The Use of a Pre-operative Carbohydrate Drink in Patients with Diabetes Mellitus: A Prospective,Non-inferiority,Cohort Study

Background

Pre-operative fasting leads to insulin resistance and increased metabolic stress in non-diabetic patients. Consumption of a carbohydrate drink may alleviate these deleterious effects. Patients with diabetes mellitus represent over 15% of the surgical population, yet concerns over hyperglycemia and aspiration have excluded patients with diabetes mellitus from studies assessing the utility of pre-operative carbohydrate drinks.

Objective

To assess for a clinically significant increase in pre-operative blood glucose concentration (defined as >2 mmol/L) in patients with diabetes consuming a pre-operative carbohydrate drink.

Methods

A prospective observational non-inferiority cohort study of 106 subjects with diabetes mellitus was undertaken to assess the effect of consuming a pre-operative carbohydrate drink in surgical patients. All patients with diabetes mellitus undergoing surgery (including but not limited to cardiac, neurologic, urologic, and general surgical procedures) were enrolled. Subjects were instructed to consume two carbohydrate-rich drinks, one before sleeping the evening prior to surgery and another on the day of surgery.

Results

In total, 43% of subjects were fully compliant with the pre-operative carbohydrate drink regimen. There were no significant differences between the fully compliant and non-compliant subjects with respect to baseline characteristics. Consumption of a pre-operative carbohydrate drink was determined to be non-inferior to fasting in terms of pre-operative blood glucose concentration (absolute difference 0.23 mmol/L, 95% CI: ?1.00 to 1.45 mmol/L, p _{non-inferiority} < 0.01). Neither group was found to be superior in terms of pre-operative blood glucose concentration, hyperglycemia, or length of stay.

Conclusions

These findings function as a step toward ensuring pre-operative carbohydrate drinks are safe in patients with diabetes undergoing surgery.

     

Neue Strategien und Materialien bei der endoskopischen Vakuumtherapie im unteren Gastrointestinaltrakt

Background

Endoscopic vacuum therapy is a widespread method in the postoperative treatment of lower and upper gastrointestinal (GI) tract leakage.

Objective

There is an absence of further technical development of the standardized material from 2007 for the lower GI tract.

Material and methods

New strategies and new materials for endoscopic vacuum therapy are presented.

Results

Alternative strategies in sponge placement, use of open-pore film drainage, use of a multiple sponge system, rinsing catheter, electronic pumps etc. enable the successful treatment of very complex pelvic defects.

Conclusion

The wide variability of pelvic defects often necessitates a change in therapeutic strategies during the course of treatment for an optimized outcome.

     

Anterior approach for total hip arthroplasty conversion of hip fusion

Purpose

Hip fusion conversion has shown mixed results, in particular a higher rate of failure than primary total hip replacement. Conversion is usually carried out by a lateral approach.

Methods

We reported a series of 37 hip fusion conversions performed by an anterior approach. Clinical and radiographic outcomes of this unusual approach were reported at eight years of follow up.

Results

At eight years of follow up, survivorship was 86. 6 % (IC 95 %: 62.4–95.7 %). Sixteen patients reported good relief of the pre-operative back spine or knee pain. PMA score was significantly improved. Two implant aseptic loosenings needing revision surgery were reported.

Conclusion

The anterior approach seemed to be as good as the other hip approaches for hip fusion conversion to total hip replacement.

     

Metabolic Parameters,Weight Loss,and Comorbidities 4 Years After Roux-en-Y Gastric Bypass and Sleeve Gastrectomy

Background

Sleeve gastrectomy (LSG) is now the predominant bariatric surgery performed, yet there is limited long-term data comparing important outcomes between LSG and Roux-en-Y gastric bypass (RYGB). This study compares weight loss and impact on comorbidities of the two procedures.

Methods

We retrospectively evaluated weight, blood pressure, hemoglobin A1c, cholesterol, and medication use for hypertension, diabetes, and hyperlipidemia at 1–4 years post-operatively in 380 patients who underwent RYGB and 334 patients who underwent LSG at the University of Michigan from January 2008 to November 2013. Follow-up rates from 714 patients initially were 657 (92%), 556 (78%), 507 (71%), and 498 (70%) at 1–4 years post-operatively.

Results

Baseline characteristics were similar except for higher weight and BMI in LSG. There was greater weight loss with RYGB vs. LSG at all points. Hemoglobin A1c and total cholesterol improved more in RYGB vs. LSG at 4 years. There was greater remission of hypertension and discontinuation of all medications for hypertension and diabetes with RYGB at 4 years.

Conclusions

Weight loss, reduction in medications for hypertension and diabetes, improvements in markers of diabetes and hyperlipidemia, and remission rates of hypertension were superior with RYGB vs. LSG 4 years post-operatively. Choice of bariatric procedures should be tailored to surgical risk, comorbidities, and weight loss goals.

     

Effects of topiroxostat in hyperuricemic patients with chronic kidney disease

Background

Hyperuricemia is associated with chronic kidney disease (CKD). Although topiroxostat, a novel, non-purine, selective xanthine oxidase inhibitor, has a strong effect against hyperuricemia, limited data are available on its renoprotective effect against CKD.

Methods

This study was conducted between October 2014 and May 2016. Thirty patients (20 male, 10 female) were administered 40 mg/day of topiroxostat twice daily. All patients were followed for a year. To elucidate the effects of topiroxostat, we evaluated the clinically documented primary indication of progression, viz. laboratory evidence of kidney function decline (reference indicator), uric acid, and hypertension in different patient groups, separated according to their baseline uProt levels and baseline eGFR.

Results

Topiroxostat treatment resulted in significant reduction in SUA (?1.53 mg/dL), systolic blood pressure (?8.9 mmHg), diastolic blood pressure (?5.0 mmHg), and urinary protein excretion (?795.5 mg/gCr) compared with baseline values. However, serum creatinine and urinary NAG levels, and estimated glomerular filtration rate did not change significantly.

Conclusions

Topiroxostat reduced SUA levels effectively and may exhibit renoprotective effect in hyperuricemic patients with CKD. Further studies are required to clarify whether topiroxostat prevents the progression of renal disease and improves the prognosis of CKD patients.

     

Feasibility of intermittent back-filtrate infusion hemodiafiltration to reduce intradialytic hypotension in patients with cardiovascular instability: a pilot study

Background

Intradialytic hypotension (IDH) is one of the major problems in performing safe hemodialysis (HD). As blood volume depletion by fluid removal is a major cause of hypotension, careful regulation of blood volume change is fundamental. This study examined the effect of intermittent back-filtrate infusion hemodiafiltration (I-HDF), which modifies infusion and ultrafiltration pattern.

Methods

Purified on-line quality dialysate was intermittently infused by back filtration through the dialysis membrane with a programmed dialysis machine. A bolus of 200 ml of dialysate was infused at 30 min intervals. The volume infused was offset by increasing the fluid removal over the next 30 min by an equivalent amount. Seventy-seven hypotension-prone patients with over 20-mmHg reduction of systolic blood pressure during dialysis or intervention-requirement of more than once a week were included in the crossover study of 4 weeks duration for each modality. In a total of 1632 sessions, the frequency of interventions, the blood pressure, and the pulse rate were documented.

Results

During I-HDF, interventions for symptomatic hypotension were reduced significantly from 4.5 to 3.0 (per person-month, median) and intradialytic systolic blood pressure was 4 mmHg higher on average. The heart rate was lower during I-HDF than HD in the later session. Older patients and those with greater interdialytic weight gain responded to I-HDF.

Conclusions

I-HDF could reduce interventions for IDH. It is accompanied with the increased intradialytic blood pressure and the less tachycardia, suggesting less sympathetic stimulation occurs. Thus, I-HDF could be beneficial for some hypotension-prone patients.

UMIN registration number

000013816.

     

Outcome of Henoch–Schönlein purpura 8 years after treatment with a placebo or prednisone at disease onset

Background

Corticosteroids have been shown not to prevent the development of Henoch–Schönlein nephritis. However, long-term follow-up data are scarce.

Methods

The long-term outcome of patients in a randomized placebo-controlled prednisone study was evaluated 8 years later with a health questionnaire completed by 160/171 (94%) patients and by urine and blood pressure screening (138/171, 81%).

Results

Twelve patients had hematuria and/or proteinuria and seven had hypertension. The patients with nephritis at onset of Henoch–Schönlein purpura (HSP) had an increased risk of hypertension and/or urine abnormalities (odds ratio 3.6, p?=?0.022, 95% confidence interval 1.3–10.0). There were no differences between the prednisone and placebo groups. Recurrences of purpura were reported by 15 patients, with some recurrences continuing for 10 years. All five reported pregnancies were complicated by proteinuria. Four patients presented with hematuria and/or proteinuria at the control visit, and four had hypertension. Of these, two had a decreased estimated glomerular filtration rate.

Conclusions

HSP has a good long-term prognosis in unselected patients, although skin relapses with/without late-onset nephritis may occur, even a decade after the initial disease. Urine and blood pressure abnormalities 8 years after HSP are associated with nephritis at its onset. Early prednisone treatment does not affect the outcome and should not be routinely used.

     

Biomechanical and clinical study of single posterior oblique cage POLIF in the treatment of degenerative diseases of the lumbar spine

Introduction

Aim of the study was to evaluate the biomechanical stability and the clinical efficacy of a lumbar interbody fusion obtained by single oblique cage implanted by a posterior approach.

Method

Through the realization of three finite element models (FEMs), the biomechanics of POLIF was compared to PLIF and TLIF. Ninety-four patients underwent interbody fusion by POLIF with instrumented posterolateral fusion. Clinical and radiographic outcomes were evaluated at regular intervals for at least 6 months.

Results

The FEMs showed no statistically significant differences in stability in compression and flexion–extension. Mean preoperative VAS score was 7.1, decreased to 2.1 at follow-up. Mean preoperative SF-12 value was 34.5 %, increased to 75.4 % at follow-up. All patients showed a good fusion rate and no hardware failure.

Discussion

POLIF associated to instrumented posterolateral fusion is a viable and safe surgical technique, which ensures a biomechanical stability similar to other surgical techniques.

     

Predictors of an unfavorable outcome 1.5 and 12 years after a first,uncomplicated lumbar disc surgery

Purpose

To identify predictors of both intermediate and long-term unfavorable outcomes after first time, uncomplicated lumbar disc surgery.

Methods

Patients (n = 120) who had undergone lumbar disc surgery were followed up 1.5 and 12 years thereafter. Baseline assessments were carried out 5–8 days after surgery. Clinical outcome was assessed in both follow-ups using the Low Back Pain Rating Scale. Statistical analysis included binary logistic and linear regression.

Results

Unfavorable outcomes were found in 50.5 % (1.5 years) and 52.6 % (12 years) of patients available for follow-up examination. Low pre-operative physical activity and severe pain in the first week after surgery were predictive of an unfavorable post-operative outcome at both follow-ups.

Conclusions

Identified predictors suggest that particular emphasis should put on comprehensive post-operative care at large and encouragement to adapt a physically active lifestyle in particular in rehabilitation concepts after first time uncomplicated lumbar disc surgery.

     

CA19-9 Normalization During Pre-operative Treatment Predicts Longer Survival for Patients with Locally Progressed Pancreatic Cancer

Background

Compared to the widely adopted 2–4 months of pre-operative therapy for patients with borderline resectable (BR) or locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC), our institution tends to administer a longer duration before considering surgical resection. Using this unique approach, the aim of this study was to determine pre-operative variables associated with survival.

Methods

Records from patients with BR/LA PDAC who underwent attempt at surgical resection from 1992–2014 were reviewed.

Results

After a median duration of 6 months of pre-operative treatment, 109 patients with BR/LA PDAC (BR 63, LA 46) were explored; 93 (85.3 %) underwent pancreatectomy. Those who received at least 6 months of pre-operative treatment had longer median overall survival (OS) than those who received less (52.8 vs. 32.1 months, P?=?0.044). On multivariate analysis, pre-operative treatment duration was the strongest predictor of survival (hazard ratio (HR) 4.79, P?=?0.043). However, OS was similar in those whose CA19-9 normalized regardless of whether they received more or less than 6 months of chemotherapy (71.4 vs. 101.8 months, P?=?0.930).

Conclusions

Pre-operative CA19-9 decline can guide treatment duration in patients with BR/LA PDAC. We endorse 6 months of therapy except in those patients whose values normalize, where surgery can be considered after a shorter course.

     

Komplikationsmanagement im Internet Marketing

Background

New patients come more and more often over the internet; therefore internet marketing plays an increasingly important role.

Question

How can physicians build an effective internet marketing strategy and avoid complications?

Method

Selection and authorization of a reputable agency.

Results

New customer acquisition through high visibility in the internet, at the same time increasing the image and awareness.

Conclusions

In the overall “marketing mix” internet marketing has become indispensable to physicians who want to be successful. Those who are well positioned in Google are well known by their target audience and thus receive a higher response.

     

Minor-Amputationen beim diabetischen Fußsyndrom

Objective

The treatment strategy for diabetic foot syndrome must take into account protective sensibility of the foot, open wounds, infection status, and the rules of septic bone surgery. Interventions are classified as elective, prophylactic, curative, or emergency. Amputations in the forefoot and midfoot region are performed as ray amputations (including metatarsal), which can often be carried out as ”inner“ amputations. Gentle tissue treatment mandatory because of greater risk of revision with re-amputation compared to classical amputation.

Indications

Good demarcation of infection, acute osteomyelitis, osteolytic lesions, neurotropic ulcer, arterial and venous blood flow to the other toes, gangrene of other toes with metatarsal affection.

Contraindications

Arterial occlusive disease, infection of neighboring areas, avoidable amputations, poorly healing ulcers on the lower leg.

Surgical technique

Primary dorsal approach; minimal incisional distance (5 cm) to minimize skin necrosis risk. Atraumatic preparation, minimize hemostasis to not compromise the borderline perfusion situation. In amputations, plantar skin preparation and longer seams placed as dorsal as possible, either disarticulated and maintain cartilage, or round the cortical metatarsal bone after resection.

Postoperative treatment

Diabetes control. Braun splint, mobilization in a shoe with forefoot decompression and hindfoot support, physiotherapy. Antibiotics based on resistance testing. If no complications, dressing change on postoperative day 1. Optimal wound drainage by lowering foot several times a day; drainage removal after 12–24 h. Insoles and footwear optimization.

Results

Amputations require continued attention and if necessary treatment to avoid sequelae. Insufficient treatment associated with recurrent ulceration and altered anatomy.

     

Effect of elevated blood pressure on quality of life in children with chronic kidney disease

Background

Although hypertension is known to have an adverse impact on health-related quality of life (HRQoL) in adults, little is known about the effects of hypertension and use of antihypertensive medications on HRQoL in hypertensive children with chronic kidney disease (CKD).

Methods

Cross-sectional and longitudinal assessment of impact of elevated blood pressure (BP) and antihypertensive medication use on HRQoL scores obtained in children enrolled in the Chronic Kidney Disease in Children (CKiD) Study. Blood pressure was measured both manually and by ambulatory blood pressure monitoring. HRQoL was assessed with the PedsQL survey.

Results

The study sample included 551 participants with sufficient data for cross-sectional and longitudinal analyses. Cross-sectional analysis of presence of prehypertension or hypertension and impact on HRQoL found mild associations between elevated BP and HRQoL scores with overall PedsQL parent and child scores averaging 79 vs. 76.5 and 83 vs. 78.5, respectively. However, no associations persisted under longitudinal multivariate analysis.

Conclusions

Despite apparent small effects of elevated BP on HRQoL at baseline, no association was found between the presence of elevated BP and HRQoL over time in children with mild-to-moderate CKD. In addition, antihypertensive medication use did not appear to have an impact on HRQoL in this population.

     

Cemented versus uncemented hemiarthroplasty of the hip in patients with a femoral neck fracture: a comparison of two modern stem design implants

Purpose

We wished to compare the outcome of two types of cemented and uncemented modern stem design implants after hemiarthroplasty, with both an Orthopaedic Data Evaluation Panel rating of 10A.

Methods

This retrospective study compares data obtained from two centres, with a total study population of 655 (n?=?393 cemented, n?=?262 uncemented). Patients were matched at baseline for gender, age, surgery side, American Society of Anesthesiologists score, body mass index and pre-operative haemoglobin level. Outcome measurements were prosthesis-related complications, pre- and post-operative, with reoperation rate and mortality and other complications after 1 year, surgery time, blood loss and immobility at discharge.

Results

There were no significant differences in mortality after 1 year, total other complications, immobility at the time of discharge and total prosthesis-related complications between both groups. Significantly more periprosthetic fractures and post-operative infections were seen in the uncemented group with significantly more reoperations compared to the cemented group. Significant differences were seen in cardiovascular complications, blood loss and surgery time in favour of the uncemented group.

Conclusions

In consequence of the significant higher prosthesis-related complications (e.g. infections, periprosthetic fractures and reoperations) in the uncemented group in this study, we recommend cemented hemiarthroplasty in patients with a femoral neck fracture.

Level of evidence

Level III, Case Controlled Study.

     

Is a drain tube necessary for minimally invasive lumbar spine fusion surgery?

Purpose

This study aimed to evaluate if closed suction wound drainage is necessary in minimally invasive surgery of transforaminal lumbar interbody fusion (MIS TLIF).

Methods

This is a prospective randomized clinical study. Fifty-six patients who underwent MIS TLIF were randomly divided into groups A (with a closed suction wound drainage) and B (without tube drainage). Surgical duration, intraoperative blood loss, timing of ambulation, length of hospital stay and complications were recorded. Patients were followed up for an average of 25.3 months. Clinical outcome was assessed using the Oswestry disability index and visual analogue scale (VAS). Fusion rate was classified with the Bridwell grading system, based on plain radiograph.

Results

Both groups had similar patient demographics. The use of drains had no significant influence on perioperative parameters including operative time, estimated blood loss, length of stay and complications. Patients in group B started ambulation 1 day earlier than patients in group A (p < 0.001). Clinical outcomes were comparable between group A and group B.

Conclusion

A drain tube can lead to pain, anxiety and discomfort during the postoperative period. We conclude that drain tubes are not necessary for MIS TLIF. Patients without drains had the benefit of earlier ambulation than those with drains.

     

Time Course of Blood Pressure Decrease After Bariatric Surgery in Normotensive and Hypertensive Patients

Background

Bariatric surgery leads to remission of several obesity-related comorbidities, including hypertension. Although antihypertensive medication use is decreased after bariatric surgery, the exact time course of decrease in blood pressure after surgery is not known.

Methods

A database of patients undergoing bariatric surgery at our institute was used to study the effect of surgery on time course of blood pressure changes. Data from surgeries performed between January 2010 and December 2012 were used.

Results

Maximum blood pressure and body weight decreases were observed at 2 weeks and 1 year after surgery, respectively. Average decrease in the mean arterial pressure (MAP) was 4.46 mmHg (61.5?±?17.1% of maximal decrease) and 7.17 mmHg (maximum decrease) at 1 and 2 weeks after surgery, when the decrease in body weight is 22.8?±?1.6 and 28?±?1.4% of maximal weight loss, respectively. In hypertensive patients, MAP decreased from 98.5?±?0.78 to 92.3?±?1.76 and 93.1?±?0.92 mmHg at 1 and 2 weeks post-surgery, respectively. In normotensive patients, the MAP decreased from 96.2?±?0.79 to 88.7?±?1.25, 90.0?±?0.94, 86.5?±?1.35, 88.0?±?1.13, and 86.4?±?2.13 mmHg at 2 weeks, 3 and 6 months, and 1 and 3 years after surgery, respectively.

Conclusions

These data demonstrate that significant decrease in MAP occurs within 2 weeks after bariatric surgery in hypertensive as well as normotensive patients. Future studies are required to investigate the weight-independent mechanisms of blood pressure decreases after bariatric surgery.

     

Effect of vaginal infiltration with ornipressin or saline on intraoperative blood loss during vaginal prolapse surgery: a randomised controlled trial

Introduction and hypothesis

Hydrodissection incorporating different types of vasoconstrictors is commonly used in vaginal prolapse surgery. There is little evidence as to whether it adds clinical value or whether it exposes the patient to unnecessary risk. The aim of this study was to compare the effect of a vasoconstrictor compared with saline alone on operative blood loss and cardiovascular parameters in a randomised clinical trial setting.

Methods

Patients undergoing vaginal prolapse surgery were randomised to an ornipressin (Por-8, Ferring) solution or saline alone for hydrodissection. The surgeon and patient were blinded to the solution used. Operative blood loss was accurately quantified and blood pressure and pulse readings recorded Pre, intra- and postoperatively.

Results

Eighty women were randomised. There was a statistically significant difference in the median blood loss: 35 ml (1-209 ml) in the ornipressin group compared with 81 ml (2-328 ml) in the saline group, p?=?0.03. There was no statistically significant difference in the median pre and postoperative blood pressure or pulse rate between groups.

Conclusions

The use of a vasoconstrictor (ornipressin) resulted in a statistically significant decrease in operative blood loss during vaginal prolapse surgery. This occurred without any significant changes in measured cardiovascular parameters.

     

Risk factors for surgical site infection after posterior fixation surgery and intraoperative radiotherapy for spinal metastases

Purpose

Posterior surgery with intraoperative radiotherapy for spinal metastases offers effective therapy, as we have reported previously. However, the procedure involves transfer from the operating room to the radiotherapy room, and as these patients are somewhat immunocompromised, the risk of postoperative surgical site infection (SSI) may be increased. The aim of our study was to identify risk factors and patient characteristics associated with postoperative SSI following posterior fixation surgery and intraoperative radiotherapy for spinal metastases.

Methods

Participants comprised 279 patients who underwent IORT for the treatment of spinal metastases between August 2004 and June 2013. Patients who suffered SSI within 1 month after surgery were categorized as infected, and all others were categorized as non-infected. We compared factors of age, sex, use of pre-operative corticosteroid, medical history of diabetes, prognosis scores (Tomita, Tokuhashi, and Katagiri), pre- and postoperative Frankel scale scores, site of tumor origin, administration of pre-operative radiotherapy, operation time, intraoperative blood loss, intraoperative irradiation dose, and pre- and postoperative performance status between groups.

Results

SSI occurred in 41 patients (14.7 %). Katagiri’s and Tokuhashi’s prognostic scores (P < 0.05 each), postoperative Frankel scale score (P < 0.01), administration of pre-operative radiotherapy (P < 0.05), and postoperative performance status (P < 0.05) all correlated significantly with occurrence of SSI. Multivariate analysis using those factors revealed administration of pre-operative radiotherapy as a factor independently associated with SSI (P < 0.05).

Conclusions

Patient prognosis, postoperative ambulatory function, and pre-operative radiotherapy were risk factors for SSI in patients with spinal metastases. Duration of surgery and intraoperative blood loss were not associated with occurrence of SSI.

     

Harnröhrenrekonstruktion bei vorausgegangener Hypospadieoperation

Background

The tasks involved in reconstructing the urethra after failed hypospadias repair range from correction of a trivial meatal stenosis to reconstruction of the entire anterior urethra.

Objectives

To describe pathological findings in the urethra after failed hypospadias repair and the respective surgical methods used for their correction.

Materials and methods

The various pathological findings after unsuccessful hypospadias surgery are classified according to their location and complexity.

Results

The general rules of reconstruction that should be applied in each particular situation are described.

Conclusions

Successful reconstruction of the urethra in patients with failed hypospadias surgery requires experience and good knowledge of the anatomy of the normal and hypospadic urethra and penis. Mastery of plastic surgical techniques and profound knowledge of the various surgical methods of hypospadias surgery are essential.

     

A clinical evaluation of renal amyloidosis in the Japan renal biopsy registry: a cross-sectional study

Background and aim

The available clinical data are limited in a rare glomerular disease, renal amyloidosis. We aimed to clarify the clinical features of renal amyloidosis from database of the Japan Renal Biopsy Registry (J-RBR).

Methods

We performed a cross-sectional study with database of the J-RBR of the Japanese Society of Nephrology. We identified 281 cases of renal amyloidosis from 20,997 cases enrolled into the J-RBR from 2007 to 2014. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were compared among the levels of ages, amount of urine protein excretion (AUPE) or CKD G stages.

Results

The prevalence of renal amyloidosis was 1.3 % (281/20,997). DBP significantly decreased in higher age quartiles (P = 0.034). SBP and DBP did not increase in the progression of AUPE levels and CKD G stages. In multiple regression analysis, eGFR was a significant independent factor for SBP in all cases and a subgroup without hypertensive agents. There was a reverse significant relationship between SBP and eGFR.

Conclusion

Blood pressure did not significantly increase in elderly and much proteinuric condition in renal amyloidosis. The progression of CKD and decrease of eGFR did not produce the higher SBP. The mechanism underlying these results remains unclear; however, they are unique features of renal amyloidosis. The couple of hypotensive and hypertensive conditions might produce no relationship between blood pressure and CKD stages.