with neural tube defects, but without any history of intrinsic renal diseases, have small kidneys when compared with age-matched standard renal growth. The aim of this study was to investigate the possible causes of small renal size in children with spina bifida by comparing growth hormone deficiency, physical limitations and hyperhomocysteinemia.

Methods

The sample included 187 newborns with spina bifida. Renal sizes in the patients were assessed by using maximum measurement of renal length and the measurements were compared by using the Sutherland monogram. According to the results, the sample was divided into two groups—a group of 120 patients with small kidneys (under the third percentile) and a control group of 67 newborns with normal kidney size. Plasma total homocysteine was investigated in mothers and in their children. Serum insulin-like growth factor-1 (IGF-1) levels were measured.

Results

Serum IGF-1 levels were normal in both groups. Children and mothers with homocysteine levels >10 μmol/l were more than twice as likely to have small kidneys and to give to birth children with small kidneys, respectively, compared with newborns and mothers with homocysteine levels <10 μmol/l. An inverse correlation was also found between the homocysteine levels of mothers and kidney sizes of children (r = ? 0.6109 P ≤ 0.01).

Conclusions

It is highly important for mothers with hyperhomocysteinemia to be educated about benefits of folate supplementation in order to reduce the risk of small renal size and lower renal function in children.     

High uric acid and low superoxide dismutase as possible predictors of all-cause and cardiovascular mortality in hemodialysis patients

Purpose

We investigated the role of serum uric acid (sUA) and superoxide dismutase (SOD) as predictive factors for mortality in hemodialysis (HD) patients.

Methods

SOD, butyrylcholinesterase, and malondialdehyde were estimated spectrophotometrically and the other parameters by standard procedures. High-sensitive C-reactive protein was assayed by a sandwich ELISA method.

Results

sUA among survivors (112.1 ± 13.82 μmol/L) was significantly lower than in deceased (160.8 ± 16.81 μmol/L, p < 0.001), while SOD was higher in survivors (31.8 ± 6.61 kU/L) than among deceased (20.2 ± 3.03, p < 0.05). Kaplan–Meier survival curves showed the greatest mortality risk in the highest tertile of basal sUA concentration (≥127.11 μmol/L, p < 0.001), and for SOD in the lowest tertile (≤23.83 kU/L, p < 0.05).

Conclusion

Our results suggest that high sUA and low SOD may predict all-cause and cardiovascular mortality in HD patients.     

Automatic smoke evacuation in laparoscopic surgery: a simplified method for objective evaluation

Background

Although its theoretical usefulness has been reported, the true value of automatic smoke evacuation system in laparoscopic surgery remains unknown. This is mainly due to the lack of objective evaluation. The purpose of this study was to determine the efficacy of the automatic smoke evacuator in laparoscopic surgery, by real-time objective evaluation system using an industrial smoke-detection device.

Methods

Six pigs were used in this study. Three surgical ports were placed and electrosurgical smoke was generated in a standard fashion, using either a high-frequency electrosurgical unit (HF-ESU) or laparosonic coagulating shears (LCS). The smoke was evacuated immediately in the evacuation group but not in the control nonevacuation group. The laparoscopic field-of-view was subjectively evaluated by ten independent surgeons. The composition of the surgical smoke was analyzed by mass spectrometry. The residual smoke in the abdominal cavity was aspirated manually into a smoke tester, and stains on a filter paper were image captured, digitized, and semiquantified.

Results

Subjective evaluation indicated superior field-of-view in the evacuation group, compared with the control, at 15 s after activation of the HF-ESU (P < 0.05). The smoke comprised various chemical compounds, including known carcinogens. The estimated volume of intra-abdominal residual smoke after activation of HF-ESU was significantly lower in the evacuation group (47.4 ± 16.6) than the control (76.7 ± 2.4, P = 0.0018). Only marginal amount of surgical smoke was detected in both groups after LCS when the tissue pad was free from burnt tissue deposits. However, the amount was significantly lower in the evacuation group (21.3 ± 10.7) than the control (75 ± 39.9, P = 0.044) when the tissue pad contained tissue sludge.

Conclusions

Automatic smoke evacuation provides better field-of-view and reduces the risk of exposure to harmful compounds.     

The Effect of Biliopancreatic Diversion Surgery on Renal Function—a Retrospective Study

Background

The prevalences of obesity and chronic kidney disease (CKD) have increased simultaneously. Should a pathophysiological relationship exist between the two conditions, bariatric surgery and associated weight loss could be an important intervention in extremely obese individuals to slow the progression of CKD.

Methods

We conducted a retrospective analysis of 25 patients who had undergone biliopancreatic diversion (BPD) surgery for extreme obesity (body mass index >40 kg/m²), with mean follow-up of 4 years. We assessed pre- and post-surgery renal function, body weight and blood pressure (BP) obtained from electronic hospital and primary care records.

Results

There was a significant reduction in mean body weight at 4 years by 50.3 kg (SD?=?20.65). The creatinine and estimated glomerular filtration rate (eGFR) also improved significantly: serum creatinine reduced by 16.2 μmol/l (SD?=?19.57) while the eGFR improved by 10.6 ml/min/m² (SD?=?15.45). The greatest improvement in eGFR was in the group (n?=?7) with eGFR ≤60 ml/min/m². A subset of patients (n?=?11) had evaluable BP readings and had a reduction in BP of 17/10 mmHg (SD?=?33/12).

Conclusions

This retrospective study demonstrates a clinically significant improvement in renal function following BPD. Several mechanisms including weight loss could account for the positive impact on renal function. The physiology underlying this improvement requires further study.     

Optimal fentanyl dosage for attenuating systemic hemodynamic changes, hormone release and cardiac output changes during the induction of anesthesia in patients with and without hypertension: a prospective, randomized, double-blinded study

Purpose

The purpose of this study was to compare the dose-related effects of fentanyl on systemic hemodynamics, hormone release and cardiac output in response to endotracheal intubation in patients with and without hypertension.

Methods

Forty-five patients without hypertension and 45 patients with hypertension (total 90 patients) undergoing elective general surgical, urological or gynecological procedures under general anesthesia were studied. The patients were randomly divided into three groups to receive either saline (control), 2.0 μg/kg fentanyl or 4.0 μg/kg fentanyl before tracheal intubation. Anesthesia was induced via intravenous target controlled infusion of propofol (plasma concentration, 4.0 μg/mL) followed by administration of the three drugs. Heart rate, blood pressure, and cardiac output were continuously monitored using Flo Trac/Vigileo system? and Bispectral index from before anesthetic induction until 10 min after tracheal intubation.

Results

In patients without hypertension, there was a significant difference in mean arterial pressure (MAP) among the three groups 2 min after intubation. Cardiac index (CI) in all three groups decreased before intubation compared with that in the awake period, returning to awake values after intubation in all three groups. There was a significant difference in CI between the 4 μg/kg fentanyl group and the other two groups immediately and 1 min after intubation. In patients with hypertension, a differential time course of MAP changes was observed among the three groups after intubation. CI in the three groups decreased after the induction of anesthesia and increased after intubation in control and 2 μg/kg fentanyl groups compared with that in the awake period.

Conclusions

The present study shows that it is preferable to administer 2 μg/kg fentanyl in patients without hypertension and 4 μg/kg fentanyl in patients with hypertension in order to minimize the changes in heart rate, systolic blood pressure and cardiac output associated with tracheal intubation.     

The preventive effect of pentoxifylline on contrast-induced nephropathy: a randomized clinical trial

Background

Percutaneous coronary intervention provides a high-risk condition for incidence of CIN even in patients with normal renal function. Pentoxifylline (PTX) with a variety of mechanisms may prevent CIN.

Materials and methods

Between April 5, 2011, and February 20, 2012, all consecutive eligible patients referred for elective percutaneous coronary intervention were asked to participate in the study (n = 199). Eligibility was defined as the age between 18 and 65 years and baseline serum creatinine ≤132.6 μmol/l (1.5 mg/dl). The patients were randomly allocated to two groups either receiving saline or saline plus pentoxifylline 400 mg orally three times a day for 48 h. Serum creatinine was measured 24 h prior to the procedure and 48 h thereafter. The primary endpoint was occurrence of CIN defined as 25 % rise in serum creatinine 48 h after the procedure.

Results

The overall incidence of CIN was 6 % in this study (6.2 % in the PTX group versus 5.9 % in the hydration group, P = 0.92). Absolute rise in serum creatinine was not also significantly different between the two groups (P = 0.97). In hypertensive patients, however, the incidence of CIN was lower among those receiving PTX: 5 % in the PTX group versus 8.7 % in the hydration group. Nevertheless, this difference was not statistically significant (P = 0.68).

Conclusion

Short-term prophylaxis with pentoxifylline added to optimal hydration does not seem to reduce the risk of CIN in patients with normal renal function undergoing PCI. Further clinical trials in patients with renal impairment are warranted to define its role.     

Early Predictor of Mortality due to Irreversible Posthepatectomy Liver Failure in Patients with Hepatocellular Carcinoma

Background

Although mortality after liver resection has declined, posthepatectomy liver failure (PHLF) remains a major cause of operative mortality. To date there is not consensus on a definition for PHLF. However, there have been many efforts to define PHLF causing operative mortality. In the present study we sought to identify early predictors of death from irreversible PHLF.

Materials and methods

We retrospectively analyzed the medical records of 359 patients with hepatocellular carcinoma who underwent liver resection between March 2000 and December 2010. Various biochemical parameters from postoperative days (POD) 1, 3, 5, and 7 were analyzed and compared with the “50–50” criterion.

Results

Operative mortality was 4.7 %. Prothrombin time (PT) <65 % and bilirubin ≥38 μmol/L on POD 5 showed the only significant difference as compared with “50–50” criterion. The new combination of bilirubin level and the international normalized ratio showed higher sensitivity, area under the curve, as well as similar accuracy (sensitivity 78.6 vs. 28.6 %; p = 0.002; area under the curve 0.8402 vs. 0.6396; p = 0.00176; accuracy 88.6 vs. 93.4 %; p = 0.090). Multivariate analysis revealed the combination of PT <65 % and bilirubin ≥38 μmol/L on POD 5 to be the only independent predictive factor of mortality (odds ratio, 82.29; 95 % confidence interval 8.69–779.64; p < 0.001).

Conclusions

In patients with chronic liver disease who will undergo liver resection the combination of PT <65 % and bilirubin ≥38 μmol/L on POD 5 may be a more sensitive predictor than the “50–50” criterion of mortality from PHLF. Although it needs to validated by prospective study, this measure may be applied to select patients receiving artificial liver supports or liver transplantation.     

The relationship of plasma ADMA levels with cardiac functions and metabolic parameters in peritoneal dialysis patients

Background

Asymmetric dimethylarginine (ADMA) is accepted as a risk factor for coronary artery disease because it causes endothelial dysfunction and vasospasm. In this study we aimed to investigate the relationship between ADMA levels and echocardiographic and metabolic parameters in peritoneal dialysis (PD) patients.

Methods

This is a cross-sectional study in which PD patients aged 18–80, with at least 3-month duration of dialysis and without active cardiac, infectious or malignant diseases, and clinically evident hypervolemia, were included. ADMA levels and echocardiographic parameters were recorded.

Results

Of the 55 patients included, the mean age was 53 ± 15 years. Mean ADMA level was 81.9 ± 48.0 μmol/l. The variables found to be positively correlated with ADMA levels were weight, body surface area, body mass index (BMI), serum glucose level, uric acid and sodium levels, ultrafiltration volume, left atrium diameter, intraventricular end-systolic diameter and intraventricular end-diastolic diameter. The parathyroid hormone, dialysate K _t/V and ejection fraction were negatively correlated with ADMA levels. ADMA levels were higher in patients with hypertension. With multivariate analysis, gender, BMI and use of acetyl salicylic acid were found to be the independent variables determining ADMA levels.

Conclusion

The correlation of ADMA with BMI, gender, hypertension, left atrium diameter, intraventricular end-systolic diameter and intraventricular end-diastolic diameter led to the idea that ADMA may aid in the determination of cardiovascular disease risk in PD patients.     

The effect of withdrawal of ACE inhibitors or angiotensin receptor blockers prior to coronary angiography on the incidence of contrast-induced nephropathy

Background

The effect of continuing or discontinuing chronic angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) therapy prior to coronary angiography on the incidence of contrast-induced nephropathy (CIN) is not clear. We undertook a randomized trial to evaluate the effect of withdrawing ACEIs or ARBs 24 h prior to coronary angiography on the incidence of CIN associated with coronary angiography.

Methods

A total of 220 patients with chronic kidney disease (CKD) stages 3–4 (glomerular filtration rate 15–60 ml/min/1.73 m²) on ACEI or ARB therapy were randomized before angiography to either ACEI/ARB continuation group or discontinuation group. A third group of patients with CKD stages 3–4 but not on angiotensin blockade therapy were also followed. The primary outcome measure was the incidence of CIN defined by a rise in serum creatinine by 25% or 0.5 mg/dl (44 μmol/l) from baseline.

Results

There was no statistically significant difference in the incidence of CIN between the three groups (P = 0.66). The incidences were 6.2%, 3.7%, and 6.3% for the continuation, discontinuation, and angiotensin blockade naïve group, respectively. There was also no significant difference found between the groups in mean serum creatinine and glomerular filtration rate values at baseline and post contrast administration.

Conclusion

Withholding ACEIs and ARBs 24 h before coronary angiography does not appear to influence the incidence of CIN in stable patients with CKD stages 3–4.     

Alprostadil plays a protective role in contrast-induced nephropathy in the elderly

Purpose

To evaluate the protective effects of alprostadil on contrast-induced nephropathy (CIN) in elderly patients.

Methods

We randomized 370 patients into the control or alprostadil group. The patients in the control group were injected with 100 ml sterile saline and the patients in the alprostadil group with alprostadil (0.4 μg/kg/day) in 100 ml sterile saline before and after iohexol-enhanced (100 ml) computed tomography (CT). Serum creatinine (Scr), blood urea nitrogen (BUN), cystatin C (CysC), and creatinine clearance (Ccr) were analyzed or calculated. ΔScr and ΔCysC were determined by the changes between baseline and highest Scr and CysC levels. The standard for CIN was a postdose Scr increase >44.2 μmol/l or >25 % over baseline.

Results

In the control group, peak Scr (P < 0.05) and ΔScr (P < 0.01) were higher than those in the alprostadil group. The postdose CysC at 24 h (P < 0.05), 48 h (P < 0.05), and 72 h (P < 0.05), peak CysC (P < 0.01), and ΔCysC (P < 0.05) in the control group were higher than those in the alprostadil group. The incidence of CIN in the control group was 22.2 %, which was higher than in the alprostadil group (9.1 %, P < 0.01). Subgroup analyses in patients with advanced age (≥80 years), concomitant hypertension or diabetes, and abnormal baseline renal function (Ccr ≤60 ml/min) showed that the alprostadil group had lower ΔScr and ΔCysC than the control group after contrast-enhanced CT examination in all four subgroups (P < 0.05 or P < 0.01).

Conclusions

In this cohort of older patients undergoing contrast CT, the use of alprostadil reduced the incidence of CIN.     

Preoperative predictors for allogenic blood transfusion in hip and knee arthroplasty for rheumatoid arthritis

Introduction

To identify the preoperative predictors of requirement for postoperative allogenic blood transfusion following hip and knee joint arthroplasty.

Materials and methods

We analysed the retrospective data on patients with rheumatoid arthritis who had undergone either total hip or knee arthroplasty at a single university teaching hospital. Factors of age, sex, procedure type, preoperative haemoglobin, blood transfusion data, comorbidities and body mass index were investigated for association with postoperative allogenic blood after hip or knee arthroplasty.

Results

Three hundred and forty nine cases of patients with rheumatoid arthritis were reviewed. 21 % (n = 72) required allogenic blood transfusion. The only significant predictive preoperative factors associated with postoperative blood transfusion were a low preoperative haemoglobin (Hb) level (p < 0.001), procedure of total hip arthroplasty (p = 0.008), a previous history of myocardial infarction (p = 0.038) and previous allogenic blood transfusion (p = 0.03). A preoperative haemoglobin <120 g/l was associated with a tenfold increase in transfusion requirement. All patients with a preoperative Hb level <90 g/l were transfused.

Conclusions

The ability to identify those within this high-risk group who are likely to receive blood transfusion allows for an informed, appropriate and cost effective approach to blood management strategies.