Promoting functioning and well-being in older CKD patients: review of recent evidence

Osteoporosis, falls, sleep difficulty, cognitive impairment, and depressed mood are major clinical concerns in the geriatric population that are physiologically and psychologically based and are often interrelated. All of these issues have implications for patients’ daily functioning and quality of life (QOL). This review synthesizes recent evidence about these prominent issues in geriatric care and related implications for care of older patients with chronic kidney disease (CKD). Recent evidence about pre-dialysis and dialysis treatment strategies that may help to optimize management of older patients is also considered. Although elderly patients often report better psychosocial adjustment to dialysis than do younger patients, physical functioning and cognitive functioning losses challenge the QOL of many elderly persons. Early management of CKD and attention to anemia, consideration of the benefits of peritoneal dialysis compared with hemodialysis, and inclusion of some form of exercise or regular physical activity in routine care provide key opportunities to enhance the functioning and well-being of older patients.     

Serendipitous renal cell carcinoma in the post-CT era: continued evidence in improved outcomes

PURPOSE: To compare patient and tumor characteristics, including survival data, between serendipitous and non-serendipitously discovered renal cell carcinoma (RCCA) in an era of more frequent use of CT scanning and ultrasonography. MATERIALS AND METHODS: The Tumor Registry of the Audie L. Murphy VA Hospital in San Antonio, TX, was reviewed for new diagnoses or initial treatment of RCCA from January 1985 through December 1999. Records were evaluated as to whether the initial diagnosis of RCCA was made serendipitously. Prognostic and epidemiological variables, were collected and disease-specific and overall survival data were computed. RESULTS: Of 257 patients with RCCA, 93 (36.2%) presented with serendipitously discovered tumors and 100 presented with metastases at diagnosis. Mean tumor size was smaller in the serendipitous group, compared both pathologically (6.74 cm vs. 4.49 cm, P < 0.0001) and by radiographic measurement (8.04 cm vs. 4.87 cm, P < 0.0001). Sixty-six (71%) of 93 serendipitously discovered tumors were Stage I at diagnosis, vs. only 30 (18.4%) of 163 non-serendipitous tumors (P < 0.0001). When non-serendipitous tumors with metastatic disease at presentation were excluded, the percentage of patients with Stage I disease was lower than for serendipitous tumors (46.8% vs. 71%, P = 0.004). Pathologically confirmed tumor stage was more favorable for serendipitously discovered tumors: 40 of 77 (60%) non-serendipitous tumors were 相似文献   

Dyslipidemia, inflammation and dialysis outcomes: what we know now

PURPOSE OF REVIEW: The limited prognosis of patients with chronic kidney disease starts when renal function begins to decline. RECENT FINDINGS: Available interventions did not prove their efficacy. Treatment of dyslipidemia and inflammation by statins was shown to be effective in post-hoc subgroup analyses of large-scale randomized controlled trials in patients with chronic kidney disease stages 2 and 3. So far, randomized controlled trials in dialysis patients (HEMO, ADEMEX, 4D study) and after kidney transplantation (ALERT study) have produced so-called 'negative results'. It is most likely that these trials had limited power to prove the primary hypothesis. It is also probable that cardiac disease in renal patients changes its character from a vascular atherosclerotic to a more complex structural heart disease in combination with stiff arteries (arteriosclerosis). Clinically, this leads to a high proportion of sudden cardiac deaths: of 270 cardiac deaths in the 4D trial, 160 were of sudden cardiac origin. A complex pathogenetic process and a number of new emerging cardiovascular disease risk factors in the setting of high-grade inflammation/infection are proposed as being responsible. SUMMARY: This review focuses on outcome variables in diabetic hemodialysis patients with special focus on risk factors such as inflammation and dyslipidemia.     

CKD与非CKD患者冠状动脉钙化发生情况的比较研究

目的:比较CKD患者与非CKD患者的冠状动脉钙化情况。方法:选取473例曾在我院行冠脉CT检查的CKD及非CKD患者,通过收集其生化指标及冠脉CT检查结果,分析并比较两组患者冠状动脉钙化的发生情况。结果:CKD患者冠状动脉钙化的发生率为76.5%,且钙化累及分支更多,LAD、RCA多发。钙化组的尿素氮、血磷水平及钙磷乘积显著高于非钙化组,而GFR则显著低于非钙化组(P<0.01)。结论:CKD患者冠状动脉钙化发生率高,累及范围广,程度更重,且LAD、RCA钙化多发。钙化组的尿素氮、血磷水平及钙磷乘积显著高于非钙化组,而GFR则显著低于非钙化组。     

Implications of proteinuria: CKD progression and cardiovascular outcomes

In this review, we summarize the evidence for the associations of proteinuria with incident CKD, progression of kidney disease, development of kidney failure, as well as the association with surrogates of cardiovascular disease (CVD), clinical cardiovascular outcomes, and all-cause mortality. Results reveal that proteinuria is a powerful and independent risk factor for kidney and cardiovascular outcomes, and that these relationships are independent of the level of glomerular filtration rate. Furthermore, these associations are true in populations at high, medium, and low risk for kidney disease progression and development of CVD. We show data which demonstrate that the associations with CVD are present even at levels of proteinuria below current cutoffs for microalbuminuria, and that changes in proteinuria may be a useful predictor of future outcomes. Finally, we provide some theories as to why proteinuria may be a risk factor for development of CVD.     

Pancreaticoduodenectomy in the era of evidence based medicine

The aim of this comprehensive literature review was to analyse evidence based data in the field of pancreaticoduodenectomy. Pylorus preserving does reduce mortality or morbidity of the standard procedure and could increase the risk of delayed gastric emptying. Pancreaticogastrostomy does not decrease the rate of postoperative pancreatic fistula and is not superior to the pancreaticojejunal anastomosis which is more physiological. No other procedure (chemical occlusion, octreotide, stenting) has been demonstrated to prevent pancreatic fistula. Octreotide injection could be advocated in centres where there is a high rate of pancreatic fistula, when pancreatic parenchyma is soft and the main pancreatic duct thin. Intra-abdominal drainage is not beneficial and could be associated with some morbidity. Its use needs to be further evaluated. When a resection is done for pancreatic cancer, less than 5% of patients are a live five years after surgery with postoperative mortality rate of 5% in expert centres and a high morbidity rate (25-50%). Extended lymphadenectomy does not increase survival. The first trials showed that adjuvant therapies could be beneficial for pancreatic cancers, but further trials did not confirm these findings. Adjuvant therapy is not validated for pancreatic cancers and needs to be considered only in the settings of clinical trials.     

Obesity and outcomes in trauma - a systematic review and meta-analysis

BackgroundThe physiological abnormalities relating to obesity and metabolic syndrome can contribute to worse outcomes following trauma especially in class 2 and 3 obesity. The aim of this systematic review was to determine whether patients with a higher class of obesity who suffer traumatic injury have a higher risk of worse outcomes including in-hospital mortality than normal-weight patients.MethodsA systematic search of MEDLINE, EMBASE, CENTRAL, Web of Science and CINAHL was performed for studies that reported a comparison of in-hospital obesity-related outcomes against normal-weight individuals aged 15 years and older following trauma. Single or multiple injuries from either blunt and/or penetrating trauma were included. Burn-related injuries, isolated head injury and studies focusing on orthopaedic related perioperative complications were excluded.ResultsThe search yielded 7405 articles; 26 were included in this systematic review. 945,511 patients had a BMI>30. A random-effects meta-analysis was performed for analysis of all four outcomes. Patients with class 3 obesity (BMI>40) have significantly higher odds of in-hospital mortality than normal-BMI individuals following blunt and penetrating trauma (OR, 1.75; 95% CI, 1.39-2.19, p=<0.00001), significantly longer hospital LOS (SMD, 0.23; 95% CI, 0.21-0.25; p<0.00001) and significantly longer ICU LOS (SMD, 0.19; 95% CI, 0.12-0.26; p<0.0001). In contrast, studies that examined blunt and penetrating trauma and classified obesity with a threshold of BMI>30 found no significant difference in the odds of in-hospital mortality (OR, 0.94; 95% CI, 0.86-1.02, p=0.13).ConclusionsThere is a higher risk of in-hospital mortality in patients living with class 3 obesity following trauma when compared with individuals with normal BMI. The management of patients with obesity is complex and trauma systems should develop specific weight related pathways to manage and anticipate the complications that arise in these patients.Systematic review registration numberPROSPERO registration: CRD42021234482Level of Evidence: Level 3     

Surgical outcomes of open cholecystectomy in the laparoscopic era

Background

Although laparoscopic cholecystectomy has become the standard of care for symptomatic cholelithiasis and cholecystitis, 10% to 30% of cholecystectomies are still performed in open fashion. Because the total number of cholecystectomies is increasing with time, the average patient undergoing open cholecystectomy in the laparoscopic era is older and has more comorbidities.

Methods

The records of 1629 consecutive patients who underwent cholecystectomy from July 1997 to September 2006 were evaluated. Analysis of variance, chi-square test, logistic regression, and linear regression were used to compare the following outcomes: length of procedure, length of stay, readmission (within 15 days and within 31 days), reoperation, and complication.

Results

Major complications (death, bile duct injury, bile leak, or bleeding requiring reoperation or transfusion) occurred more frequently in laparoscopic cholecystectomy patients who were coverted to open procedure (5.9%) than in those who underwent open cholecystectomy (4.4%). Mortality rates were 2.9%, 1.5%, and 0% for open, converted, and laparoscopic cholecystectomy, respectively.

Conclusions

Older patients, male patients, and patients with previous upper abdominal surgery are at higher risk for mortality. They should be considered for open cholecystectomy given their increased likelihood of major complications when laparoscopic cholecystectomy is converted to open surgery.     

Successful outcomes in pheochromocytoma surgery in the modern era

PURPOSE: We describe our experience with surgical management, complications and treatment outcome of histologically confirmed pheochromocytoma. MATERIALS AND METHODS: The records of 113 patients who underwent surgical excision of pheochromocytoma were reviewed and assessed for preoperative medical treatment, intraoperative findings, postoperative hospitalization and complications. RESULTS: There were no surgical mortalities. Average length of stay in the intensive care unit was 1.2 days. There were only 6 major cardiovascular complications all of which occurred in patients who received preoperative medications, including 5 with alpha blockade. Patients receiving no preoperative alpha blockade required an average of 956 cc less in total intraoperative fluids, which approached statistical significance, and 479 cc less fluids on postoperative day 1, which was statistically significant. CONCLUSIONS: Preoperative alpha-adrenergic blockade is not essential in pheochromocytoma patients. Calcium channel blockers are just as effective and safer when used as the primary mode of antihypertensive therapy. Surgery for pheochromocytoma is safe in the modern era.     

Achieving vascular access success in the quality outcomes era

BACKGROUND: In 1997 the National Kidney Foundation put forth guidelines for hemoaccess through its Dialysis Outcomes Quality Initiative (DOQI). Some centers have been able to meet these standards; most have not. METHODS: A retrospective review was made of our database of more than 3,500 hemoaccess procedures from 1986 to 2003. RESULTS: Our approach, increased use of transposed fistulas and preoperative duplex mapping, has led to a fistula incidence (84%) and prevalence (54%) exceeding DOQI criteria. Meeting the DOQI guideline for thrombectomy rate (0.5 per year) is mostly achieved by increased use of fistulas. Additionally, access monitoring, as well as intraoperative angiography, angioplasty, stenting, and surgical revision, can aid in decreasing the frequency of occlusions (0.45 per year). This operative approach has led to a 98% success rate for surgical thrombectomy, exceeding the DOQI guideline of 85%. Earlier referrals from nephrologists have lowered the catheter use prevalence to 9%. CONCLUSIONS: An aggressive approach to placing fistulas, maintaining the access, and receiving prompt referrals can lead to success in meeting DOQI criteria.     

Effect of statins on the clinical outcomes of patients with sepsis

Despite numerous attempts at novel intervention and tests to aid in earlier diagnosis and improved treatment, there has been an increased incidence of overall mortality related to sepsis, despite improvements in in-hospital mortality. Statins have emerged as potential immunomodulatory and antioxidant agents that might impact on sepsis outcomes. Definitive evidence to support the routine use of statins in patients with sepsis has not yet been elicited. We retrospectively analysed data from patients who presented with sepsis, severe sepsis or septic shock, stratifiying them according to statin use into two groups (statin and no statin). Sequential Organ Failure Assessment was used to evaluate severity of illness. The primary outcome was hospital mortality. Secondary outcomes included intensive care unit (ICU) mortality, hospital and ICU length of stay, and mechanical ventilation and vasopressor therapy duration. Five hundred and sixty-eight patients were included. Patients with prior statin use (statin group) were older; more obese and had higher prevalence of smoking, diabetes and ischaemic heart disease. There was no difference in Sequential Organ Failure Assessment scores and mortality did not vary between the two groups (19.6 vs. 16.9%). Furthermore, secondary outcomes including ICU mortality, hospital and ICU length of stay, mechanical ventilation and vasopressor duration did not differ Multivariate analysis revealed age and Sequential Organ Failure Assessment score were independent predictors of survival, while history of statin use was not (p = 0.403). This current retrospective study did not find any benefit of statin use on primary and secondary outcomes of the patients admitted to an academic hospital with sepsis.     

Perioperative outcomes and type of anesthesia in hip surgical patients: An evidence based review

Over the last decades the demand for hip surgery, be it elective or in a traumatic setting, has greatly increased and is projected to expand even further. Concurrent with demographic changes the affected population is burdened by an increase in average comorbidity and serious complications. It has been suggested that the choice of anesthesia not only affects the surgery setting but also the perioperative outcome as a whole. Therefore different approaches and anesthetic techniques have been developed to offer individual anesthetic and analgesic care to hip surgery patients. Recent studies on comparative effectiveness utilizing population based data have given us a novel insight on anesthetic practice and outcome, showing favorable results in the usage of regional vs general anesthesia. In this review we aim to give an overview of anesthetic techniques in use for hip surgery and their impact on perioperative outcome. While there still remains a scarcity of data investigating perioperative outcomes and anesthesia, most studies concur on a positive outcome in overall mortality, thromboembolic events, blood loss and transfusion requirements when comparing regional to general anesthesia. Much of the currently available evidence suggests that a comprehensive medical approach with emphasis on regional anesthesia can prove beneficial to patients and the health care system.     

Arteriovenous fistula outcomes in the era of the elderly dialysis population

BACKGROUND: The growth of patients > or =65 years on hemodialysis is increasing. Guidelines recommend arteriovenous fistula (AVF) access but their outcomes in elderly patients are controversial. This study compared the outcomes of AVF in patients <65 years old (65- group) versus those > or =65 years old (65+ group). METHODS: This retrospective analysis of prospectively collected data included 444 incident, first-time AVF created in a large dialysis center between January 1, 1995 and July 1, 2003. The primary outcome of AVF cumulative patency was evaluated using Kaplan-Meier survival analysis with log-rank test comparison. A Cox model determined factors associated with AVF loss. RESULTS: One hundred ninety-six patients (44%) were in the 65+ group. In total, there were 230 (52.2%) radiocephalic, 186 (42.2%) brachiocephalic, and 25 (5.6%) basilic vein transposed AVF. The one-year AVF cumulative survival was 75.1% (65+ group) and 79.7% (65- group); the five-year survival was 64.7% (65+ group) and 71.4% (65- group). The overall total procedure, angioplasty, thrombolysis, and revision rates per access-year were 0.83, 0.30, 0.66, and 0.16, respectively. The 65+ group had a relative risk of 1.7 of their AVF failing to mature compared with the 65- group. Multivariate analysis yielded these variables significant for AVF loss: male sex HR 0.63 (95% CI 0.44-0.91), coronary artery disease HR 2.1 (95% CI 1.5-3.0), and Caucasian ethnicity HR 0.63 (95% CI 0.44-0.91). CONCLUSION: Age should not be a limiting factor when determining candidacy for AVF creation due to equivalent survival and procedural rates. Failure of fistula maturation is a primary concern to patients of all ages and demands further study.