High Prevalence of Vertebral Fractures Assessed by Quantitative Morphometry in Hemodialysis Patients, Strongly Associated with Vascular Calcifications

Few studies have provided information on the prevalence of vertebral fractures (VFs) and their risk factors in hemodialysis patients. A multicenter, cross-sectional, observational study was carried out to assess the prevalence of VFs and vascular calcifications (VCs) in 387 hemodialysis patients (mean age 64.2 ± 14.1 years, 63 % males) and in a control group of 51 osteoporotic subjects. Biochemical tests included 25(OH) vitamin D, bone Gla protein (total and undercarboxylated), and total matrix Gla protein. Vertebral quantitative morphometry was carried out centrally for the detection of VF, defined as reduction by ≥20 % of one of the vertebral body dimensions. In the same radiograph, aortic and iliac VC scores were calculated. Prevalence of VF was 55.3 % in hemodialysis patients and 51.0 % in the control group. Multivariate analysis disclosed that male gender (59.8 vs. 47.6 %, p = 0.02; OR = 1.78, 95 % CI 1.15–2.75) and age (mean ± SD 66.7 ± 13.1 vs. 61.0 ± 14.7 years, p < 0.001; OR = 1.03, 95 % CI 1.01–1.05) were significantly associated with VF. The prevalence of aortic VC was significantly higher in hemodialysis patients than in controls (80.6 vs. 68.4 %, p = 0.001). The factors with the strongest association with VC, apart from atrial fibrillation, were serum 25(OH)vitamin D levels below 29 ng/mL for aortic VC (OR = 1.85, 95 % CI 1.04–3.29) and VF both for aortic (OR = 1.77, 95 % CI 1.00–3.14) and iliac (OR = 1.96, 95 % CI 1.27–3.04) VC. In conclusion, the prevalence of VF, especially in males, and VC, in both genders, is high in hemodialysis patients. VF is associated with VC. Vitamin D deficiency is also associated with VC. Further longitudinal studies are warranted to investigate fractures in renal patients.     

Is larger tumor size a contraindication to retroperitoneal laparoscopic adrenalectomy?

Purpose

To evaluate the surgical feasibility of retroperitoneal laparoscopic adrenalectomy for tumors exceeding 5 cm.

Methods

A retrospective review was carried out on all adrenalectomies performed between 2002 and 2011. All surgical procedures were performed or supervised by one of two experienced laparoscopic surgeons. A total of 133 patients who underwent retroperitoneal laparoscopic adrenalectomy were divided according to tumor size: group I (n = 57) had tumors <5 cm and group II (n = 76) had tumors ≥5 cm. The operative outcomes included surgical time, change in hemoglobin level, estimated blood loss, necessity for blood transfusion, time to ambulation, hospitalization duration, postoperative complications according to the Clavien-Dindo classification, and the rate of conversion to open surgery.

Results

The estimated blood loss (271.75 ± 232.98 mL vs. 367.24 ± 275.11 mL; p = 0.037), time to ambulation (1.60 ± 0.49 days vs. 1.89 ± 0.31 days; p = 0.001), and postoperative hospitalization (7.88 ± 3.08 days vs. 9.264 ± 3.10 days; p = 0.012) were significantly higher in group II. The operation time and hemoglobin level change were not statistically different between groups. Blood transfusions were performed in 3 patients from group I and 6 patients from group II (5.3 vs. 7.9 %; p = 0.449). No patients experienced conversion to open surgery.

Conclusions

Retroperitoneal laparoscopic adrenalectomy can be used in patients with tumors larger than 5 cm.     

Sodium gradient,xerostomia, thirst and inter-dialytic excessive weight gain: a possible relationship with hyposalivation in patients on maintenance hemodialysis

Purpose

The aim of the study was to assess whether hyposalivation is linked with increased thirst sensation and weight gain in hemodialysis (HD) patients and whether there is any connection between hyposalivation and sodium balance.

Methods

One hundred and eleven participants (64 males and 47 females) receiving maintenance hemodialysis, mean age 59.1 ± 13.6 years old, were involved in the study. All participants completed a survey evaluating thirst intensity (DTI) and xerostomia inventory (XI). In addition, pre-dialysis sodium concentration and inter-dialytic weight gain (IWG) were assessed. The division into no-hyposalivation and hyposalivation groups was based on an unstimulated whole saliva (UWS) flow rate.

Results

Hyposalivation, UWS below 0.1 mL/min, was reported in 28.8 % of HD patients. In these participants, IWG was higher than in patients with UWS > 0.1 mL/min (3.65 ± 1.78 vs 3.0 ± 1.4; p = 0.042), as well as the pre-dialysis sodium gradient (3.22 ± 2.1 vs 1.6 ± 2.8; p = 0.031). The mean XI and DTI scores did not differ between study groups. In the hyposalivation group, pre-dialysis sodium serum gradient negatively correlated with saliva outflow (ρ = ?0.61, p = 0.019) and positively with IWG (ρ = 0.49, p = 0.022). IWG correlated with XI (ρ = 0.622, p = 0.016) in hyposalivation group and with DTI in no-hyposalivation group (ρ = 0.386, p = 0.033).

Conclusions

Hyposalivation significantly correlates with IWG; however, its influence on thirst and self-reported mouth dryness seems to be weaker than expected. Additionally, hyposalivation was found to be associated with an elevated pre-dialysis sodium gradient.     

Is closed-suction drainage necessary after intradural primary spinal cord tumor surgery?

Purpose

The efficacy of closed-suction drainage in primary intradural spinal cord tumor surgery has not been addressed. We investigated whether closed-suction drainage is essential after primary intradural spinal cord tumor surgery.

Methods

From January 2003 to October 2011, 169 consecutive patients with primary intradural spinal cord tumors operated by a single surgeon were selected. Closed-suction drainage was inserted in patients before August 2007, but was not used after August 2007. After removal of tumor and meticulous hemostasis, the opened dura was closed and made watertight using 4-0 silk with interrupt suture and 1.0 cm³ of surgical glue was applied in common. Closed-suction drainage was inserted below the muscular fascia in 75 patients (group I, M:F = 39:36; 46.20 ± 15.63 years) and was not inserted in 94 patients (group II, M:F = 46:48; 51.05 ± 14.89 years).

Results

Neurological deficit precluding ambulation did not occur in all patients. Between group I and II, there were no significant differences in body mass index (22.75 ± 3.16 vs. 23.51 ± 3.22 kg/m²; p = 0.13), laminectomy level (2.45 ± 1.46 vs. 2.33 ± 1.91; p = 0.65), operation time (260.65 ± 109.08 vs. 231.52 ± 90.08 min; p = 0.06), estimated intraoperative blood loss (456.93 ± 406.62 vs. 383.94 ± 257.25 cm³; p = 0.18), and hospital stay period (9.25 ± 5.01 vs. 9.35 ± 5.75 days; p = 0.91). Two patients in group I underwent revision surgery due to wound problems, while revision surgery was not performed in group II (p = 0.20).

Conclusion

Closed-suction drainage may not be essential after primary intradural spinal cord tumor surgery.     

Preservation of residual renal function by not removing water in new hemodialysis patients: a randomized,controlled study

Purpose

To investigate the effect of no water removal (NWR) on preservation of residual renal function (RRF) in new hemodialysis (HD) patients.

Methods

Fifty-six patients with a daily urine volume ≥1,000 mL were included. Patients were randomized to different fluid management groups of NWR or water removal (WR) for 6 months. If predialysis BP was >150/90 mmHg, patients could take antihypertensive drugs. The primary endpoints included death, cardio-cerebral vascular disease, refractory hypertension, and edema or an auxiliary examination indicating obvious fluid retention. The secondary endpoint was oliguria. A daily urine volume, 24-h urine creatinine clearance, the defined daily dose (DDD) index of antihypertensive drugs, erythropoietin resistance index, cardiothoracic ratio, and left ventricular mass index (LVMI) were recorded.

Results

Eight patients in the NWR group reached the primary endpoints. Nine patients in the WR group reached the secondary endpoint. At the end of the study, patients in the NWR group had more increased systemic blood pressure (9.0 ± 8.3 vs. ?2.4 ± 2.0 mmHg, p < 0.001), DDD index (1.2 ± 1.02 vs. ?0.9 ± 0.51, p < 0.001), daily urine volume (164 ± 351 vs. ?726 ± 342 mL, p < 0.001), cardiothoracic ratio (0.02 ± 0.04 vs. ?0.03 ± 0.03, p < 0.001), LVMI (9.6 ± 17.0 vs. ?12.0 ± 21.4 g/m², p < 0.001), and less decreased urine creatinine clearance (?1.0 ± 0.4 vs. ?2.0 ± 1.0, p < 0.001), compared with those patients in the WR group.

Conclusions

Preservation of RRF by NWR is warranted in new HD patients, but is not appropriate for all patients.     

Dialysis Patients With the Metabolic Syndrome Need Less Recombinant Human Erythropoietin for Similar Hemoglobin Levels

IntroductionThe metabolic syndrome (MS) components, such as dyslipidemia, prothrombotic status, and increased blood pressure, are risk factors for patients with renal disease. Visceral fat mass is closely related to the MS and atherosclerosis. We investigated the effects of body compositions and MS on anemia parameters and recombinant human erythropoietin (rHuEPO) requirements in maintenance hemodialysis patients.MethodsBody composition (body mass index and bioimpedance analysis) and laboratory data were obtained from 110 dialysis patients. The MS was identified according to ATP-III criteria. Anemia parameters, hemoglobin (Hgb), albumin, C-reactive protein (CRP), calcium, phosphorus, parathormone levels, and rHuEPO requirements over the last 6 months were retrospectively analyzed.ResultsPatients with the MS seem to reach target Hgb levels more frequently (10–12 g/dL; 66.3% vs 84.8%; P = .03) without any difference in total intravenous iron therapy dosage. MS patients also required lower rHuEPO for reaching similar Hgb levels compared with patients without MS (2679.3 ± 1936.1 vs 3702.5 ± 2213.0 U/kg/6 mo; P = .02). There were no differences in serum CRP, albumin, or Hgb levels between the 2 groups (P > .05). We observed that patients with MS had significantly higher fat mass and visceral fat ratio, but similar muscle mass values compared with no-MS counterparts (P = .0001 and .001, respectively). However, when we compared the ratios of these parameters we observed a significant reduction in muscle ratios and a significant increase in fat ratios of MS patients (P = .0001).ConclusionOur results indicate that MS might be an advantage for reaching higher Hgb levels with lower rHuEPO dosages. The possible reason for this might be the good nutritional state and increased fat mass of patients with MS.     

Robotic versus laparoscopic adrenalectomy in obese patients

Background

Recently, we demonstrated better perioperative outcomes with robotic versus laparoscopic adrenalectomy (LA) with the posterior retroperitoneal approach in general, and for removal of large adrenal tumors. It is unknown if robotic adrenalectomy (RA) is equivalent to LA in obese patients. The aim of this study is to compare perioperative outcomes of RA versus LA in obese patients.

Methods

Between 2003 and 2012, 99 obese (BMI ≥ 30 kg/m²) patients underwent adrenalectomy at a tertiary academic center. Of these, 42 patients had RA and 57 had LA. The perioperative outcomes of these patients were compared between the RA and LA groups. Data were collected from a prospectively maintained, institutional review board approved database. Clinical and perioperative parameters were analyzed using Student t and χ² tests. All data are expressed as mean ± standard error of the mean.

Results

The groups were similar in terms of age, gender, and tumor side. Body mass index was lower in the robotic versus laparoscopic group (35.4 ± 1.0 vs. 38.8 ± 0.8 kg/m², respectively, p = 0.01). Tumor size (4.0 ± 0.4 vs. 4.3 ± 0.3 cm, respectively, p = 0.56), skin-to-skin operative time (186.1 ± 12.1 vs. 187.3 ± 11 min, respectively, p = 0.94), estimated blood loss (50.3 ± 24.3 vs. 76.6 ± 21.3 ml, respectively, p = 0.42), and hospital stay (1.3 ± 0.1 vs. 1.6 ± 0.1 days, respectively, p = 0.06) were similar in both groups. The conversion to open rate was zero in the robotic and 5.2 % in the laparoscopic group (p = 0.06). The 30-day morbidity was 4.8 % in the robotic and 7 % in the laparoscopic group (p = 0.63).

Conclusions

Our study did not show any difference in perioperative outcomes between RA and LA in obese patients. These results suggest that the difficulties in maintaining exposure and dissection in obese patients nullify the advantages of robotic articulating versus rigid laparoscopic instruments in adrenal surgery.     

Peritoneal dialysis outcomes in a modern cohort of overweight patients

Background

The incidence of obesity is increasing both in the general population and in incident dialysis patients. While there is evidence that being overweight is associated with good outcomes in hemodialysis, the evidence in peritoneal dialysis (PD) patients is not very clear. We studied a modern cohort of PD patients to examine outcomes in large patients.

Methods

Forty-three patients who started PD, who weighed more than 90 kg at dialysis initiation, between January/2000 and June/2010 were matched with 43 control patients who weighed less than 90 kg. Detailed review of the charts was undertaken.

Results

The mean weight and body mass index of the wt < 90 kg group were 69.3 ± 11.3 kg and 25.0 ± 3.9 kg/m². The number of peritonitis episodes per year was 0.33 ± 0.6 (wt < 90 kg) and 0.82 ± 1.7 (wt ≥ 90 kg) (p = 0.26). The median time to first peritonitis showed a trend toward earlier peritonitis in larger patients [9.5 (4.3, 27) months in wt ≥ 90 kg, 19.1(7.9, 30.8) months in wt < 90 kg] but did not reach statistical significance (p = 0.12). Surprisingly, hernias and leaks were more common in the weight <90 kg group (44 vs. 18.6 % p = 0.02). There was no difference in total number of hospitalizations or the number of days hospitalized. Kaplan–Meier analysis of survival on PD showed no differences between the two groups (logrank p = 0.99). Cox regression analysis using age, race, cause of ESRD due to diabetes and Charlson comorbidity index as the covariates did not show weight to be associated with survival on PD.

Conclusions

Large patients tend to do just as well on PD, with survival on PD being no different compared to individuals with lower weight and body mass index.     

Prevalence and related factors of the absence of anemia among Chinese chronic hemodialysis patients: a multicenter cross-sectional study

Background

Some chronic hemodialysis (HD) patients can maintain normal hemoglobin levels without requiring erythropoiesis-stimulating agents (ESAs). However, the prevalence and the factors associated with this condition in Chinese chronic HD patients have not been reported. The aim of this study was to investigate clinical features, iron metabolism, and other characteristics to survey the prevalence rate and the related factors of this condition among Chinese chronic HD patients.

Methods

A total of 1,318 chronic HD patients participated in this study. The patients were classified into a non-ESA group (n = 11) and an ESA group (n = 1,307). The r-HuEPO-independent (non-ESA) HD patients were defined as having hemoglobin greater than 12 g/dl for more than 6 months without r-HuEPO injection, blood transfusion, or androgen therapy. Epidemiological and laboratory data were collected. Renal sonography was also performed on each patient to evaluate the formation of renal and liver cysts, and the number and size of the cysts were recorded.

Results

Approximately 0.84 % of all HD patients were found to be r-HuEPO independent. The non-ESA group had a higher proportion of men (79.6 vs. 58.3 %), a longer duration of renal replacement therapy (RRT) (8.6 ± 6.1 vs. 5.1 ± 3.3 years), a higher prevalence of adult polycystic kidney disease (APKD) (46.3 vs. 9.7 %), a higher prevalence of hepatitis C virus (HCV) liver disease (26.2 vs. 3.2 %, P < 0.01), and had older patients (63.3 ± 13.6 vs. 49.6 ± 13.5 years). Endogenous erythropoietin levels in the non-ESA group were significantly higher than those in the ESA group (61.8 ± 27.1 vs. 29.3 ± 11.7 mU/ml). Non-ESA patients had a significantly higher number of renal (38.1 vs. 13.2 %) and hepatic cysts (9.3 vs. 1.9 %), which were also larger in size (2.9 ± 1.6 vs. 1.3 ± 0.3 cm) compared with those of patients in the ESA group. No significant difference in iron metabolism was found between two groups. In the multivariate Cox analysis, the independent predictor factors for the absence of anemia in these HD patients were the number of renal cysts >6 cysts (95 % CI 1.058–1.405; P = 0.00), endogenous erythropoietin levels (95 % CI 1.139–1.361; P = 0.05), HCV+ liver disease (95 % CI 1.129–1.316; P = 0.01), and time on RRT (95 % CI 1.019–1.263; P = 0.05).

Conclusions

To our knowledge, this study is the first to report on r-HuEPO independence among Chinese HD patients. The prevalence among Chinese chronic HD patients is significantly lower than that reported in the literature. Factors contributing to this condition are complex and multiple. The frequency of this condition is higher in men and in older patients with long-term RRT, in patients with HCV+ liver disease, and in APKD patients. This condition is associated with increased endogenous erythropoietin production and the presence of renal and hepatic cysts.     

Effect of intradialytic exercise on daily physical activity and sleep quality in maintenance hemodialysis patients

Purpose

Physical inactivity and sleep disturbance are frequently observed and relate to poor clinical outcomes in maintenance hemodialysis patients. We aimed to investigate the effect of intradialytic exercise on daily physical activity and sleep quality, measured by an accelerometer, in maintenance hemodialysis patients.

Methods

This study randomly assigned ambulatory maintenance hemodialysis patients aged ≥ 20 years on dialysis ≥ 6 months, without a hospitalization history for the previous 3 months to 4 groups: aerobic exercise (AE), resistance exercise (RE), combination exercise (CE), and control. A stationary bike was used for AE and a TheraBand^®/theraball for RE. A 12-week intradialytic exercise program (3 times/week) was completed in the AE (n = 11), RE (n = 10), and CE (n = 12) groups. The control group (n = 13) received only warm-up stretching. At baseline and 12-week follow-up, daily physical activity and sleep quality were measured with a triaxial accelerometer (wActiSleep-BT; ActiGraph, Pensacola, FL) during a continuous 7-day wear period.

Results

We observed a significant increase in metabolic equivalent (MET; kcal/h/kg) in the AE (1.02 ± 0.03 vs 1.04 ± 0.04, P = 0.04) and CE (1.06 ± 0.05 vs 1.09 ± 0.08, P = 0.01) groups at 12 weeks compared with baseline. When comparing between-group changes in MET, there was a significant increase in METs in the CE group (0.03 ± 0.03 vs ? 0.01 ± 0.04, P = 0.02) compared with the control group. The total number of sedentary bouts (per week) decreased significantly in the AE (200 ± 37 vs 174 ± 36, P = 0.01), RE (180 ± 31 vs 130 ± 49, P = 0.03), and CE groups (180 ± 45 vs 152 ± 46, P = 0.04) at 12 weeks compared with baseline. The average sleep fragmentation index, indicating poor sleep quality, decreased significantly at 12 weeks compared with baseline in the AE (51.4 ± 8.0 vs 44.5 ± 9.6, P = 0.03) and RE groups (52.3 ± 7.3 vs 40.0 ± 15.4, P = 0.01).

Conclusions

Intradialytic exercise appears to be clinically beneficial in improving daily physical activity and sleep quality in maintenance hemodialysis patients.

     

Serum osteoprotegerin is markedly increased and may contribute to decreased blood T cell count in hemodialysis patients

Purpose

Acquired immunity is impaired in hemodialysis (HD) patients, and decreased T cell number may contribute. Receptor activator of nuclear factor-κB ligand (RANKL) and osteoprotegerin (OPG) are expressed in cells of the immune system and affect T cell development, homeostasis and proliferation. Serum levels of RANKL and OPG and their relation to blood T cell number were evaluated in HD patients.

Methods

Thirty-four HD patients and 20 healthy controls participated in the study. Serum RANKL and OPG were measured by ELISA and T cell number was assessed by flow cytometry.

Results

Median RANKL concentration did not differ between HD patients and healthy volunteers (300.00 pmol/L; range, 3,340.00 vs. 330.00 pmol/L; range, 440.00 pmol/L; p = 0.528). Median OPG was markedly higher in HD patients than in healthy volunteers (13.12 ± 4.71 vs. 4.71 ± 0.93 pmol/L, p < 0.001). The T cell count was significantly lower in HD patients than in healthy controls (1,177.00 ± 567.71 vs. 1,519.80 ± 594.96 cells/mm³, p = 0.044). In HD patients, blood T cell number was correlated positively with serum RANKL (ρ = 0.462, p = 0.007) and negatively to serum OPG (r = ?0.449, p = 0.008).

Conclusion

Serum OPG concentration is markedly increased in HD patients and may contribute to decreased blood T cell count and impaired acquired immunity that characterizes this population.     

Is residual renal function and better phosphate control in peritoneal dialysis an answer for the lower prevalence of valve calcification compared to hemodialysis patients?

Introduction

Cardiac valve calcification (CVC) has long been regarded as a consequence of abnormal calcium–phosphate metabolism in uremic patient associated with increased cardiovascular mortality in this population. We evaluated the association between residual renal function (RRF), phosphate level and valve calcification in peritoneal dialysis (PD) and hemodialysis (HD) patients.

Methods

We studied 30 stable PD patients (60 % males; mean age 57 ± 12.36 years) and 34 HD patients (58.8 % males; mean age 50.8 ± 10.4 years) on renal replacement therapy (RRT) from 6 up to 36 months. The presence of CVC was assessed by standard bi-dimensional echocardiography. RRF was calculated by standard technique.

Results

Valve calcification was more frequently found in HD compared to PD patients (70.6 vs 29.4 %, p = 0.007). Significantly lower phosphate [1.38 ± 0.41 versus 1.99 ± 0.35 mmol/L (p < 0.0001)], a higher RRF [4.09 ± 2.09 ml/min vs 0.62 ± 0.89 ml/min (p < 0.0001)], and older age [57 ± 12.36 years vs 50.8 ± 10.4 years (p = 0.033)] were observed in PD as compared to HD patients. The logistic regression analysis for the presence of valve calcification when adjusted for age and diabetes, with type of therapy, serum phosphate, RRF, CRP, and serum albumin as variables in the model, revealed significant association between the presence of valve calcification and age and RRF. The correlation between phosphate levels and RRF was even stronger in PD patients than in HD patients (r = ?0.704; p = 0.0001) vs (r = ?0.502; p = 0.02).

Conclusions

Our study shows that the residual renal function in PD patients contributes significantly to the maintenance of phosphate balance and may explain the lower prevalence of valve calcification in PD patients compared with HD patients in the period up to first 3 years under renal replacement therapy.     

Effect of frequency of intravenous iron administration on hemoglobin variability in maintenance hemodialysis patients

Target

To observe the effect on hemoglobin (Hb) variability with different treatment frequencies of intravenous iron in maintenance hemodialysis (MHD) patients.

Methods

There were 41 MHD patients enrolled in the cohort. The patients were separated into two groups randomly. The baseline data were collected after oral iron agents for 1 month (wash out). There were two methods of intravenous iron administration, either continuous or intermittent. For continuous administration (CA), 100 mg sucrose iron agents were given during every HD session with total dose of 1000 mg. For intermittent administration (IA), 100 mg sucrose iron agents were given once every week with the same total dose of 1000 mg. The protocol were designed to do a follow-up of 7 months, which included two to three-month steps of different administrations of intravenous iron and 1 month of wash-out period by oral iron agents between two steps, respectively. Patients in Group one (G1) administrated iron agents by CA at the first step and IA at the second step. Patients in Group two (G2) did IA and then transfer to CA. The clinical parameters including Hb, serum ferritin (SF), transferrin saturation (TAST), and doses of recombined human erythropoietin (rHuEPO) were detected and recorded during follow-up period. The standard deviation of Hb (Hb-SD) and coefficient variation of Hb (Hb-CV) were calculated. The baseline data were compared between two groups. The parameters on month 3 and 7 were compared with those on month 0 in two groups, respectively. The effects of both CA and IA on Hb-SD and Hb-CV were compared by two-stage cross-comparison general linear model (GLM) method.

Results

There were 34 patients (82.9%) completed the trail. The amounts of cases, rates of gender and primary diseases, the mean value of age, Hb, SF, TSAT, and doses of rHuEPO on baseline in two groups were similar (p?>?0.05). The SF levels in two groups increased significantly during follow-up period, which were 235.4?±?51.8 ng/ml on month 0, 362.4?±?140.2 ng/ml on month 3, and 315.0?±?97.73 ng/ml on month 7 in G1 (p?<?0.01), and 250.5?±?37.8 ng/ml, 332.2?±?118.9 ng/ml, and 347.4?±?124.3 ng/ml in G2 (p?<?0.01), respectively. Compared to CA, IA could decline the Hb-SD (5.93?±?3.97 g/l vs. 7.36?±?3.81 g/l, F?=?4.377, p?=?0.044) and Hb-CV (0.054?±?0.035 vs. 0.069?±?0.030, F?=?7.042, p?=?0.012) significantly. The mean levels of Hb and doses of rHuEPO were similar between CA and IA.

Conclusion

The administration of intravenous iron by CA or IA has the similar effects on iron supplement and anemia treatment. However, IA may be more benefit to Hb variability than CA in MHD patients.

     

High uric acid and low superoxide dismutase as possible predictors of all-cause and cardiovascular mortality in hemodialysis patients

Purpose

We investigated the role of serum uric acid (sUA) and superoxide dismutase (SOD) as predictive factors for mortality in hemodialysis (HD) patients.

Methods

SOD, butyrylcholinesterase, and malondialdehyde were estimated spectrophotometrically and the other parameters by standard procedures. High-sensitive C-reactive protein was assayed by a sandwich ELISA method.

Results

sUA among survivors (112.1 ± 13.82 μmol/L) was significantly lower than in deceased (160.8 ± 16.81 μmol/L, p < 0.001), while SOD was higher in survivors (31.8 ± 6.61 kU/L) than among deceased (20.2 ± 3.03, p < 0.05). Kaplan–Meier survival curves showed the greatest mortality risk in the highest tertile of basal sUA concentration (≥127.11 μmol/L, p < 0.001), and for SOD in the lowest tertile (≤23.83 kU/L, p < 0.05).

Conclusion

Our results suggest that high sUA and low SOD may predict all-cause and cardiovascular mortality in HD patients.     

Laparoscopic left hemihepatectomy: a safety and feasibility study of 19 cases

Background

Laparoscopic liver resection was performed at some institutes. The procedure mainly included local resection, segmentectomy, and left lateral segmentectomy. With experience accumulation and technique innovation, laparoscopic left hemihepatectomy was performed in selected patients. This study was designed to introduce and evaluate the safety and feasibility of this procedure.

Methods

Nineteen successive patients underwent laparoscopic left hemihepatectomy from 2005 to 2007. They were compared by the matched-pair method with 19 other patients who underwent conventional open left hemihepatectomy. Surgical feature, postoperative course, and the learning curve of laparoscopic left hemihepatectomy were studied.

Results

Laparoscopic hemihepatectomy was successfully performed in 17 cases. Two conversions were required. Compared with the open group, the blood loss was significantly less in the laparoscopic group (462 ± 372 vs. 895 ± 704, p = 0.03). Postoperative hospital stay of the laparoscopic group was shorter but not significant compared with the open group (9 ± 5 vs. 13 ± 7, p = 0.086). Postoperative albumin level in the laparoscopic group was significantly higher than the open group (33 ± 4.8 vs. 27.6 ± 3.2, p = 0.001). There was no perioperative mortality in either group. Two complications occurred in the laparoscopic group (11%) and four in the open group (21%). A tendency of gradually decreased transecting time was noticed in the early cases (R² = 0.676; p = 0.012).

Conclusions

Laparoscopic left hemihepatectomy is a safe and feasible procedure for select patients.     

Transvaginal specimen extraction versus conventional minilaparotomy after laparoscopic anterior resection for colorectal cancer: mid-term results of a case-matched study

Background

Although the vagina is considered a viable route during laparoscopic surgery, a number of concerns have led to a need to demonstrate the safety of a transvaginal approach in colorectal surgery. However, the data for transvaginal access in left-sided colorectal cancer are extremely limited, and no study has compared the clinical outcomes with a conventional laparoscopic procedure.

Objective

We compared the clinical outcomes of totally laparoscopic anterior resection with transvaginal specimen extraction (TVSE) with those of the conventional laparoscopic approach with minilaparotomy (LAP) for anastomosis construction and specimen retrieval in left-sided colorectal cancer.

Methods

Fifty-eight patients underwent TVSE between October 2006 and July 2011 and were matched by age, surgery date, tumor location, and tumor stage with patients who underwent conventional LAP for left-sided colorectal cancer.

Results

Operative time was significantly longer in the TVSE group (149.3 ± 39.8 vs. 131.9 ± 41.4 min; p = 0.023). Patients in the TVSE group experienced less pain (pain score 4.9 ± 1.6 vs. 5.8 ± 1.9; p = 0.008), shorter time to passage of flatus (2.2 ± 1.1 vs. 2.7 ± 1.2 days; p = 0.026), and higher satisfaction with the cosmetic results (cosmetic score 8.0 ± 1.4 vs. 6.3 ± 1.5; p = 0.001). More endolinear staplers for rectal transection were used in the LAP group (1.2 ± 0.5 vs. 1.1 ± 0.2; p = 0.021). Overall morbidities were similar in both groups; however, three wound infections only occurred in the LAP group. After a median follow-up of 34.4 (range 11–60) months, no transvaginal access-site recurrence occurred. The 3-year disease-free survival was similar between groups (91.5 vs. 90.8 %; p = 0.746).

Conclusions

Transvaginal access after totally laparoscopic anterior resection is safe and feasible for left-sided colorectal cancer in selected patients with better short-term outcomes.     

Predicting regression of Barrett’s esophagus: results from a retrospective cohort of 1342 patients

Introduction

Barrett’s esophagus (BE) is the most predictive risk factor for development of esophageal adenocarcinoma (EAC), a malignancy with the fastest increasing incidence in the US. The aim of this study was to investigate differences in exposures, demographics, and comorbidities between regressing and non-regressing patients.

Methods and procedures

We retrospectively collected and analyzed data from a cohort of BE patients participating in a single-center study comprised of all patients diagnosed with BE over a 10-year period. We collected information from the patient’s electronic medical records regarding demographic data, endoscopic findings, histological findings, exposures, and history of antireflux surgery.

Results

This study included 1,342 BE patients, 505 (37.6 %) of which experienced regression. The regressed group was 52.3 % male, while the non-regressing group was 68.3 % male (p < 0.001). Mean age was 65.2 ± 12.8 and 62.0 ± 13.1 years for non-regressing and regressing patients, respectively (p < 0.001). No difference was seen in BMI between regressing and non-regressing groups (27.5 ± 5.7 vs. 27.7 ± 5.4, p = 0.52). No difference was seen between groups with respect to PPI use (93.5 % non-regressing vs. 94.1 % regressed patients, p = 0.70), but regressed patients were more likely to take vitamin D than non-regressing patients (34.1 vs. 42.1 %, p = 0.003). Regressed patients had an average segment length of 1.48 cm (±1.58 cm), in contrast to those not regressing (3.58 ± 3.09 cm (p < 0.001)). Interestingly, one patient in the regression group progressed to dysplasia, while 101 of the non-regressing patients progressed to dysplasia/EAC, a result found to be independent of segment length on multivariate analysis (p < 0.001).

Conclusions

Currently, several studies have shown risk factors that can predict progression of non-dysplastic BE, but few investigate predictors for regression. Our study reports several factors that can be used to predict patients who will regress from BE and those who likely will not, tools that will be useful in tailoring therapeutic and surveillance strategies.     

Ionized and total serum magnesium in hemodialysis: predictors and variability. A longitudinal cross-sectional study

Background

Ionized Magnesium (ion-Mg) represents the active biological fraction of the serum magnesium content. The assessment of total serum Mg (tot-Mg) might not accurately identify patients with hypo-or hyper-magnesaemie. In hemodialysis, serum tot-Mg levels in the upper part of the distribution, have been associated with reduced mortality and fewer vascular calcifications; thus, resulting in the tendency to increase the Mg concentration in the dialysate, traditionally set at 0.5 mmol/L.

Methods

Single-center study in chronic hemodialysis patients, designed in two phases, cross-sectional and longitudinal, aimed to investigate: (1) the sensitivity for pathological values of ion-Mg compared to tot-Mg (2) the predictors of ion-Mg developing ad hoc equations; (3) the inter- and intra-individual variabilities of ion-Mg; and (4) the risk factors for hypermagnesemia. Tot-Mg, ion-Mg, and covariates of 42 hemodialysis sessions, in 42 patients during the cross-sectional phase and of 270 sessions in 27 patients in the longitudinal one were analysed.

Results

Ion-Mg significantly correlates with tot-Mg: β = 0.52; r = 0.88, p < 0.001. Multiple linear regressions in normo- and hypo-albuminemic patients gave the following results: ion-Mg = tot-Mg/2-K⁺/50 + Ca²⁺/5-HCO^3?/100 and ion-Mg = tot-Mg/2 + albumin/100. Ion-Mg showed a high temporal variability in the longitudinal phase (between months p < 0.001; winter vs. summer, p < 0.027). A high intra-individual variability was also found: coefficient of variation 0.116. Comparing patients with high and low intra-individual variability, we found: age 67 vs. 77 years; p < 0.001; urea 26.3 ± 0.5 vs. 21.2 ± 0.4 mmol/L, p < 0.001; nPCR 0.92 ± 0.1 vs. 0.77 ± 0.1 g/kg day, p < 0.001; PTH 46.3 ± 4 vs. 28.5 ± 3 pmol/L, p < 0.001.

Conclusions

Ion-Mg can be useful in unmasking unrecognized hyper- and hypo-magnesemic and false hyper-magnesemic patients. Ion-Mg is characterized by high intra- and inter-individual variabilities particularly in younger women and those with better nutrition. Patients with greater variability could potentially be at risk if exposed to higher concentrations of magnesium in the dialysate. An interventional study, with controlled increase of magnesium concentrations in the dialysate has been planned.

     

The role of short daily hemodialysis in the control of hyperphosphatemia, secondary hyperparathyroidism and anemia

Background

Hyperphosphatemia, secondary hyperparathyroidism (SHPT) and anemia are common secondary complications in hemodialysis patients with end-stage renal disease (ESRD). Compared with conventional hemodialysis (CHD), short daily hemodialysis (sDHD) has been found to be more effective in patients with ESRD. The objective of this study was to determine whether sDHD could improve hyperphosphatemia, SHPT and anemia in patients with ESRD.

Methods

Twenty-seven patients (11 women and 16 men, 46.8 ± 13.4 years old) were switched from CHD to sDHD. All hematologic parameters were measured prior to the switch (baseline), at 3 months after the switch (sDHD₁) and at 6 months after the switch (sDHD₂).

Results

The serum phosphate decreased from 2.54 ± 0.32 mmol/L at baseline to 2.15 ± 0.36 mmol/L (p < 0.001) at sDHD₁ and 1.97 ± 0.33 mmol/L (p < 0.001) at sDHD₂. Calcium-phosphate product decreased from 5.18 ± 1.24 mmol²/L² at baseline to 4.20 ± 0.71 mmol²/L² (p < 0.001) at sDHD₁ and 4.02 ± 0.83 mmol²/L² (p < 0.001) at sDHD₂. The serum PTH levels decreased from 223.9 ± 124.7 pmol/L at baseline to 196.3 ± 101.3 pmol/L (p < 0.05) at sDHD₂. The hemoglobin concentration increased significantly from CHD to sDHD. However, the requirement for erythropoietin (EPO) dose decreased from 6847.8 ± 1057.3 u/week at baseline to 5869.6 ± 1094.6 u/week (p < 0.05) at sDHD2.

Conclusions

sDHD may decrease serum phosphate, calcium-phosphate product and PTH, increase hemoglobin levels and decrease exogenous EPO dose requirements compared with CHD in hemodialysis patients.     

Surgical training in robotic surgery: surgical experience of robotic-assisted transabdominal preperitoneal inguinal herniorrhaphy with and without resident participation

Robotic-assisted surgery is becoming more popular in general surgery. Implementation of a robotic curriculum is necessary and will influence surgical training. The aim of this study is to compare surgical experience and outcomes with and without resident participation in robotic inguinal herniorrhaphy. A retrospective review of patients who underwent either unilateral or bilateral robotic-assisted transabdominal preperitoneal (TAPP) inguinal herniorrhaphy, with and without resident participation as console surgeons from January through December 2015, was performed. Patient demographics, procedure-related data, postoperative variables, and follow-up data were analyzed. A total of 104 patients were included. Patients were significantly older in the Resident group (57.5 ± 14.1 vs 50.6 ± 13.5 years, p = 0.01). Gender, BMI, and ASA classification were similar between groups. There were similar mean operative times for unilateral (89.9 ± 19.5 vs 84.8 ± 22.2 min, p = 0.42) and bilateral (128.4 ± 21.9 vs 129.8 ± 50.9 min, p = 0.90) inguinal herniorrhaphy as well as mean robot console times for unilateral (73.2 ± 18.4 vs 67.3 ± 29.9 min, p = 0.44) and bilateral (115.5 ± 24.6 vs 109.3 ± 55.4 min, p = 0.67) inguinal herniorrhaphy with and without resident participation, respectively. Postoperative complications included urinary retention (11.1 vs 2.0%, p = 0.11), conversion to open repair (0 vs 2%, p = 0.48), and delayed reoperation (0 vs 4%, p = 0.22) with and without resident participation, respectively. Patients’ symptoms/signs at follow-up were similar among groups. Robotic-assisted TAPP inguinal herniorrhaphy with resident participation as console surgeons did not affect the hospital operative experience or patient outcomes. This procedure can be implemented as part of the resident robotic curriculum with rates of morbidity equivalent to those of published studies.Level of evidence 2b.