Simultaneous kidney-pancreas transplantation for end-stage renal disease patients with insulin-dependent diabetes and detectable C-peptide

Introduction

There is controversy regarding the place of simultaneous pancreas-kidney (SPK) transplantation in end-stage renal disease (ESRD) patients with insulin-dependent diabetes mellitus (IDDM) and detectable c-peptide. We sought to compare outcomes of recipients with and without pretransplantation c-peptide.

Methods

This retrospective single-center review included consecutive primary SPK transplantations performed between September 2007 and May 2010. Demographic characteristics and outcomes were compared between recipients with and without pretransplantation c-peptide.

Results

Seven of 25 (28%) consecutive SPK transplant recipients with a diagnosis of IDDM and ESRD had detectable c-peptide prior to transplantation. The mean c-peptide level was 6.3 ± 6.1 ng/mL. For those recipients with and without c-peptide, mean age at diagnosis of IDDM (12.4 ± 7.8 vs 17.1 ± 6.6 years; P = not significant [NS]), duration of IDDM prior to transplantation (30 ± 10 vs 23 ± 9 years; P = NS), and body mass index (25.9 ± 4.5 vs 26.7 ± 4.5 kg/m²; P = NS) were equivalent between the groups. With a median follow-up of 17 months (range, 3–35 months) there was 1 graft loss (due to cardiovascular death) among the 25 patients. At the most recent follow-up, for recipients with and without c-peptide, both the mean serum creatinine (1.3 ± 0.6 vs 1.0 ± 0.2 ng/mL; P = NS) and the mean HbA1c level (5.3 ± 0.4 vs 5.3 ± 0.5; P = NS) were equivalent between the groups.

Conclusion

For nonobese ESRD patients diagnosed with IDDM at a young age, the presence of detectable c-peptide should not influence the decision to proceed with SPK transplantation.     

Blood pressure and total peripheral resistance in children with chronic kidney disease

We performed a study to assess cardiac output (CO) and total peripheral resistance (TPR) at rest and during peak exercise with the goal to better define the role of these parameters in the development of hypertension in children with chronic kidney disease (CKD) stage 2–4. Fifty-two pediatric patients with CKD (mean age 12.7±3.7 years) and 28 healthy individuals of comparable age and sex participated in the study. At rest, children with CKD had a significantly higher systolic and diastolic blood pressure (BP) and calculated mean arterial pressure (MAP) than healthy controls. Total peripheral resistance was significantly higher in children with CKD than in controls (1627.7±534.6 vs 1354.6±338.9 dyne×s×cm^–5, p =0.02). There was no significant difference in heart rate or CO between the two groups. Children taking antihypertensive medications had lower TPR than children without BP medications (1514.6±439.6 vs 1788.2±505.4 dyne×s×cm^–5, respectively, p =0.06). At peak exercise, children with CKD had a significant increase in MAP, heart rate and CO and had a significant decrease in TPR (difference between rest and peak exercise: –782.4±375.9 dyne×s×cm^–5, p <0.001). Children taking BP medications had blunted MAP and CO responses when compared to controls ( CO: 6.2±2.8 l/min vs 9.8±4.5 l/min, respectively, p =0.01; MAP: 13.9±10.2 mmHg vs 21.5±11.7 mmHg, respectively, p =0.01). Children without BP medications had a similar to controls response to exercise in respect to CO, MAP and TPR. We conclude that increased TPR is a major contributor to elevated blood pressure in children with CKD and suggest that BP medications decreasing vascular resistance should be used as a first line of antihypertensive therapy in these patients.     

Clinical outcome of renal transplantation in end-stage renal disease patients with positive pretransplantation hepatitis B surface antigen

Background

Renal transplantation (RTx) is the best therapeutic modality for patient suffering from end-stage renal disease (ESRD) with positive pretransplantation hepatitis B surface antigen (HbsAg). We report 11 years of single-center experience on RTx vis-à-vis patient/graft survival, graft function in terms of serum creatinine (SCr), and rejection episodes in 35 ESRD patients with pretransplantation HbsAg positivity.

Patients and Methods

Thirty-five ESRD patients with pretransplantation HbsAg positivity underwent RTx at our center between 2000 and 2010. Mean recipient age was 36.06 ± 12.22 years; 30 were males and 5 were females. Mean donor age was 43.51 ± 13.63 years; 13 were males and 22 were females. The majority of donors were parents (31.42%) and spouses (22.85%). Mean HLA match was 2 ± 1.37. The most common recipient diseases leading to ESRD were chronic glomerulonephritis (51%) and diabetes (17.5%). Posttransplantation immunosuppression consisted of a calcineurin inhibitor-based regimen.

Results

Over mean follow-up of 6.16 ± 3.69 years, patient and graft survival rates were 71.42% and 71.42%, respectively, with mean SCr of 1.92 ± 0.62 mg% with 20% biopsy-proven acute rejection episodes. In total, 10 (28.57%) patients were lost, mainly to infections.

Conclusion

RTx for ESRD with pretransplantation HbsAg positivity has acceptable graft function and patient/graft survival over 11 years follow-up and should be encouraged.     

Renal cell carcinoma (RCC) in patients with end-stage renal disease exhibits many favourable clinical, pathologic, and outcome features compared with RCC in the general population

Background

Patients with end-stage renal disease (ESRD) are at risk of developing renal tumours.

Objective

Compare clinical, pathologic, and outcome features of renal cell carcinomas (RCCs) in ESRD patients and in patients from the general population.

Design, setting, and participants

Twenty-four French university departments of urology participated in this retrospective study.

Intervention

All patients were treated according to current European Association of Urology guidelines.

Measurements

Age, sex, symptoms, tumour staging and grading, histologic subtype, and outcome were recorded in a unique database. Categoric and continuous variables were compared by using chi-square and student statistical analyses. Cancer-specific survival (CSS) was assessed by Kaplan-Meier and Cox methods.

Results and limitations

The study included 1250 RCC patients: 303 with ESRD and 947 from the general population. In the ESRD patients, age at diagnosis was younger (55 ± 12 yr vs 62 ± 12 yr); mean tumour size was smaller (3.7 ± 2.6 cm vs 7.3 ± 3.8 cm); asymptomatic (87% vs 44%), low-grade (68% vs 42%), and papillary tumours were more frequent (37% vs 7%); and poor performance status (PS; 24% vs 37%) and advanced T categories (≥3) were more rare (10% vs 42%). Consistently, nodal invasion (3% vs 12%) and distant metastases (2% vs 15%) occurred less frequently in ESRD patients. After a median follow-up of 33 mo (range: 1-299 mo), 13 ESRD patients (4.3%), and 261 general population patients (27.6%) had died from cancer. In univariate analysis, histologic subtype, symptoms at diagnosis, poor PS, advanced TNM stage, high Fuhrman grade, large tumour size, and non-ESRD diagnosis context were adverse predictors for survival. However, only PS, TNM stage, and Fuhrman grade remained independent CSS predictors in multivariate analysis. The limitation of this study is related to the retrospective design.

Conclusions

RCC arising in native kidneys of ESRD patients seems to exhibit many favourable clinical, pathologic, and outcome features compared with those diagnosed in patients from the general population.     

Association between "Malnutrition Inflammation Score" and airway obstruction in patients awaiting renal transplantation: a preliminary study

Background

A chronic inflammatory state is a prominent feature in patients with end-stage renal disease (ESRD) who are undergoing maintenance hemodialysis (MHD). “Malnutrition Inflammation Score” (MIS) is a comprehensive scoring system that measures nutrition and inflammation in MHD patients. Inflammation and malnutrition are important risk factors in ESRD patients with pulmonary diseases. The aim of the study was to determine if pulmonary dysfunction, as assessed by airway obstruction, was associated with malnutrition and inflammatory factors in ESRD patients awaiting renal transplantation (RT).

Methods

Patients with ESRD who were on MHD and had pulmonary function tests (PFTs) were retrospectively enrolled in the study. Patients' renal function tests, albumin, C-reactive protein (CRP) levels, white blood cell count, and PFTs (forced expiratory flow rate in one second [FEV1], forced vital capacity [FVC], forced expiratory flow at 25%-75% [FEF25%-75%], and peak expiratory flow [PEF]) were recorded. MIS was calculated for each patient.

Results

A total of 81 patients (male = 54; mean age: 50.6 ± 13 years) were recruited. Mean body mass index (BMI) was 22.5 ± 4.4 kg/m², mean MIS was 7.1 ± 3.3, mean CRP level was 24.9 ± 48.1 mg/L, mean FEV1% was 94 ± 22, and mean FEF25%-75% was found to be 72.3 ± 30.3. Mean duration of MHD was 10.5 ± 5.2 years. There was a negative correlation between FEV1, FVC, FEF25%- 75%, PEF, and MIS (r = −0.3, P = .00; r = −0.32, P = .00; r = −0.22, P = .04; r = −0.30, P = .00, respectively). Nevertheless, FEV1 values significantly correlated with BMI (P = .03) and the MIS (P = .00).

Conclusion

Impaired pulmonary function could be a marker of inflammation and malnutrition in ESRD patients awaiting RT. Prospective studies are needed to investigate the relationship between pulmonary function, inflammation, and malnutrition in larger populations of ESRD patients. Treatment geared towards malnutrition and inflammation markers may help maintain PFTs within normal range, which may prevent pulmonary complications following RT.     

Glomerular function and microalbuminuria in children with insulin-dependent diabetes

Renal function has been evaluated in 45 diabetic children (age 12.5±4 years) with a mean diabetes duration of 4.9±3.5 years. Glomerular filtration rate (GFR; inulin and creatinine clearances), renal plasma flow (RPF; PAH clearance), resting urinary albumin excretion (UAE) were measured and compared with indexes of metabolic control: Hb A₁C and blood glucose values (mean, post-prandial and maximal excursion) on the same day. GFR (inulin clearance) and RPF were significantly increased in the diabetic group (171±31 and 778±172 ml/min per 1.73 m²) compared with controls (124±18 and 631±128 ml/min per 1.73 m²). Both parameters were strongly correlated (r=0.73;P<0.001). Creatinine clearance was not correlated to inulin clearance. Hyperfiltration (inulin clearance above 160 ml/min per 1.73 m²) was noted in 61% of the patients and was independent of diabetes duration. Five diabetic children had a UAE level above 15 g/min. No relationship could be established between UAE and any of the metabolic indexes; GFR was weakly correlated to HbA₁C (r=0.35;P<0.05), to mean (r=0.35;P<0.05) and post-prandial blood glucose (r=0.37;P<0.05). In contrast, there was a strong correlation between GFR and the maximal blood excursion (r=0.62;P<0.001). The study shows that renal abnormalities can be detected with a high frequency in diabetic subjects characterized by both an early onset and a short duration of diabetes and suggests the need for a more systematic evaluation of renal parameters in this population.     

Interdialytic weight gain and 48-h blood pressure in haemodialysis patients

Background: Hypertension, which is often associated with hypervolaemia is common in haemodialysis patients and is a known determinant of target organ damage. Interdialytic weight gain due to volume overload has also been associated with mortality in haemodialysis patients. Methods: We therefore studied 27 chronic haemodialysis patients who underwent 48-h ambulatory blood pressure monitoring between two midweek dialysis sessions, and 2D and M-mode echocardiography for determination of left ventricular mass index. Results: Left ventricular hypertrophy (left ventricular mass index in men >131 g/m², women >100 g/m²) was present in 70% (19/27) patients despite a mean 48-h blood pressure of 132±19/81±15 mmHg. Mean interdialytic weight gain was 1.6±0.8 kg and was not related to left ventricular mass index. Two patterns of interdialytic blood pressure change were apparent: in group 1 (16 patients) 48-h blood pressure increased (+19±12/13±9 mmHg), whereas in group 2 (11 patients) blood pressure fell (-10±13/-8±10 mmHg P <0.0001). In both groups the number of hypertensive patients (group 1, 10/16; group 2, 6/11), the 48-h blood pressure (132±20/80±15 vs 132±18/82±15 mmHg and interdialytic weight gain (+1.9±0.7 vs +1.3±0.7 kg) were similar. There was also no correlation between interdialytic blood pressure change and weight gain in either group. Conclusions: We conclude that interdialytic blood pressure changes cannot be directly related to interdialytic fluid gain, even in apparent volume-dependent hypertension, emphasizing the importance of additional factors in the control of blood pressure in end-stage renal disease.     

Analysis of Sexual Function in Kidney Transplanted Men

Introduction

Sexual dysfunction among renal failure and kidney transplant patients remains controversial. The aim of this study was to evaluate sexual functions of men on hemodialysis compared with patients undergoing kidney transplantation.

Materials and Methods

Our study was based on 36 end-stage renal disease (ESRD) patients undergoing hemodialysis versus 32 kidney transplanted patients. A control group was composed of 23 healthy patients. The patients underwent an anamnesis, a physical examination, and the International Index of Erectile Function about sexual performance. Statistical analysis was performed by Student's t-test or the chi-square test with the level of significance set at P < .05. Data are reported as mean values ± standard error of the means.

Results

The mean scores of the control, ESRD, and transplanted group were, respectively: for erectile function, 27.4 ± 0.5, 22.4 ± 1.3, 23.4 ± 1.3; for orgasmic function, 9.5 ± 0.1, 7.6 ± 0.5, 8.9 ± 0.5; for sexual desire function 9.4 ± 0.1, 7.1 ± 0.3, 9.0 ± 0.5; for intercourse satisfaction 12.8 ± 0.3, 9.4 ± 0.7, 11.0 ± 0.7; and for satisfaction related to sexual life 9.2 ± 0.2, 7.7 ± 0.3, 8.6 ± 0.6, proving that there were significant differences regarding orgasmic function, sexual desire, and intercourse satisfaction.

Conclusion

It was possible to conclude from our study that kidney transplants do improve sexual function of patients with ESRD on hemodialysis.     

Brain oxygen monitoring: in-vitro accuracy,long-term drift and response-time of Licox- and Neurotrend sensors

Summary Background. Oxygen tension sensors have been used to monitor tissue oxygenation in human brain for several years. The working principals of the most frequently used sensors, the Licox (LX) and Neurotrend (NT), are different, and they have never been validated independently for correct measurement in vitro. Therefore, we tried to clarify if the two currently available sensors provide sufficient accuracy and stability.Method. 12 LX oxygen tension sensors and NT sensors were placed into a liquid-filled tonometer chamber. The solution was kept at 37 ± 0.2 °C and equilibrated with five calibration gases containing different O₂- and CO₂-concentrations. After equilibration, readings were taken for each gas concentration (accuracy test). Afterwards, the sensors were left in 3% O₂ and 9% CO₂ and readings were taken after 24, 48, 72, 96 and 120 hours (drift test). Thereafter, a 90% response time test was performed transferring sensors from 1% to 5% oxygen concentration and back, using pre-equilibrated tonometers.Findings. All Licox oxygen probes [12] were used for this study. Two of 14 Neurotrend sensors did not calibrate, revealing a failure rate of 14% for NT. Oxygen tension during the accuracy test was measured as follows: 1% O₂ (7.1 mmHg): LX 6.5 ± 0.4, NT 5.3 ± 2.3 mmHg, 2% O₂ (14.2 mmHg): LX 12.9 ± 0.6, NT 12.1 ± 2.2 mmHg, 3% O₂ (21.4 mmHg): LX 19.8 ± 0.7, NT 19.4 ± 2.4 mmHg, 5% O₂ (35.8 mmHg): LX 33.4 ± 1.0 mmHg, NT 33.5 ± 2.9 mmHg, 8% O₂ (57.0 mmHg): 53.8 ± 1.5, NT 53.6 ± 3.3 mmHg. After 120 hours in 3% O₂ (21 mmHg), LX measured 19.8 ± 1.9 mmHg, NT 17.9 ± 4.7 mmHg. 90% response time from 1% to 5%/5% to 1% oxygen concentration was 129 ± 27/174 ± 26  sec for LX, 55 ± 19/98 ± 39 sec for NT.Conclusions. Both systems are measuring oxygen tension sufficiently, but more accurately with LX probes. NT sensors read significantly lower pO₂ in 1% O₂ and show an increasing deviation with higher oxygen concentrations which was due to two of twelve probes. A slight drift towards lower oxygen tension readings for both sensors but more pronounced for the NT does not impair long-term use. NT measures pCO₂ and pH very accurately.     

Ambulatory blood pressure monitoring in renal transplant patients: should it be routinely performed?

Introduction

Arterial hypertension is common among kidney transplant patients. It increases cardiovascular risk and is a factor for progression of renal failure. Our objective was to perform ambulatory blood pressure monitoring (ABPM) in renal transplant patients with office hypertension.

Methods

Patients were divided into 2 groups according to their mean ABPM blood pressures with treatment: well-controlled hypertension (blood pressure [BP] <130/85 mmHg), and poorly controlled hypertension (BP > 130/85 mmHg). A “nondipper pattern” was defined as a decrease of <10% or an increase, and a “raiser pattern,” in which mean blood pressure was greater during the nocturnal than the diurnal period. “White coat effect” was considered when the mean of 3 BP measurements in the clinic was >140/90 mmHg among well-controlled hypertensive patients as documented by ABPM.

Results

ABPM was performed in 53 patients: 25 (47%) “well-controlled hypertensives” and 28 (53%) “poorly controlled hypertensives.” Of the latter, 24 (85%) showed a nondipper or raiser pattern with only 4 revealing dipper patterns. We compared well-controlled with poorly controlled hypertensives. The latter cohort were older (54.4 ± 9.3 vs 45.5 ± 13.8 years; P = .009), received grafts from older donors (56.7 ± 15.0 vs 45.8 ± 17 years; P = .02); had worse renal function measured by serum creatinine (1.7 ± 0.5 vs 1.4 ± 0.4 mg/dL, P = .03) or the Modification of Diet in Renal Disease (MDRD) = 4 formula (41.8 ± 14.0 vs 55.4 ± 20.5 mL/min/1.73 m²; P = .009), and displayed more proteinuria (0.30 ± 0.33 vs 0.18 ± 0.10 g/d, P = .08). Nondipper or raiser patients showed a higher mean body mass index (27.1 vs 21.7 kg/m²; P = .04). Among 25 well-controlled patients, 11 presented “white coat phenomenon.”

Conclusion

We observed an important “white coat” effect, a large prevalence of uncontrolled nocturnal hypertension, and a small but important incident of “masked hypertension.” Factors related to hypertension control were patient age, donor age, renal function, induction use, and proteinuria.     

Risk factors for prolonged ICU stay in patients following coronary artery bypass grafting with a long duration of cardiopulmonary bypass

Purpose Risk factors for prolonged stay in the intensive care unit (ICU) in patients following coronary artery bypass grafting (CABG) have been reported in many previous studies. However few have focused on circulatory and respiratory status as immediate postoperative risk factors. Therefore we examined immediate postoperative risk factors for prolonged ICU stay after CABG with a long duration of cardiopulmonary bypass (CPB).Methods We studied retrospectively 100 consecutive patients undergoing elective CABG with CPB. Patients were excluded from this study if the duration of aortic cross-clamping was less than 60min. Patients were divided into three groups according to the duration of the ICU stay. Patients in group A (n = 68) were discharged from the ICU on the next morning after surgery, those in group B (n = 19) stayed for 3 days, and group C (n = 13) stayed for more than 3 days. Perioperative variables were compared among the three groups and we demonstrated risk factors for prolonged (more than 3 days) ICU stay.Results There were significant differences in duration of CPB (157 ± 34 versus 184 ± 48 minutes, P < 0.05) and aortic cross-clamping (119 ± 32 versus 141 ± 40min) between groups A and B. On the other hand, there were significant differences in age (62.8 ± 7.8 versus 67.4 ± 6.2 years), mean pulmonary artery pressure (MPAP) (17 ± 2 versus 22 ± 3mmHg), and Pa_{O 2}/FI _{O 2} (PF ratio) (409 ± 94 versus 303 ± 108mmHg) on admission to the ICU between groups A and C. There were no significant differences in intraoperative fluid balance and duration of CPB. Multiple logistic regression analysis identified age (>65 years), MPAP (>21mmHg), and PF ratio (<300mmHg) as independent risk factors for more than a 3-day ICU stay.Conclusion Advanced age, increased MPAP, and decreased PF ratio on admission to the ICU were significant risk factors for a prolonged ICU stay of more than 3 days.     

Comparison of 1-84 and intact parathyroid hormone assay in pediatric dialysis patients

The non-invasive diagnosis of renal osteodystrophy (ROD) in patients with end-stage renal disease (ESRD) remains dependent on the determination of an accurate parathyroid hormone (PTH) level. Older assays that determine the intact PTH molecule are known to cross react with various PTH fragments, resulting in overestimation of PTH levels. Recently, assays that determine the whole 1-84 PTH molecule have been made available. Monthly PTH values in chronic dialysis patients at our institution were compared using the Nichols Bio-Intact PTH (BiPTH, 1-84 PTH) and the intact PTH (iPTH) assay over 3 consecutive months. One hundred twenty-four samples were obtained from 51 (29 male) pediatric dialysis patients (27 HD). The mean patient age was 14.2±5.6 years (1.8–25.7 years), with 12 patients<10 years and 15 patients <30 kg. The mean 1-84 PTH/iPTH ratio was 0.48±0.11. While BiPTH values correlated closely with iPTH values ( r =0.98, P <0.05), we observed significant intra-patient (16.4±15.4%; range: –73.9 to 67.7%, total % error: 47.2%) and inter-patient (17.2±18.9%; range: –73.9 to 129.9%, total % error: 55%) variability in the 1–84 PTH/iPTH ratio over the 3-month study period. Thus, our findings suggest that ROD management based on prior associations between iPTH levels and bone biopsy findings should not be extrapolated using the newer 1-84 PTH assay.     

Inhaled Nitric Oxide Therapy After Fontan-Type Operations

Purpose Inhaled nitric oxide (NO) therapy is a newly developed strategy designed to reduce pulmonary vascular resistance after the Fontan-type operation. We reviewed our experience to evaluate its efficacy and true indications.Methods We retrospectively examined 47 children who received inhaled NO therapy after the Fontan-type operation between August 1996 and December 2002. The maximal dose of NO ranged from 5 to 30ppm (median 10ppm), and the duration of inhaled NO therapy ranged from 5h to 52 days (median 2 days).Results Inhaled NO significantly decreased the central venous pressure (CVP), from 16.2 ± 2.2 to 14.6 ± 2.2mmHg (P < 0.0001), and the transpulmonary pressure gradient between the CVP and left atrial pressure, from 9.9 ± 2.9 to 8.4 ± 2.7mmHg (P < 0.0001). It also increased the systolic systemic arterial pressure from 71.9 ± 15.2 to 76.8 ± 14.5mmHg (P < 0.05). In 26 patients with additional fenestration, inhaled NO led to a significant improvement in SaO₂ from 90.1% ± 9.6% to 93.3% ± 7.9% (P < 0.01). However, patients with a CVP <15mmHg or a transpulmonary pressure gradient <8mmHg, or both, after the Fontan-type operation, showed no significant changes in hemodynamics during inhaled NO therapy.Conclusions We propose that a CVP 15mmHg or a transpulmonary pressure gradient 8mmHg, or both, after Fontan-type operations are appropriate indications for inhaled NO therapy.     

Epidemiology of end-stage renal failure in Reunion Island (results from the registry of the Indian Ocean Society of Nephrology)

Background: End-stage renal disease (ESRD) on long-term dialysis is a substantial problem in Reunion because of the high incidence and prevalence of this disease due to non-insulin-dependent diabetes mellitus (NIDDM) and systemic arterial hypertension. Subjects and methods: In 1996 the renal study group of the Indian Ocean Society of Nephrology established a regional registry of end-stage renal failure (ESRD) on long-term dialysis. The present report summarizes data obtained from this registry. Results: In 1996, there were 125 patients who were initiated on long-term dialysis, 657 patients on dialysis with a mean age 52±17 years, and 110 patients with a functioning kidney graft. The incidence rate of ESRD was 188 per million population (p.m.p.) and the prevalence rate of this pathology was 1155 p.m.p. The sex ration (F/M) was 1.4/1. The two most common causes of ESRD were NIDDM in 33.6% and systemic arterial hypertension in 27.5%. The mean Kt/V value was 1.47±0.23 and the mortality rate was 8.1% per year. Conclusion: The results demonstrate high incidence and prevalence rates of ESRD mainly as a result of NIDDM and systemic arterial hypertension. Key words: diabetes mellitus; dialysis; end-stage renal failure; hypertension      

Endothelin and cardiovascular remodelling in end-stage renal disease

Background. Plasma endothelin (ET) is elevated in end-stage renal disease (ESRD), but the origin and consequences of this increase remain unclear. In the present study we analysed the relationships between plasma ET levels and cardiovascular alterations in ESRD. Methods and results. Common carotid artery (CCA) intima-media thickness (IMT) and diameter, atherosclerotic plaque occurrence, and left ventricular (LV) geometry and function were determined by ultrasound imaging in 76 haemodialysis patients and in 57 age-, sex-, and blood pressure-matched controls. Arterial stiffness was evaluated via carotid-femoral pulse wave velocity (CF-PWV), forearm post-ischaemic vasodilation was measured by venous plethysmography, and plasma ET levels were determined using a specific immunoenzymoassay. Compared with controls, ESRD patients had elevated plasma ET levels (1.6±1.4 vs 4.6±3.8 pg/ml; P<0.001), increased LV mass (P<0.001), increased CCA-IMT (P<0.001), a higher prevalence of atherosclerotic plaques (P<0.001) and increased CF-PWV (P<0.01). Plasma ET levels correlation positively with LV outflow velocity integral (r=0.57; P<0.0001), stroke index (P<0.01), and baseline forearm blood flow (P<0.001) which were all significantly higher in ESRD patients than in controls (P<0.01). After adjustment for age, blood pressure, haemoglobin levels, gender and body dimensions, plasma ET levels were significantly correlated to LV mass (r=0.46; P<0.001), CCA-IMT and CCA intima -media cross-sectional area (r=0.41; P<0.001), and CF-PWV (p<0.05). Post-ischaemic forearm vasodilation was decreased in ESRD (85±31 vs 119±28%; P<0.001) and there was a negative correlation between post-ischaemic flow recovery and ET levels (r=-0.49; P<0.001). In ESRD patients, plasma ET levels were positively and independently correlated with the prevalence of CCA atherosclerotic plaque (P<0.01). Conclusions. These results indicate that the increased plasma ET levels in ESRD patients are associated with left ventricular hypertrophy and arterial intima-media thickening, suggesting that increased ET concentrations in ESRD patients may be of pathophysiological significance in the process of cardiovascular remodelling.     

Reversibility of fixed pulmonary hypertension in left ventricular assist device support recipients

Objective: Conflicting data still exist concerning the reversibility of secondary severe ‘fixed’ pulmonary hypertension (PH) by the use of left ventricular assist device (LVAD) support in terms of time necessary to provide a bridge to ‘transplantability’. Methods: We retrospectively reviewed 145 patients with heart failure and severe PH treated by LVAD support between 2000 and 2009. There were 133 men (91.7%) and 12 women (8.3%) with a mean age of 52.95 ± 12.01 years. Patients were divided into two groups depending on preoperative PH reversibility. Fixed PH was defined by a mean pulmonary arterial pressure (mPAP) >25 mmHg, a pulmonary vascular resistance (PVR) >2.5 Wood Unit (WU) and a transpulmonary gradient (TPG) >12 mmHg, despite pharmacological treatment. Results: Fifty-six patients had fixed PH (group A) and 89 reversible PH (group B). Only 27 patients of group A underwent right heart catheterization evaluation during LVAD support; the remaining 29 patients had other contraindications to heart transplantation (HTx). The 27 patients were divided into three subgroups on the basis of examination time during LVAD support: <6 months (11 patients), between 6 and 12 months (six patients) and >12 months (10 patients). The mPAP, PVR, and TPG decreased significantly during LVAD support (mPAP, 37.26 ± 6.35 mmHg vs 21.00 ± 7.51 mmHg, p = 0.007; PVR, 3.49 ± 1.47 WU vs 1.53 ± 0.66 WU, p = 0.000; and TPG, 15.04 ± 5.22 mmHg vs 7.78 ± 3.21 mmHg, p = 0.019). A significant reduction of all parameters was observed during the first 6 months and later on there was no further decrease. There were no significant differences between the three subgroups (mPAP, p = 0.680; PVR, p = 0.723; and TPG, p = 0.679) in terms of time of reversibility. LVAD support allowed 19 patients to be transplanted. Conclusions: Patients with fixed PH can be treated with LVAD support. Our data suggest that 6 months after LVAD implantation it is possible to observe an important reduction of PH and evaluate the potential transplantability of patients. Longer support does not add any effect of LVAD on PH.     

Determination of urinary bicarbonate with the Henderson-Hasselbalch equation

The determination of urinary bicarbonate with the Henderson-Hasselbalch equation was compared using two methods: (1) correcting the pK in every urine sample according to ionic strength and using the solubility constant of CO₂ in urine (=0.0309) and (2) using a fixed pK value (6.1) and a CO₂ solubility constant of 0.0301, which we use to calculate blood bicarbonate. Nine patients were studied and 29 determinations were performed. A high correlation was found between the methods ( r =0.99). Bicarbonate calculated with corrected pK was 24.3±6.6 mEq/l (95% confidence interval 11.4–37.2) and bicarbonate calculated with pK fixed at 6.1 was 25.6±6.6 mEq/l (95% confidence interval 12.7–38.5). For each urine sample, the bicarbonate was calculated as the difference between the bicarbonate obtained with pK at 6.1 minus that obtained with the corrected pK (mean 1.25, standard error 0.83, P =0.15). This indicates that the difference between the methods was not significant. No difference was found whether pK was corrected or fixed (6.1). Therefore, our results suggest that it is valid to take the value shown by the equipment for blood gas determination as the urinary bicarbonate value. This would allow the rapid and accurate determination of urinary bicarbonate in patients with hyperchloremic acidosis, especially those with renal tubular acidosis.Technical assistant: E. Alvarado, Engineer     

Number of argyrophilic nucleolar organizer regions is a good indicator of lymph node metastasis in patients with esophageal carcinoma

The number of argyrophilic nucleolar organizer regions (AgNORs) was evaluated as a predictor of lymph node metastasis in 45 patients who had undergone resection of advanced squamous cell carcinoma of the esophagus. The mean AgNOR score of carcinomas was 5.0 ± 1.8, and it was greater than that of normal esophageal epithelium adjacent to a carcinoma (2.3 ± 0.5, P<0.001). The AgNOR score of tumors from 26 patients with lymph node metastasis was 6.1 ± 1.6, and it was greater than that of tumors from 19 patients without lymph node metastasis (3.7 ± 1.0, P<0.001). The AgNOR scores of metastatic lymph nodes (4.9 ± 1.5) from 26 patients with lymph node metastasis were closely related to the number of metastatic lymph nodes of individual patients (r =0.582, P<0.001). The 3-year survival rate in patients with low AgNOR scores (AgNOR score <5, n=22) was 56.2%. By contrast, that in patients with high AgNOR scores (AgNOR score 5, n=20) was only 13.1%. There was a statistically significant difference between the two survival curves (P<0.05). These results indicate that the AgNOR score is a good indicator of lymph node metastasis and suggest that it might also be a useful prognostic marker in patients with esophageal cancer.

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Die Anzahl argyrophiler nukleolärer organizer regions (AgNOR) ist ein guter indikator für lymphknotenmetastasen bei patienten mit ösophaguskarzinom

Zusammenfassung Die Anzahl der AgNOR wurde als Indikator für Lymphknotenmetastasen (LKM) bei 45 Patienten mit reseziertem Plattenepithelkarzinom des Ösophagus untersucht. Der mittlere AgNOR-Karzinomscore betrug 5,0 ± 1,8 und war damit höher als bei normalem Ösophagealepithel in der Nachbarschaft des Karzi noms (2,3 ± 0,5, p<0,001). Der AgNOR-Tumorscore betrug bei 26 Patienten mit LKM 6,1 ± 1,6 und war damit höher als bei 19 Patienten ohne LKM (3,7 ± 1,0, p< 0,001). Die AgNOR-Scores der metastatischen Lymphknoten (4,9 ± 1,5) bei 26 Patienten mit LKM wiesen eine enge Korrelation zur Anzahl metastatischer Lymphknoten bei einzelnen Patienten auf (r=0,582, p<0,001). Die Dreijahresüberlebensrate mit niedrigen AgNOR-Scores (AgNOR-Score <5, n=22) betrug 56,2%, hingegen bei Patienten mit hohen AgNOR-Scores (AgNOR-Score 5, n=20) nur 13,1%. Es gab einen statistischen signifikanten Unterschied zwischen beiden Überlebenskurven (p< 0,05). Nach diesen Resultaten ist der AgNOR-Score ein guter LKM-Indikator und könnte auch gut zur Prognose bei Patienten mit Ösophaguskarzinom verwendet werden.

     

Earlier appearance and higher incidence of the rectoanal relaxation reflex in patients with imperforate anus repaired with laparoscopically assisted anorectoplasty

Background: This study aimed to evaluate clinically and manometrically the anorectal function of patients with imperforate anus after repair with laparoscopically assisted anorectoplasty (LAR), as compared with the function of patients after undergoing the conventional method, posterior sagittal anorectoplasty (PSARP). Methods: The defecation status and anorectal manometry of patients with high or intermediate type imperforate anus repaired with LAR (n = 9) and age-matched patients repaired with PSARP (n = 13) were assessed and compared during the first year of postoperative follow-up evaluation. The defecation status was classified by the frequency of bowel openings (<1, 1–4, and >5 times per day). Manometric assessment was performed by an open-tip hydraulic capillary infusion system. The presence of the rectoanal relaxation reflex was determined, and the resting sphincteric pressure and resting rectal pressure were measured. Results: Seven of nine LAR patients had an acceptable frequency of one to four bowel openings per day, in contrast to 7 of 13 PSARP patients. The difference in the presentation of daily stooling is not significant (p > 0.05). A positive RAR was detected in 88.9% (8/9) of the LAR patients, and in only 30.8% (4/13) of the PSARP patients (p < 0.01). The presence of a rectoanal relaxation reflex also significantly correlated with an acceptable frequency of bowel opening (1–4 times per day) in both LAR and PSARP patients (p < 0.05). Moreover, a rectoanal relaxation reflex was detected significantly earlier in LAR than in PSARP patients (4.9 ± 1.2 vs 10.1 ± 2.5 months; postoperatively p < 0.0001). Both the LAR and PSARP patients had a similar resting sphincteric pressure (21.5 ± 4.7 vs 25.4 ± 6.2 cm H₂O; p > 0.05). By contrast, the resting rectal pressure was significantly lower in LAR than in PSARP patients (7.7 ± 1.5 vs 11.5 ± 1.3 cmH₂O; p < 0.05). Conclusions: In the early postoperative stage, patients repaired with LAR had more favorable findings in anorectal manometry than patients repaired with PSARP. Long-term follow-up studies to confirm a superior defecation continence achieved with LAR are warranted.     

Comparison of clinical outcomes and anorectal manometry in patients with congenital anorectal malformations treated with posterior sagittal anorectoplasty and laparoscopically assisted anorectal pull through

Purpose

The objective of this study is to analyze the clinical outcomes and anorectal manometry (AM) in infants with congenital high anorectal malformations treated with posterior sagittal anorectoplasty (PSARP) and laparoscopically assisted anorectal pull through (LAARP).

Materials and Methods

From August 2005 to December 2008, 23 patients with congenital high anorectal malformations were randomly distributed into PSARP and LAARP groups. All of them underwent LAARP (11 cases) or PSARP (12 cases) at 2 or 3 months old. Clinical outcomes and results of anorectal manometry were compared between patients at the age of 17.4 ± 4.9 and 19.3 ± 6.2 months (P = .4270), respectively.

Results

Kelly's clinical score for patients in LAARP and PSARP groups was 3.91 ± 1.14 and 3.83 ± 1.40 (P = .8827), respectively. Anal canal resting pressure and high-pressure zone length were 29.4 ± 7.2 vs 23.4 ± 6.5 mm Hg (P = .0479) and 14.9 ± 3.0 vs 13.9 ± 3.1 mm (P = .4414), respectively. Rectal anal inhibitory reflex was observed in 81.8% (9/11) and 83.3% (10/12) patients (P = 1.0000), respectively. The mean length of stay during the second hospitalization was 10.6 ± 0.9 and 14.3 ± 1.4 days (P < .0001), respectively.

Conclusions

Although no significant difference can be noted in clinical scoring between both groups, the results of anorectal manometry indicate that LAARP can significantly improve anal canal resting pressure and reduce the length of stay.