Barriers to medication adherence and its relationship with outcomes in pediatric dialysis patients

Background

Medication adherence is a major factor determining outcome in children with chronic disease. Children with end-stage renal disease are challenged with requirements for renal replacement therapy in addition to complicated medication regimens.

Methods

We assessed barriers to medication adherence in 22 pediatric patients receiving chronic dialysis [63.6 % hemodialysis (HD), 36.4 % peritoneal dialysis (PD); age 15.9?±?0.7 years, dialysis vintage 31.6?±?6.5 months]. Adherence was assessed by a 16-question survey with a maximum score (difficulty) of 64.

Results

The overall mean adherence score was 30.9?±?2.4 (range 16–49; median? 27.5). There was a trend for lower adherence scores in patients on HD (27.5?±?2.9) compared to those on PD (36.8?±?3.7) (p?=?0.06). Compared to HD patients, the mean score/question was significantly higher in PD patients (1.7?±?0.2 vs. 2.4?±?0.2, respectively; p?=?0.006). Of the 16 questions, HD and PD patients gave a mean response of ≤1.2 for five and zero questions, respectively. Neither gender, age nor dialysis vintage was related to adherence scores. There was also a trend for adherence scores to be higher in females (35.6?±?3.7) than in males (27.5?±?2.9) (p?=?0.1), but this difference did not reach statistical significance. Markers of mineral bone disease were similar in HD and PD patients. Among all targets in HD and PD patients combined, there was no relationship between adherence scores and number of targets reached (r?=??0.09, p?=?0.7).

Conclusion

There are many barriers to medication adherence in pediatric patients receiving dialysis. In our patient group the difficulties were more evident in patients receiving PD than in those receiving HD.     

Serum non-high-density lipoprotein cholesterol (non-HDL-C) levels and cardiovascular mortality in chronic hemodialysis patients

Background

Non-high-density lipoprotein cholesterol (non-HDL-C) has been proposed as a predictor of cardiovascular disease (CVD) in the general population. The aim of this study was to evaluate the utility of non-HDL-C in predicting CV mortality in chronic hemodialysis (HD) patients.

Methods

We calculated the serum non-HDL-C level of 259 HD patients by subtracting their HDL-C levels from their total cholesterol. Cox proportional hazards models were used to estimate the hazards ratio (HR) for CV mortality and the 95% confidence interval (CI). A receiver-operating characteristic (ROC) analysis was performed to estimate the relationship between sensitivity and specificity of a diagnostic parameter.

Results

There were 44 deaths (17.0%) during the follow-up period, 33 (12.7%) of which were due to CVD. A multivariate Cox analysis with adjustments for age, diabetes, dialysis vintage, systolic blood pressure, serum albumin, and lipid levels showed that non-HDL-C was an independent predictor of CV mortality (HR 1.015, 95% CI 1.004–1.025, p?=?0.0083). An ROC analysis showed that the plots of the non-HDL-C levels yielded significant specificity and sensitivity for predicting the risk of CVD mortality in HD patients [area under the curve (AUC) 0.62416; p?=?0.0366; cutoff value 111.0?mg/dl]. The Kaplan–Meier survival curves of HD patients showed significant differences in CV mortality according to their tertiles with respect to serum non-HDL-C levels (p?=?0.0165).

Conclusion

The results of this study suggest that serum non-HDL-C level is a significant CV mortality predictor of chronic HD patients.     

A comparison of arteriovenous fistulas and central venous lines for long-term chronic haemodialysis

Background

Despite the Fistula First initiative there is still reluctance to use arteriovenous fistulas (AVF) for chronic haemodialysis (HD) in children. Our aim was to compare outcomes of AVFs and central venous lines (CVL) in children on chronic HD in a centre where AVF is the primary choice for vascular access.

Patients and methods

This was a retrospective case notes analysis of access complications, dialysis adequacy and laboratory outcomes in children who underwent dialysis for at least a year by AVF (n?=?20, median age 14.2 years, range (2.9–16.5) and CVL (n?=?5, median age 2.4 years, range 2.0–12.2) between January 2007 and December 2010.

Results

Primary access failure rate (patient-months) was 1 per 78.8 for AVF (n?=?5) and 1 per 15.5 for CVLs (n?=?7, p?=?0.3). Failure thereafter was 1 per 131.3 and 1 per 18.5 for AVF and CVLs respectively (n?=?3 and 6 respectively; p?=?0.2). The annualised hospitalisation rate for access malfunction was 0.44% and 3.1% for AVFs and CVLs respectively (p?=?0.004). Patients with AVFs had a lower infection rate of 0.25 per 100 patient-months compared with CVL at 3.2 per 100 (p?=?0.002). There was no difference in dialysis adequacy or laboratory values between AVF and CVL groups. Access survival rates (including both primary and secondary access failure) were significantly higher for AVF compared with CVL (p?=?0.0002, hazard ratio?=?0.15, 95% confidence interval 0.04–0.37).

Conclusions

Patients with AVF spend less time in hospital than those dialysed by CVLs and have a much lower access infection rate. These findings emphasise the need to use AVF as first-line access for paediatric patients on chronic HD.     

Disparities in dialysis treatment and outcomes for Dutch and Belgian children with immigrant parents

Background

In Belgium and the Netherlands, up to 40% of the children on dialysis are children with immigrant parents of non-Western European origin (non-Western). Concerns exist regarding whether these non-Western patients receive the same quality of care as children with parents of Western European origin (Western). We compared initial dialysis, post-initial treatment, and outcomes between non-Western and Western patients on dialysis.

Methods

All children <19?years old on chronic dialysis in the Netherlands and Belgium between September 2007 and May 2011 were included in the study. Non-Western patients were defined as children of whom one or both parents were born in non-Western countries.

Results

Seventy-nine of the 179 included patients (44%) were non-Western children. Compared to Western patients, non-Western patients more often were treated with hemodialysis (HD) instead of peritoneal dialysis (PD) as first dialysis mode (52 vs. 37%, p?=?0.046). Before renal transplantation, non-Western patients were on dialysis for a median (range) of 30 (5–99) months, vs. 15 (0–66) months in Western patients (p?=?0.007). Renal osteodystrophy was diagnosed in 34% of non-Western vs. 18% of Western patients (p?=?0.028). The incidence rate ratio [95% confidence interval] for acute peritonitis was 2.44 [1.43-4.17] (p?=?0.032) for non-Western compared to Western patients.

Conclusions

There are important disparities between children on chronic dialysis with parents from Western European origin and those from non-Western European origin in the choice of modality, duration, and outcomes of dialysis therapy.     

Neither Neoadjuvant nor Adjuvant Therapy Increases Survival After Biliary Tract Cancer Resection with Wide Negative Margins

Background

We investigated the role of neoadjuvant/adjuvant therapies on survival for resectable biliary tract cancer. We hypothesized that neoadjuvant and adjuvant therapy should improve the survival probability in these patients.

Methods

This was a retrospective review of a prospective database of patients resected for gallbladder cancer (GBC) and cholangiocarcinoma (CC). One hundred fifty-seven patients underwent resection for primary GBC (n?=?63) and CC (n?=?94). Fisher??s exact test, Student??s t test, the log-rank test, and a Cox proportional hazard model determined significant differences.

Results

The 5-year overall survival rate after resection of GBC and CC was 50.6 % and 30.4?%, respectively. Of the patients, 17.8?% received neoadjuvant chemotherapy, 48.7?% received adjuvant chemotherapy, while 15.8?% received adjuvant chemoradiotherapy. Patients with negative margins of at least 1?cm had a 5-year survival rate of 52.4?% (p?<?0.01). Adjuvant therapy did not significantly prolong survival. Neoadjuvant therapy delayed surgical resection on average for 6.8?months (p?<?0.0001). Immediate resection increased median survival from 42.3 to 53.5?months (p?=?0.01).

Conclusions

Early surgical resection of biliary tract malignancies with 1?cm tumor-free margins provides the best probability for long-term survival. Currently available neoadjuvant or adjuvant therapy does not improve survival.     

Optimized outcomes for renal allografts with cold ischemic times of 20?h or greater

Background

Prolonged cold ischemia time (CIT) has been associated with inferior graft survival in kidney transplantation (KT). The aim of this study was to evaluate the impact of prolonged CIT on short- and long-term outcomes and to determine the possible ways to optimize the use of these organs.

Methods

All kidney transplants from April 2001 to December 2010 with CIT????20?h were considered. Donor and recipient data were analyzed with uni- and multivariate Cox proportional hazard analyses. Graft and patient survival were calculated using the Kaplan?CMeier method.

Results

One hundred and eighty-one patients were transplanted with 184 grafts. Median recipient age and waiting time on dialysis were 52.5 and 4.9?years, respectively. After a median follow-up of 4.9?years, 148 of 181 patients are alive, 143 of them with functioning grafts. One-, three, and five-year graft and patient survival rates were 90, 87, and 79?%, and 96, 91, and 85?%, respectively. Donor age (p?p?=?0.0025), and induction therapy with interleukin-2 antagonists (p?=?0.0487) were predictors of graft survival by univariate analysis. Donor age and retransplantation remained significant by multivariate analysis (p?p?=?0.0046, respectively). Donor age (p?=?0.0176) and creatinine level at 1-month post-KT (p?=?0.0271) were predictors of patient survival by univariate analysis. Only donor age reached multivariate significance (p?=?0.0464). The calculated donor age cut off was 60?years.

Conclusions

Satisfactory long-term kidney transplant outcomes in the setting of CIT????20?h can be achieved with grafts from donors <60?years in first-time recipients. Induction therapy should preferably be with an interleukin-2 antagonist.     

Vitamin D receptor agonist supplementation and suppression of inflammation may have advantage for all-cause mortality in hemodialysis patients

Background

Vitamin D deficiency is common in hemodialysis (HD) patients. The aim of this study was to determine whether HD patients with low 25-hydroxyvitamin D [25(OH)D] levels are at increased risk of mortality.

Methods

This was a prospective cohort study of Japanese HD patients. We selected all patients with measured serum 25(OH)D levels at the time of entry. We assessed the impact of low serum 25(OH)D levels on the long-term mortality of HD patients by performing Cox regression analyses. Associations between serum 25(OH)D levels and all-cause mortality were also investigated.

Results

Data from 100 patients (mean age 61.0?±?11.8?years, 64?% males) were available. There was a high prevalence (55?%) of 25(OH)D insufficiency?p?=?0.777). After adjustments for possible confounders, the hazard ratio (with 95?% CI) for all-cause mortality was 1.091 (1.024–1.167) for age, 0.734 (0.566–1.167) for dialysis vintage, 1.012 (0.995–1.031) for serum total cholesterol values, 2.028 (1.093–3.701) for serum phosphate levels, and 0.291 (0.088–0.855) for treatment with alfacalcidol. A survival advantage of alfacalcidol treatment was observed (log-rank, p?=?0.0150). The group of subjects whose serum (25(OH)D level was <20?ng/ml and who were not treated with alfacalcidol had the highest mortality rate.

Conclusion

Vitamin D deficiency in HD patients who had not taken vitamin D receptor agonist (VDRA) is associated with an increased risk of all-cause mortality. VDRA supplementation may suppress chronic inflammation and have some advantage for mortality of HD patients with vitamin D deficiency.     

Patient outcome in primary peritoneal dialysis patients versus those transferred from hemodialysis and transplantation

Background

According to the concept of integrated care, renal transplantation, peritoneal dialysis (PD), and hemodialysis (HD) should be considered three complementary methods of renal replacement therapy. This study tried to evaluate patient outcomes in three different groups of PD patients, namely primary PD patients, those transferred to PD with failing kidney transplant, and those transferred to PD from HD.

Method

From January 1, 1995, to end of 2006 from 26 PD centers, 1,355 patients including demographic, clinical and laboratory data, which were monthly collected through questionnaires, were enrolled in the study. We compared patients?? characteristics, factors affecting patient survival, and patient outcomes between primary PD patients (group 1, n?=?1,067), patients transferred from transplantation (group 2, n?=?43) and those transferred from HD (group 3, n?=?245), which had been on HD for at least 3?months before switching to PD.

Results

There was no difference in the proportion of patients with diabetes in the three groups. Overall, 238 patients (17.5%) were transferred to HD but there was no significant difference in PD technique survival on between the three groups. Death occurred in 256 (24%), 3 (7%) and 65 (26.5%) subjects in groups 1, 2 and 3, respectively. Most patients (81.5%) in group 2 underwent re-transplantation. The Kaplan?CMeier survival rates were not different between the three groups. In the Cox multiple regression model, age, presence of diabetes and serum albumin level significantly influenced patient survival.

Conclusion

We concluded that PD could be considered safe for patients experiencing complications on HD, as well as for those with renal transplantation.     

Residual renal function and erectile dysfunction in patients on hemodialysis

Introduction

Residual renal function and erectile dysfunction are important parameters of quality of life in dialysis patients.

Goal

The purpose of our investigation was to determine correlations between erectile dysfunction and residual diuresis in patients on hemodialysis.

Methods

The survey was organized as a cross-sectional study in men aged up to 65?years on hemodialysis. All respondents voluntarily completed the questionnaire of the International Index of Erectile Function (IIEF)-5. Demographic and anthropometric characteristics, the duration of dialysis, smoking, alcohol consumption, residual renal function, comorbidity, and routine biochemical parameters were determined for all patients. The adequacy of dialysis was calculated as Kt/V. Based on residual renal function, the patients were divided into a group without residual diuresis and a group with preserved residual renal function.

Results

Nearly two-thirds of our patients did not have preserved diuresis, while 82.8% of our respondents had erectile dysfunction. Patients with preserved residual renal function were heavier (P?=?0.047) and had higher body mass index (P?=?0.047), but the prevalence of cardiovascular disease (P?<?0.0001) and erectile dysfunction (P?<?0.0015) was lower, compared to patients without residual diuresis. The regression model also demonstrated a statistically significant relationship between the residual diuresis and the total IIEF score (b?=?4.74; P?<?0.001).

Conclusion

Hemodialysis patients with preserved diuresis retain erectile function better.     

Selective Reoperation for Locally Recurrent or Metastatic Pancreatic Ductal Adenocarcinoma Following Primary Pancreatic Resection

Background

Resection of certain recurrent malignancies can prolong survival, but resection of recurrent pancreatic ductal adenocarcinoma is typically contraindicated because of poor outcomes.

Methods

All patients from 1992 to 2010 with recurrent pancreatic cancer after intended surgical cure were retrospectively evaluated. Clinicopathologic features were compared from patients who did and did not undergo subsequent reoperation with curative intent to identify factors associated with prolonged survival.

Results

Twenty-one of 426 patients (5?%) with recurrent pancreatic cancer underwent potentially curative reoperation for solitary local-regional (n?=?7) or distant (n?=?14) recurrence. The median disease-free interval after initial resection among reoperative patients was longer for those with lung or local-regional recurrence (52.4 and 41.1?months, respectively) than for those with liver recurrence (7.6?months, p?=?0.006). The median interval between reoperation and second recurrence was longer in patients with lung recurrence (median not reached) than with liver or local-regional recurrence (6 and 9?months, respectively, p?=?0.023). Reoperative patients with an initial disease-free interval >20?months had a longer median survival than those who did not (92.3 versus 31.3?months, respectively; p?=?0.033).

Conclusion

Patients with a solitary pulmonary recurrence of pancreatic cancer after a prolonged disease-free interval should be considered for reoperation, as they are more likely to benefit from resection versus other sites of solitary recurrence.     

Increasing Tumor Thickness is Associated with Recurrence and Poorer Survival in Patients with Merkel Cell Carcinoma

Background

Merkel cell carcinoma (MCC) is a rare, aggressive cutaneous neuroendocrine tumor usually occurring on sun-exposed skin in elderly patients. Clinical and pathologic factors associated with disease progression and mortality in patients with MCC are poorly defined. Recently, it has been reported that p63 expression in primary MCC is strongly associated with clinical outcome.

Methods

MCC patients diagnosed between July 1, 1993 and July 31, 2009 were identified from the surgical pathology records of the Sydney South West Area Health Service. Clinical, pathologic, treatment, and survival data were obtained and immunohistochemical analyses for p53, p63, and Ki-67 were performed. The associations of clinical and pathologic features with disease-free and disease-specific survival were analyzed.

Results

Ninety-five patients were identified (67 males, 28 females; median age at diagnosis of primary MCC 76 [range, 42?C93] years). Increasing primary tumor thickness was significantly associated with poorer disease-free survival (5-year survival 18?% in tumors >10?mm thick compared with 69?% for patients with tumors ??10?mm thick, p?=?0.002) and disease-specific survival (5-year survival 74?% in tumors >10?mm thick compared with 97?% for patients with tumors ??10 mm thick, p?=?0.006). There was a strong positive correlation between the Ki-67 index (proportion of Ki-67-positive tumor nuclei) and tumor thickness (r?=?0.39, n?=?45, p?=?0.008). Positive staining for p63 in MCC was infrequent (9?% of primary MCC) and showed no significant association with disease outcome.

Conclusions

Tumor thickness is significantly associated with disease-free survival in MCC. We recommend that primary tumor thickness be routinely recorded in the pathology reports of patients with primary MCC.     

Metastasectomy for Distant Metastatic Melanoma: Analysis of Data from the First Multicenter Selective Lymphadenectomy Trial (MSLT-I)

Background

For stage IV melanoma, systemic medical therapy (SMT) is used most frequently; surgery is considered an adjunct in selected patients. We retrospectively compared survival after surgery with or without SMT versus SMT alone for melanoma patients developing distant metastases while enrolled in the first Multicenter Selective Lymphadenectomy Trial.

Methods

Patients were randomized to wide excision and sentinel node biopsy, or wide excision and nodal observation. We evaluated recurrence site, therapy (selected by treating clinician), and survival after stage IV diagnosis.

Results

Of 291 patients with complete data for stage IV recurrence, 161 (55?%) underwent surgery with or without SMT. Median survival was 15.8 versus 6.9?months, and 4-year survival was 20.8 versus 7.0?% for patients receiving surgery with or without SMT versus SMT alone (p??60?months vs. 12.4?months; 4-year survival 69.3?% vs. 0; p?=?0.0106), M1b (median 17.9 vs. 9.1?months; 4-year survival 24.1 vs. 14.3?%; p?=?0.1143), and M1c (median 15.0 vs. 6.3?months; 4-year survival 10.5 vs. 4.6?%; p?=?0.0001) disease. Patients with multiple metastases treated surgically had a survival advantage, and number of operations did not reduce survival in the 67 patients (42?%) who had multiple surgeries for distant melanoma.

Conclusions

Our findings suggest that over half of stage IV patients are candidates for resection and exhibit improved survival over patients receiving SMT alone, regardless of site and number of metastases. We have begun a multicenter randomized phase III trial comparing surgery versus SMT as initial treatment for resectable distant melanoma.     

Risk of Cancer-specific Mortality following Recurrence After Radical Nephroureterectomy

Purpose

To describe the natural history and identify predictors of cancer-specific survival in patients who experience disease recurrence after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).

Methods

Of 2,494 UTUC patients treated with RNU without neoadjuvant chemotherapy, 597 patients experienced disease recurrence. A total of 148 patients (25?%) received adjuvant chemotherapy before disease recurrence. Multivariable Cox regression model addressed time to cancer-specific mortality after disease recurrence.

Results

The median time from RNU to disease recurrence was 12?months (interquartile range 5?C22). A total of 491 (82?%) of 597 patients died from UTUC, and 8 patients (1.3?%) died from other causes. The median time from disease recurrence to death of UTUC was 10?months. Actuarial cancer-specific survival estimate at 12?months after disease recurrence was 35?%. On multivariable analysis that adjusted for the effects of standard clinicopathologic characteristics, higher tumor stages [hazard ratio (HR) pT3 vs. pT0?CT1: 1.66, p?=?0.001; HR pT4 vs. pT0?CT1: 1.90, p?=?0.002], absence of lymph node dissection (HR 1.28, p?=?0.041), ureteral tumor location (HR 1.44, p?<?0.0005) and a shorter interval from surgery to disease recurrence (p?<?0.0005) were significantly associated with cancer-specific mortality. The adjusted 6-, 12- and 24-month postrecurrence cancer-specific mortality was 73, 60 and 57?%, respectively.

Conclusions

Approximately 80?% of patients who experience disease recurrence after RNU die within 2?years after recurrence. Patients with non-organ-confined stage, absence of lymph node dissection, ureteral tumor location and/or shorter time to disease recurrence died of their tumor more quickly than their counterparts. These factors should be considered in patient counseling and risk stratification for salvage treatment decision making.     

Outcomes of dialytic modalities in a large incident registry cohort from Eastern Europe: the Romanian Renal Registry

Background

Studies comparing survival in hemodialysis (HD) or peritoneal dialysis (PD) patients reported controversial results, mainly during the first 2 years of treatment. Moreover, there is a significant geographic variation in the use of these modalities. We aimed to compare the survival of HD and PD patients using data from the Romanian Renal Registry.

Methods

In an intention-to-treat analysis using Kaplan–Meier and Cox proportional hazard (CPH) models, survival was compared between 8,252 incident HD patients and 1,000 incident PD patients treated between 2008 and 2011. The patients were followed from the dialysis initiation and stratified by modality on day 90. The time on dialysis was separated into four periods (3–12, 12–24, 24–36 and >36 months), and outcome comparisons were made.

Results

Mean survival time was 46.3 (44.9–47.6) months in PD group and 45.8 (45.3–46.3) months in HD group (p = 0.9, log-rank test). In the multivariate CPH models, age, diabetes-associated kidney disease (DM), primary renal disease and center size significantly influenced survival. In the first year of therapy, the mortality was higher in HD than in PD patients (HR = 1.34 (1.12–1.60), p = 0.001), while in the second and third year, HD patients survived better (HR = 0.69 (0.53–0.89), p = 0.005); HR = 0.56 (0.41–0.78), p = 0.001) and after 36 months, the survival difference was not statistically significant (HR = 0.63 (0.34–1.13), p = 0.1), respectively.

Conclusions

Despite the survival advantage for PD patients during the first year and that of HD in the next 2 years of dialysis, the overall survival in HD and PD patients was similar and was influenced by age, DM and center size.     

Surgical Outcomes and Clinical Characteristics of Elderly Patients Undergoing Curative Hepatectomy for Hepatocellular Carcinoma

Background

The aim of this study was to investigate the clinical characteristics and outcomes of elderly patients (≥70 years old) undergoing curative hepatectomy for hepatocellular carcinoma (HCC).

Methods

Clinicopathological data and treatment outcomes in 100 elderly patients (≥70 years old) and 120 control patients (≤70 years old) with HCC who underwent curative hepatectomy between 2000 and 2011 were retrospectively collected and compared.

Results

The overall survival rate was similar between the two groups, but the disease-free survival rate was worse in the elderly group when compared with the control group. Prognostic factors for overall and disease-free survival were the same when comparing the two groups. The elderly group had higher rate of females (p?=?0.0230), higher hepatitis C virus infection rate (p?=?0.0090), higher postoperative pulmonary complication rate (p?=?0.0484), lower rate of response to interferon (IFN) therapy (p?=?0.0203) and shorter surgical time (p?=?0.0337) when compared with the control group. The overall recurrence rate was higher in the elderly group than in the control group (p?=?0.0346), but the rate of recurrence within 2 years after the operation was similar when comparing the two groups.

Conclusion

The survival of elderly patients with HCC was similar to that of younger patients. However, the disease-free survival was worse in elderly patients than in younger patients. Aggressive antiviral therapy (e.g. IFN therapy) may be necessary to improve the disease-free survival, even in elderly patients. Additionally, clinicians should be aware of the risk of pulmonary complications in elderly patients after hepatectomy.     

Outcome of conventional treatment and prognostic factor in elderly glioblastoma patients

Background

Glioblastoma (GBM) is the most life-threatening primary brain tumour. Especially in elderly patients, a poorer outcome is noticeable. Until now, the effectiveness of the conventional active treatment has been controversial. The purpose of this study is to find the optimal treatment for elderly patients with newly diagnosed GBM.

Method

The authors retrospectively reviewed 301 patients who were diagnosed with GBM at a single centre from January 2006 to December 2010. All patients were divided into younger and elderly groups based on the cut-off age of 65 years, and the treatment outcome was analysed.

Results

Of 301 patients, 67 (23.3 %) patients were 65 years old or older, and 234 (77.7 %) patients were younger than 65 years. In the elderly group, 49 patients received surgical resection and 18 patients received biopsy. Forty-seven patients (70.1 %) underwent concomitant chemoradiotherapy (CCRT) and 38 patients (56.7 %) underwent adjuvant temozolomide (TMZ) chemotherapy. The median overall survival (OS) of elderly patients was 12.0 months and the progression-free survival (PFS) was 8.5 months. The median OS of elderly patients who underwent CCRT and adjuvant TMZ chemotherapy increased to 16.2 months. On the multivariate analysis, tumour infiltration (p?=?0.005), and resection (p?=?0.001) were significant independent prognostic factors in elderly patients. The grade 3 or 4 complication rate was not statistically different between the younger group (n?=?22, 9.4 %) and the elderly group (n?=?8, 12 %).

Conclusion

Elderly patients diagnosed with GBM had a survival benefit and a low complication rate with the conventional treatment. Therefore, elderly patients should be encouraged to receive the conventional active treatment.     

The efficacy and safety of totally laparoscopic hepatectomy for non-cirrhotic hepatocellular carcinoma in the elderly

Background

Laparoscopic hepatectomy (LH) has been identified to be effective and safe for elderly patients (≥70?years). This study aims to assess the short-and long-term outcome of totally laparoscopic liver resection for elderly patients with Hepatocellular carcinoma (HCC).

Methods

We retrospectively reviewed 93 patients with HCC who underwent LH from August, 2003 to July, 2013 in a single center. Short-term operative and postoperative outcomes together with long-term outcomes, including disease free survival (DFS) and overall survival (OS) were analyzed.

Results

A total of 81 patients was finally reviewed, of which 23 patients (28.40%) were grouped to elderly (≥70?years) and 58 patients (71.60%) were divided into younger group (<?70?years). The mean ages of patients in the elderly and younger cohorts were 74.9?±?3.4 and 50.9?±?12.7?years old, respectively. The median follow-up durations in elderly cohort and young cohort were 30?months and 24?months. The mean postoperative hospital stay was nearly 4?days longer in the elderly cohort than that in younger group (13.4 vs 9.5; p?=?0.003). The elderly cohort has a higher rate of non-surgical complications than that in the younger cohort (P?=?0.045), while the risks of surgical complications were comparable between the two groups. For the postoperative complications, elderly patients were more easily to develop grade III or more of Clavien-Dindo classification than that in the younger patients (P?=?0.008). The median OS in the elderly group and younger group was 44.09?months and 42.49?months, respectively, with p?=?0.089. The median DFS in the elderly group and the younger group was 39.87?months and 37.86?months, respectively, with p?=?0.0616.

Conclusions

Elderly patients could obtain comparable operative and survival benefits from LH for HCC as younger counterparts. Age may not be a contraindication to laparoscopic liver resection for elderly patients.

     

Outcomes following radical cystectomy for micropapillary bladder cancer versus pure urothelial carcinoma: a matched cohort analysis

Purpose

Micropapillary (MP) bladder cancer is a rare variant of urothelial carcinoma (UC) which has been associated with an aggressive natural history. We sought to report the outcomes of patients with MP bladder cancer treated with radical cystectomy (RC) and compare survival to patients with pure UC of the bladder.

Methods

We identified 73 patients with MP bladder cancer and 748 patients with pure UC who underwent RC at our institution with median postoperative follow-up of 9.6?years. MP patients were stage-matched 1:2 to patients with pure UC. Survival was estimated using the Kaplan?CMeier method and compared with the log-rank test.

Results

MP cancers were associated with a high rate of adverse pathologic features, as 48/73 patients (66?%) had pT3/4 tumors and 37 (50?%) had pN+ disease. Ten-year cancer-specific survival in MP patients was 31?%, compared with 53?% in the overall cohort with pure UC (p?=?0.001). When patients with MP bladder cancer were then stage-matched to those with pure UC, no significant differences between the groups were noted with regard to 10-year local recurrence-free survival (62 vs. 69?%; p?=?0.87), distant metastasis-free survival (44 vs. 56?%; p?=?0.54), or cancer-specific survival (31 vs. 40?%; p?=?0.41).

Conclusion

MP cancers are associated with a higher rate of locally advanced disease. However, when matched to patients with pure UC, patients with MP tumors did not have increased local/distant recurrence or adverse cancer-specific survival following RC.     

The MELD score predicts the short-term and overall survival after liver transplantation in patients with primary sclerosing cholangitis or autoimmune liver diseases

Purpose

Liver transplantation (LT) is well established in patients with autoimmune liver disease. Despite excellent outcomes, organ scarcity demands careful patients’ selection and timing of transplantation.

Methods

This retrospective study analyzes data of 79 consecutive patients with primary sclerosing cholangitis (PSC), autoimmune hepatitis (AIH), and overlap syndrome, undergoing LT between 2001 and 2012. Overall survival (OS) and graft survival were assessed using Kaplan-Meier estimate. Multivariate survival analysis was performed to identify prognostic factors by using Cox regression model.

Results

After 59.6-month median follow-up, the 5-year OS and graft survival were 75.3 and 68.8 %, respectively. The 5-year survival rates for patients with PSC (n?=?57), AIH (n?=?17), and overlap syndrome (n?=?5) were 76.3, 76.0, and 60.0 %. The 90-day mortality rate of 70.0 % was significantly higher in patients with a labMELD score ≥20 (n?=?10) compared to 26.1 % in 69 patients with a labMELD <20 (p?=?0.009). A lab Model for End-Stage Liver Disease (MELD) score ≥20 was an independent predictor of impaired OS (p?=?0.050, hazard ratio 2.5). The 5-year OS was 55.7 % in patients with a labMELD score ≥20 compared to 84.7 % in patients with a labMELD score <20.

Conclusion

The recipients’ MELD score is a predictor for the short-term outcome after LT in patients with autoimmune liver disease. Meticulous selection for transplant listing remains necessary to safe scarce donor organs.     

Determinants of outcomes after resection of renal cell carcinoma with venous involvement

Purpose

To determine the outcomes and to identify prognostic variables determining mortality and recurrence after surgery for renal cell cancer (RCC) with venous involvement.

Methods

Retrospective evaluation of the medical records of 132 patients with RCC and tumor thrombi treated at Johns Hopkins Hospital (1997?C2008) was done. Kaplan?CMeier analysis was used to determine survivals. Uni- and multivariate Cox proportional analysis was done to identify predictors for recurrence, all-cause mortality (ACM) and cancer-specific mortality (CSM).

Results

Mean follow-up was 30.3 (0.03?C159.5) months. Sixty-four (48.5?%) patients had renal vein thrombus (Group 1), 55 (41.7?%) had subdiaphragmatic inferior vena cava (IVC) tumor thrombus (Group 2), while 13 (9.8?%) had involvement of IVC above diaphragm or atrial extension (Group 3). IVC thrombus was more common from the right-sided tumors. Patients with higher thrombus levels had more blood loss and complicated and longer hospital stay. Thrombus level was not found to be a predictor of recurrence, ACM and CSM. One- and three-year recurrence-free survivals for non-metastatic patients were 69 and 53?%. Tumor size (p?=?0.015), grade (p?=?0.007) and venous wall invasion (p?=?0.027) were predictors for recurrence. Five-year overall survival was 48, 35 and 13?% for 3 groups, respectively. Presence of distant metastasis (p?=?0.032), size (p?=?0.002), histology (p?=?0.020) and grade (p?=?0.013) were predictors of ACM. Five-year cancer-specific survival was 65, 43 and 36 for 3 groups, respectively. Tumor size (p?=?0.001) and distant metastasis at presentation (p?=?0.025) were the predictors of CSM.

Conclusions

Tumor thrombus level does not predict recurrence or mortality in RCC with venous involvement. Survival is determined by inherent aggressiveness of the cancer manifested by tumor size, grade and distant metastasis at presentation.