Factors Affecting Survival in Advanced Chronic Kidney Disease Patients Who Choose Not to Receive Dialysis

Introduction. Non-dialytic treatment (NDT) has become a recognized and important modality of treatment in end stage renal disease (ESRD) in certain groups of chronic kidney disease (CKD) patients. However, little is known about the prognosis of these NDT patients in terms of hospitalization rates and survival. We analyzed our experience in managing these NDT with a multidisciplinary team (MDT) approach over a three-year period. Patients and Methods. The Renal Unit at the Royal Liverpool University Hospital set up a dedicated MDT clinic to manage NDT patients in January 2003. Patients approaching end stage chronic kidney disease who chose not to dialyse were recruited from other nephrologists. The study group was classified according to age band (<70 years, 71–80 years, and >80 years), estimated glomerular filtration rate (eGFR) (<10 ml/min, 11–20 ml/min, and >20 ml/min) according to the Modified Diet In Renal Disease formula and Stoke comorbidity grade (SCG). The SCG is a validated scoring system for the survival of patients on renal replacement therapy. We also used the ERA-EDTA primary renal diagnosis codes. As there are no existing standards for NDT patients, we used the U.K. national set for haemodialysis patients as a reference and target for our NDT patients. Data was collected prospectively. Results. The median age was 79 years and the male: female ratio was approximately 1. The most common primary cause of kidney disease in the NDT study population was chronic renal failure of unknown cause n = 22 (31%), but the most common identifiable cause was diabetic nephropathy, n = 20 (28%). The most common comorbidity was ischaemic heart disease n = 25 (34%). Those achieving the standards for anaemia were 78% at referral. Only 30% of the NDT patients achieved the standard for blood pressure (<130/80 mmHg) at referral. Forty-three patients (60%) had no admissions at all. There were a total of 30 patients admitted on 58 occasions. Thirty-one (53%) of these were due to a non-renal cause. The median length of stay for the other NDT patients was 10 days. The median overall survival (life expectancy) was 1.95 years. The one-year overall survival was 65%. SCG was an independent prognostic factor in predicting survival in NDT patients studied (p = 0.005), the hazard ratio being 2.53, for each incremental increase in the SCG. At one year, the survival for comorbidity grade 0, 1 and 2 were 83%, 70% and 56% respectively. Of the 28 patients who died, 20 did so at home (71%). Discussion. The NDT of ESRD has become an important alternative modality in renal replacement therapy. With the emergence of epidemic proportions of CKD, more elderly patients with progressive renal disease will need to make informed decisions regarding renal replacement therapy. There is likely to be increasing number of elderly patients that will tolerate dialysis badly and who will be very dependent on others. We believe that there should be a multidisciplinary approach to assist the ESRD patients in choosing their modality of renal replacement therapy, and with an agreed care plan to support these patients in managing their chosen modality to achieve the best possible quality of life. There should be integrated services with primary care, community nurses, and palliative care teams to enable the majority of the patient's treatment to be carried out at home and to allow a dignified death. However. there was a statistically significant trend for shorter survival among those with greater comorbidities, as determined by the SCG. This is the first report of the potential importance of SCG as an independent prognostic factor in NDT patients. This will help us to counsel our patients in the future about their prognosis if they choose NDT as their modality of renal replacement therapy. Conclusion. Our prospective study is the first and currently the largest observational study of a multidisciplinary approach in the management of NDT patients. SCG was an independent prognostic factor in predicting survival. In those patients who chose not to dialyse, SCG provides a potentially useful indication of expected prognosis.     

Blunt carotid and vertebral artery injuries

The recognition and treatment of blunt cerebrovascular injuries has dramatically evolved over the past two decades. As imaging technology has improved both with respect to the image quality and acquisition times, its use has become a fundamental diagnostic tool in blunt trauma evaluation. The single greatest radiological advance in the past quarter century has been the refinement and increasing use of computed tomographic imaging for the diagnosis of surgical disease. Paralleling advances in noninvasive imaging, a heightened awareness of blunt cerebrovascular injuries has emerged, and the first screening protocols were developed at high volume trauma centres. Through aggressive screening, these injuries have increasingly been recognised before devastating neurological ischaemia and adverse neurocognitive outcomes. The mainstay of treatment for these injuries is antithrombotic therapy. However, all blunt cerebrovascular injuries require short and long-term follow-up. While the majority of injuries will resolve with medical management, a proportion will require further intervention in order to reduce the risk of subsequent stroke.     

Quantifying comorbidity in peritoneal dialysis patients and its relationship to other predictors of survival.

BACKGROUND: Comorbidity is the single most important determinant of outcome in patients on renal replacement therapy. The aims of this study were to evaluate a semi-quantitative approach to comorbidity scoring in predicting survival of patients commencing peritoneal dialysis (PD), and to establish the interaction between this and other known predictors of patient outcome, in particular membrane function, residual renal function (RRF) and plasma albumin. METHODS: Comorbidity was recorded in a prospective, single centre cohort study of 303 patients commencing on PD. Using seven disease domains, chosen to reflect the dominance of cardiovascular morbidity in the end-stage renal failure population, comorbidity was graded as '0' when absent, '1' when one or two, and '2' when three or more conditions were present. The Wright comorbidity index, which includes age within the scoring method, was also evaluated. RRF, plasma albumin and peritoneal solute transport were measured every 6 months. Patients were censored at death. RESULTS: Median survival according to grade of comorbidity was 105, 42 and 29 months, respectively (P<0.0001), with good separation of the actuarial survival curves. Using Cox regression, the addition of age and the grade of comorbidity to Kt/V(urea), solute transport and plasma albumin increased the predictive power of the model. All were independent predictors of outcome with the exception of albumin. The Wright comorbidity index also enhanced the Cox model, although was not as powerful as when age and comorbidity were considered independently. At baseline, RRF was not different according to comorbidity unless diabetes was considered separately. Diabetics started with higher RRF, but after 6 months on PD this was the same as non-diabetic patients. Otherwise, initial rate of decline of RRF was similar across the comorbid grades, although the impact of higher drop-out due to earlier loss in patients with more comorbidity may have disguised earlier loss in these patients. Peritoneal solute transport tended to be higher in patients with increased comorbidity at baseline, chi(2) 13.8, P=0.032, and this was sustained with time on treatment. CONCLUSION: Comorbidity has a quantitative effect on survival that is independent of age, RRF and membrane function in PD patients. Comorbidity also appears to be associated with increased solute transport at the start of treatment, which is sustained. With the exception of diabetes, grade of comorbidity does not have a profound effect on loss of RRF.     

Vasoconstrictor effect of cyclosporin on the mesenteric artery in the dog

To evaluate the effect of cyclosporin (CyA) on the mesenteric arterial bed, studies were performed on the isolated mesenteric artery perfused at a constant flow in 20 dogs. Changes in mesenteric perfusion pressure reflected variations in vascular resistance. Pure powder CyA was dissolved in autologous blood and injected at doses of 5, 10, 20 and 40 mg. Infusions of 5 and 10 mg CyA caused nonsignificant mean increases of 3±2 mm Hg [95% confidence interval (CI)-2 to +7; P>0.05] and 3±3 mm Hg (95% CI-3 to +9; P>0.05) in mesenteric perfusion pressure, with CyA blood levels in the mesenteric vein averaging 466±153 and 692±130 nmol/l, respectively, at the end of the injections. Infusions of 20 and 40 mg CyA caused significant increases in mesenteric perfusion pressure averaging 11±3 mm Hg (95% CI 3–18; P<0.05) and 26±4 mm Hg (95 % CI 16–34; P<0.05), respectively. CyA blood levels at the end of infusion averaged 806±85 and 1118±89 nmol/l, respectively, in the mesenteric vein. Blockade of alpha-adrenergic receptors with phentolamine abolished the CyA vasoconstriction of the mesenteric artery, with the increase in perfusion pressure averaging 16±4 mm Hg before and 3±3 mm Hg after phentolamine (P<0.05). Thus, in the dog, CyA causes an acute vasoconstriction of the mesenteric artery through stimulation of alpha-adrenergic receptors.     

Long-term follow-up of callotasis lengthening of the capitate after resection of the lunate for the treatment of stage III lunate necrosis

The callotasis lengthening technique was used to gradually lengthen the capitate after resection of the lunate in stage IIIa necrosis in 23 patients. Results of ten patients with a follow-up of at least 5 years showed rapid and sufficient callus formation in every patient regardless of age. The callotasis lengthening modification of the Graner II operation provides all advantages and avoids the major inconvenience of the traditional Graner II operation. There was no increased rate of disturbed fracture healing. Results of the DTPA-gadolinium MRI study did not show any significant impairment of vascularization within the region of the capitate bone. With the “intrinsic bone formation,” contrary to every other intercarpal arthrodesis at the wrist, there is no need for an additional bone graft.     

Magnetic resonance imaging for the evaluation of rejection of a kindney allograft in the rat

Orthotopic DA (RT1^a) into Lewis (RT1¹) rat kidney allografts and control Lewis-into-Lewis grafts were assessed by magnetic resonance imaging (MRI) and perfusion measurement after intravenous injection of a superparamagnetic contrast agent. MRI anatomical scores (range 1–6) and perfusion rates were compared with graft histology (rank of rejection score 1–6). Not only acute rejection, but also chronic events were monitored after acute rejection was prevented by daily cyclosporine (Sandimmune) treatment during the first 2 weeks after transplantation. In acute allograft rejection (n=11), MRI scores reached the maximum value of 6 and perfusion rates were severely reduced within 5 days after transplantation; histology showed severe acute rejection (histologic score 5–6). In the chronic phase (100–130 days after transplantation), allografts (n=5) manifested rejection (in histology cellular rejection and vessel changes), accompanied by MRI scores of around 2–3 and reduced perfusion rates. Both in the acute and chronic phases, the MRI anatomical score correlated significantly with the histological score (Spearman rank correlation coefficient r _s 0.89, n=30, P<0.01), and perfusion rates correlated significantly with the MRI score or histological score (r _s values between-0.60 and -0.87, n=23, P<0.01). It is concluded that MRI represents an interesting tool for assessing the anatomical and hemodynamical status of a kidney allograft in the acute and chronic phases after transplantation.     

An approach to the treatment of hand burns

Burns of the dorsum of the hand may occur in isolation or as part of a more extensive burn. In planning treatment we are guided by the general condition of the patient as well as the local condition of the hand. The depth of these burns is often in doubt and a conservative policy is often indicated.

If infection is avoided many deep burns heal spontaneously. Intensive physiotherapy from the outset reduces oedema and rapidly restores mobility. A Bunyan bag technique using sulphamylon as the antibacterial agent has minimized infection and allowed free movement of the hands.

Using this method the large majority of dorsal burns of the hands heal in 4–5 weeks and show almost normal mobility.     

髋臼重建治疗Crowe Ⅲ型髋臼发育不良

目的 探讨髋臼重建治疗Crowe Ⅲ型髋臼发育不良的手术方法及疗效.方法 2001年1月至2007年6月43例(54髋)Crowe Ⅲ型髋臼发育不良继发骨关节炎患者接受全髋关节置换术治疗.术前Harris评分平均39分.髋臼重建方法包括单纯加深或穿透髋臼(A组)27例(34髋)、髋臼内壁截骨(B组)12例(15髋)、髋臼自体股骨头植骨(C组)4例(5髋).分别记录每种重建方法的手术时间、出血量、并发症.术后随访进行放射学及临床疗效评估.结果 40例(50髋)患者获得完整随访,随访时间平均29个月.在术后3～5个月随访时截骨和植骨已愈合.摄x线片测量A、B、C组重建方式的髋臼外倾角分别为(41.0±7.5)°,(46.0 ±7.7)°,(39.0±11.0)°;前倾角分别为(10.0±2.8)°,(9.0±2.5)°,(4.0±1.9)°;旋转中心上移分别为(8.4±3.6)mm,(7.3 ±2.6)mm,(1.2±0.5)mm;旋转中心内移分别为(7.0±1.5)mm,(9.9 ±1.7)mm,(-2.7 ±1.2)mm.A、B、C组末次随访平均Harris评分分别为B9、91、86分.随访患者中2例发生下肢深静脉血栓,2例可疑肺栓塞,4例坐骨神经麻痹.结论 单纯加深或穿透髋臼、髋臼内壁截骨、自体股骨头植骨是Crowe Ⅲ 型髋臼发育不良髋臼重建的有效方法.应根据术前评估、术中具体情况采用相应的重建方法.     

Injection into the extra-arachnoid subdural space

The anatomy and radiological appearances of the subdural space in the cervical region are described. Recognition of this space facilitates neurolytic injections for severe cancer pain in the distribution of the cervical nerve roots. The subdural space may have significance also in explaining the extensive sensory block which follows a delayed or 'massive' lumbar extradural injection.     

人工全髋关节置换术治疗强直性脊柱炎髋关节病变的临床疗效

目的 观察人工全髋关节置换治疗强直性脊柱炎髋关节病变的手术方法和临床效果.方法 对2001年3月至2009年6月26例(31髋)强直性脊柱炎髋关节病变患者行人工全髋关节置换并随访,置换前患者日常活动均明显受限或者严重疼痛,Harris评分平均(43.2±5.8)分,髋关节活动度平均51.8°±9.7°.记录术后末次随访的Harris评分,X线检查结果,观察假体有无松动、脱位及异位骨化. 结果 所有病例得到随访,平均随访24.9(8 ～125)个月.末次随访患者均疼痛消失,步态正常.Harris评分平均(82.4±4.7)分;髋关节活动度平均148.6°±7.4°;髋关节Harris评分及关节活动度均显著高于置换前(P＜0.05).2髋出现异位骨化,为Brooker分级Ⅰ、Ⅲ级.无脱位、骨折及假体松动下沉,无患者进行翻修. 结论 人工全髋关节置换是治疗强直性脊柱炎晚期髋关节病变的有效方法,可以恢复关节功能,缓解关节疼痛并改善患者生活质量.     

Genetic requirements for the development of the GVH reaction following small-bowel transplantation

The genetic requirements for the development of graft-versus-host (GVH) disease have been investigated in a model of semiallogenic, heterotopic small-bowel transplantation in the rat. Following semiallogenic MHC-incompatible small-bowel transplantation, all graft recipients showed characteristic signs of GVH disease and died within 14 days. On autopsy the transplanted bowel was normal, while the recipient's bowel was dilated and distended with gas. Histology showed a generalized cell infiltration of the connective tissue with macrophages and lymphocytes. After semiallogenic, RT1.A-incompatible, small-bowel transplantation, the graft recipients developed mild and temporary symptoms of GVH disease between days 25 and 40. Only two of the six animals died, while the remaining animals survived the observation period. Small-bowel transplantation across an isolated RT1.C barrier was unable to induce GVH reaction. These results indicate that the development of GVH disease after small-bowel transplantation is controlled genetically by the MHC. Class II MHC incompatibility is necessary for the induction of an acute and lethal GVH reaction.     

The Classic: Hospital for the Cure of Deformities: Course of Lectures on the Deformities of the Human Frame

This Classic Article is a reprint of the original work by W.J. Little, Hospital for the Cure of Deformities: Course of Lectures on the Deformities of the Human Frame. An accompanying biographical sketch of W.J. Little is available at DOI  10.1007/s11999-012-2301-z. The Classic Article is ©1843 and is reprinted courtesy of Elsevier from Little WJ. Hospital for the Cure of Deformities: course of lectures on the deformities of the human frame. Lancet. 1843;41:350–354.     

An unusual penetrating injury of the cheek: a case report

The immediate management of an unusual penetrating injury of the cheek is described. The early problems that arose following operation and their management are discussed. There is very little residual disturbance of function and surgical revision of the facial scars is being deferred for the time being.     

膝骨关节炎周围血供变化的影像学观察

目的:对比观察膝骨关节炎患者和正常人群膝关节周围血供变化。方法:2014年6月至2015年6月,纳入诊治的膝骨关节炎患者30例,健康成年人30例。膝骨关节炎组男9例,女21例,年龄53~82岁,平均(65.967±7.132)岁,平均动脉压(93.462±7.633)mm Hg;对照组男9例,女21例,年龄50~75岁,平均(62.867±6.356)岁,平均动脉压(92.122±9.675)mm Hg。检查方法包括彩超和下肢CTA;观察指标包括侧支循环,动脉迂曲,动脉畸形,管腔狭窄和动脉壁斑块形成情况。根据动脉的狭窄程度不同分为5级:1级为无狭窄,2级为轻度狭窄(1%~49%),3级为中度狭窄(50%~70%),4级为重度狭窄(70%~99%),5级为完全闭塞。测量两组的腘动脉、胫前动脉、胫后动脉内径的大小以及血流动力情况,并将膝骨关节炎组与对照组进行比较。结果:无剔除或脱落病例。膝骨关节炎组3例形成侧支循环,对照组4例;膝骨关节炎组0例动脉迂曲,对照组2例;两组均无动脉畸形。膝骨关节炎组动脉无狭窄0例,轻度14例,中度7例,重度9例,闭塞0例;对照组动脉无狭窄9例,轻度10例,中度6例,重度4例,闭塞1例;两组比较差异有统计学意义,膝骨关节炎组动脉狭窄比对照组严重。膝骨关节炎组30例动脉形成斑块,对照组20例形成斑块,两组比较差异有统计学意义,膝骨关节炎组动脉斑块形成比例高于对照组。膝骨关节炎组斑块钙化率100%,对照组63%。胫前动脉直径差异有统计学意义,膝骨关节炎组胫前动脉直径较大。两组腘动脉流速差异有统计学意义,膝骨关节炎组流速更快。胫后动脉流速差异有统计学意义,膝骨关节炎组流速更快。动脉流量方面,3条动脉数据比较差异均无统计学意义。结论:膝骨关节炎局部血管主要病理改变为狭窄和斑块形成,而局部动脉血流总量大致不变。临床治疗中改善局部血管病变的方法可能优于加速血流速度的方法,进一步针对局部血管异常改变的介入治疗也将为骨关节炎的临床治疗提供一个新的思路与方法。