Hormonal changes in hemodialysis patients: Novel risk factors for mortality?

Patients with end‐stage renal disease undergoing dialysis commonly experience derangements in the hypothalamic‐pituitary‐gonadal axis together with alterations at the level of synthesis and clearance of many hormones. This hormonal imbalance, even if asymptomatic, has recently been associated with increased mortality in these patients. In this review, we summarize observational and mechanistic evidence linking hormonal alterations at the level of the thyroid and sex‐hormone systems with this mortality risks.     

Are patients with Werlhof's disease at increased risk for bleeding complications when undergoing cardiac surgery?

BACKGROUND: It is generally assumed, that patients with Werlhof's disease (WD) are at increased risk for bleeding complications when undergoing cardiac surgery with extracorporeal circulation. Therefore we performed this case control study to estimate the real risk for bleeding complications of these patients. METHODS: Between 05/95 and 07/98, ten patients with WD (eight males, two females) underwent cardiac surgery employing extracorporeal circulation (WD-group). Five of these patients with platelet counts below 80/nl were treated by immunoglobulins preoperatively. Each patient with WD was matched to five patients without WD (no-WD-group) using diagnosis, age, gender, ejection fraction, number of distal anastomosis and body-mass-index as matching criteria. RESULTS: Mean number of platelet counts were significant lower in the WD-group than in the no-WD-group despite a significant increase of platelet counts after immunoglobulin treatment (54/nl-->112/nl, P=0.018). On the day before, directly after and on the first day after surgery they were 141/nl vs. 215/nl (P=0.012), 75/nl vs. 147/nl (P=0.001) and 93/nl vs. 136/nl (P=0.009). Accordingly, patients of the WD-group received significantly more platelet concentrates than patients of the no-WD-group (mean number of platelet concentrates: 2.3 versus 0.7, P=0.007). Total drainage loss via the mediastinal chest tubes was almost identical (1197 ml in the no-WD-group and 1140 ml in the WD-group). One patient of each group suffered from a bleeding complication requiring reexploration. Three patients of the no-WD-group (6%) and one patient of the WD-group (10%) expired postoperatively unrelated to WD. CONCLUSIONS: Patients with WD may possibly undergo cardiac surgery without a markedly enhanced risk for bleeding complications despite a more than usual transfusion requirement and significantly lower platelet counts perioperatively.     

Should we monitor with bispectral index in all patients at high risk for seizures in the operating room?

We report the case of a patient with a cerebral aneurysm, located in the left middle cerebral artery. During the clipping of this aneurysm, the bispectral index (BIS) increased for no apparent reason. This was then interpreted as intraoperative non-convulsive status epilepticus. This clinical condition may have negative impact in the prognosis of the patient, so it is very important to be able to detect this conditions as early as possible. Measuring the BIS while the patient is anaesthetised could be useful in this situation, considering that an increase in values greater than 60, associated with acidosis and without any other peri-anaesthetic explanation, may provide evidence of a convulsive equivalent state, allowing appropriate action to be taken.     

Are chronic dialysis patients at increased risk for cancer?

This review summarizes the plausible mechanisms of carcinogenesis, critically analyzes the literature on cancer risk and discusses issues of cancer screening in chronic dialysis patients. Despite conflicting results among various studies, there is sufficient evidence to conclude that there is a heightened incidence of at least some cancers in dialysis patients. The data most convincingly support an increased risk of genitourinary malignancies. Screening for the common solid organ cancers (prostate, colon, breast and cervix) should be individualized, and is appropriate only for the minority of patients with a life expectancy on dialysis of 10 years or longer. Further research is needed before routine screening for bladder or renal cell cancers can be recommended.     

Male risk factors for hip fracture—a 30-year follow-up study in 7,495 men

Summary  

Risk factors for hip fracture were studied in 7,495 randomly selected men during 30 years; 451 men had a hip fracture. High degree of leisure-time, but not work-related, physical activity, high occupational class, and high body mass index (BMI) protected against hip fracture. Smoking, tall stature, interim stroke, and dementia increased the risk.     

IgA antibodies against β2 glycoprotein I in hemodialysis patients are an independent risk factor for mortality

Cardiovascular complications are the most important cause of death in patients on dialysis with end-stage renal disease. Antibodies reacting with β-glycoprotein I seem to play a pathogenic role in antiphospholipid syndrome and stroke and are involved in the origin of atherosclerosis. Here we evaluated the presence of anticardiolipin and anti-β-glycoprotein I antibodies together with other vascular risk factors and their relationship with mortality and cardiovascular morbidity in a cohort of 124 hemodialysis patients prospectively followed for 2 years. Of these, 41 patients were significantly positive for IgA anti-β-glycoprotein I, and the remaining had normal values. At 24 months, overall and cardiovascular mortality and thrombotic events were all significantly higher in patients with high anti-β-glycoprotein I antibodies. Multivariate analysis using Cox regression modeling found that age, hypoalbuminemia, use of dialysis catheters, and IgA β-glycoprotein I antibodies were independent risk factors for death. Thus, IgA antibodies to β-glycoprotein I are detrimental to the clinical outcome of hemodialysis patients.     

Pressure for beds--does it put our orthopaedic patients at risk?

INTRODUCTION: High occupancy rates of NHS beds has meant that increasing numbers of trauma patients find themselves on non-orthopaedic wards. Nursing staff on these wards may not have the specialist training to nurse such patients and may not recognise complications should they arise. The failure to recognise compartment syndrome was highlighted in a Clinical Governance meeting, leading to an assessment of nursing awareness of this condition. METHODS: Fifty orthopaedic trained nurses and a matched cohort of 50 non-orthopaedic trained nurses were asked a series of questions relating to compartment syndrome. RESULTS: The majority of non-orthopaedic nurses failed to recognise the signs of early compartment syndrome. CONCLUSION: Compartment syndrome is a limb-threatening condition which requires prompt recognition. Patients at risk should be nursed in an appropriate environment.     

NSAID as pre- and postoperative medication —a potential risk for bleeding complications in reduction mammaplasty

A cluster of bleeding complications in previously healthy women operated on for macromastia by reduction mammaplasty prompted a retrospective study of 293 patients treated during 1991–1992. Nine out of ten patients with profuse intraoperative bleeding had received the NSAID diclofenac (Voltaren) as part of premedication. Eight out of 20 postoperative haematomas were noted in patients treated with the NSAIDs diclofenac (Voltaren) or ketorolac (Toradol) for postoperative analgesia. These findings indicate that NSAID treatment increases the risk of intra- and postoperative bleeding complications in certain patients operated on for macromastia by reduction mammaplasty.The Department of Plastic Surgery was formerly (until 30 June 1994) located at the Sabbatsbergs Hospital, Stockholm Correspondence to: L. Blomqvist     

Randomized clinical trial on preoperative radiotherapy 25 Gy in rectal cancer—treatment results at 5-year follow-up

Purpose

The purpose of this study was to establish the influence of time interval between preoperative hyperfractionated radiotherapy (5?×?5?Gy) and surgery on long-term overall survival (5?years) and recurrence rate in patients with locally advanced rectal cancer operated on according to total mesorectal excision technique.

Methods

The treatment group comprised 154 patients with locally advanced rectal cancer who were operated on between 1999 and 2006 in the 1st Department of General Surgery, Jagiellonian University, Cracow, Poland. The data on survival has been systematically collected until 31st of December 2010. In addition, the following aspects were analyzed: the significance of time interval between the end of radiotherapy and surgical treatment and its influence on downsizing, downstaging, rate of curative resections, and sphincter-sparing procedures. Patients were qualified to preoperative radiotherapy 5?×?5?Gy and then randomly assigned to subgroups with different time intervals between radiotherapy and surgery: one subgroup consisted of 77 patients operated on 7–10?days after the end of irradiation, and the second subgroup consisted of 77 patients operated on after 4–5?weeks. Both groups were homogenous in sex, age, cancer stage and localization, distal and circumferential resection margins, and number of resected lymph nodes.

Results

The 5-year survival rate in patients operated on 7–10?days after irradiation was 63%, whereas in those operated on after 4–5?weeks, it was 73%—the difference was not statistically significant (log rank, p?=?0.24). A statistically significant increase in 5-year survival rate was observed only in patients with downstaging after radiotherapy—90% in comparison with 60% in patients without response to neoadjuvant treatment (log rank, p?=?0.004). Recurrence was diagnosed in 13.2% of patients. A lower rate of systemic recurrence was observed in patients operated on 4–5?weeks after the end of irradiation (2.8% vs. 12.3% in the subgroup with a shorter interval, p?=?0.035). No differences in local recurrence rates were observed in both subgroups of irradiated patients (p?=?0.119). The longer time interval between radiotherapy and surgery resulted in higher downstaging rate (44.2% vs. 13% in patients with a shorter interval, p?=?0.0001) although it did not increase the rate of sphincter-saving procedures (p?=?0.627) and curative resections (p?=?0.132).

Conclusions

1. Improved 5-year survival rate is observed only in patients with downstaging after preoperative irradiation dose of 25?Gy.
2. Longer time interval after preoperative radiotherapy 25?Gy does not improve the rate of sphincter-saving procedures and curative resections (R0) despite higher downstaging rate observed in this regimen.

     

Non-pharmacological strategies used by patients at high risk for future fracture to manage fracture risk—a qualitative study

Summary

We examined patients’ self-management of bone health and fracture risk, particularly behaviors other than medication use and seeking diagnostic testing. Awareness of fracture risk was accompanied by positive lifestyle changes in participants’ lives such as being careful. Future research should evaluate how lifestyle changes mitigate fracture risk.

Introduction

We examined patients’ understanding of bone health and self-management decisions regarding bone health and fracture risk, particularly behaviors other than medication use and seeking diagnostic testing.

Methods

A phenomenological (qualitative) study was conducted. English-speaking patients, 65+ years old, who were “high risk” for future fracture and prescribed pharmacotherapy after being screened through a post-fracture osteoporosis initiative were eligible. Patients were interviewed for 1–2 h and were asked to discuss perceptions of bone health status (bone densitometry results and perceived fracture risk), recommendations received for bone health, and lifestyle changes since their most recent fracture. We analyzed the data guided by Giorgi’s methodology.

Results

We interviewed 21 fracture patients (6 males and 15 females), aged 65 to 88 years old. With the exception of one participant, all participants appeared to understand that they had low bone mass and were at risk of sustaining another fracture. Most participants (n?=?20) were predominantly concerned about being careful, and they focused their responses on personal and environmental factors that they perceived to be modifiable. Participants also spoke about strategies to manage their bone health such as exercise, having a healthy diet and taking supplements, and using aids and devices. Non-pharmacological strategies used by patients appeared to be independent of current use of pharmacotherapy.

Conclusions

Awareness of fracture risk was accompanied by a number of positive lifestyle changes in participants’ lives such as being careful and engaging in exercise. Future research needs to evaluate how lifestyle changes such as being careful mitigate fracture risk.     

Are conventional cardiovascular risk factors predictive of two-year mortality in hemodialysis patients?

BACKGROUND: In general population hypertension, diabetes mellitus, overweight, hyperlipidemia and smoking are well-established risk factors for cardiovascular disease. However, the effect of these conventional risk factors on cardiovascular disease and mortality of patients on hemodialysis is not well understood. Indeed, some risk factors such as high blood pressure, hyperlipidemia and excess weight have been recently claimed to correlate with improved survival. OBJECTIVE: This study was undertaken to define the prevalence of these conventional risk factors in 453 hemodialysis patients, predominantly African-Americans, to determine their influence on two-year survival. RESULT: High cholesterol was found in 30% of the patients, high LDL-cholesterol in 25% and high triglycerides in 16%. Lipoprotein(a) (LP(a)) was elevated in 68% of the patients. 31% of our patients had predialysis mean arterial blood pressure (MAP) over 114, and 25% were obese based on a body mass index (BMI) over 30, 26% were diabetic and 25% were active smokers. Smoking was more common among our male and Caucasian patients. The aggregate score for the risk factors were 2.4+/-0.1 per patient, which increased to 3.2+/-0.1 in patients with obesity or diabetes, to 3.0+/-0.1 with hypertension and to 2.8+/-0.1 with active smoking. In multivariate Cox model analysis, prealbumin, body weight and blood pressure showed a positive correlation with two-year survival whereas diabetes mellitus had a negative correlation. Hyperlipidemia did not correlate to patients' two-year mortality. Smoking was associated with higher mortality, but that did not reach statistical significance. CONCLUSION: Conventional risk factors at least over a two-year period do not readily account for the higher mortality of a group of predominantly African-American patients on hemodialysis. The lack of prediction is speculated to be partly due to the overriding beneficial effects of better nutrition and due to the presence of other yet to be well-defined factors such as hyperhomocysteinemia, oxidative stress, coronary calcification, hitherto unidentified uremic toxins or a combination of these factors.     

Basal elevated serum calcium phosphate product as an independent risk factor for mortality in patients with fractures of the proximal femur—A 20 year observation study

IntroductionFractures of the proximal femur are a significant cause of mortality and morbidity in the elderly population. Yet predictive marker of unfavourable prognosis are still lacking. Calcium phosphate product is a marker of osteo-renal dysregulation. This study investigated the role of serum calcium phosphate product (SCPP) levels as a prognostic parameter for outcome in those patients.Patients and methodsA total of 3577 consecutive patients with diagnosed fractures of the proximal femur were included in our study (72.5% females). SCPP was divided into tertiles: <1.92 mmol²/l², 1.93–2.38 mmol²/l² and >2.39 mmol²/l². Data collection was performed prospectively and statistical evaluation was performed retrospectively.ResultsMean follow up in our study group was 11.0 ± 0.3 months. The mean age of our study group was 79.0 years (SEM ±14 years). To facilitate analysis, patients were divided in two groups: ≤84 years (64.4%) and ≥85 years (35.6%), and mortality <12 months was 12.4% (n = 445).In our study population higher SCPP levels ad admission were associated with a markedly elevated mortality. In a multivariate logistic regression model adjusted for age and sex, plasma creatinine and haemoglobin at admission caused a 1.3 (CI: 1.01–1.6) for SCPP 1.93–2.38 mmol²/l², and a 1.6 (CI: 1.2–2.0) for SPP >2.39 mmol²/l² fold increase in overall mortality compared to patients with baseline SCPP levels (<1.92 mmol²/l²) as reference category.ConclusionThose findings in our study population with 3577 patients over a period of 20 years proved to be, that serum Ca levels may be a good predictor for mortality in patients with fracture of the proximal femur. Further studies are required to evaluate whether these high risk patients might benefit from specific therapeutic measurements. This prognostic factor may help to increase the outcome of elderly patients with a fracture of the proximal femur.