Efficacy of pentoxifylline in prevention of contrast-induced nephropathy in angioplasty patients

Background

Contrast-induced nephropathy (CIN) is an adverse consequence of contrast media use that results in significant morbidity and mortality and adds significant costs to diagnostic and interventional cardiology procedures. Various pathophysiological mechanisms have been proposed for CIN and various agents have been tested for its prevention. There is currently a general agreement that adequate pre-procedure hydration constitutes the cornerstone of prevention, yet there are reports of the use of some other agents with various efficacies. We prospectively tested pentoxifylline (PTX), an antioxidant, anti-inflammatory drug, for CIN prevention in patients undergoing coronary angioplasty.

Materials and methods

In this prospective, randomized, single-blind, single-center clinical trial, 286 consecutive patients were randomly assigned to the control group (n?=?146), with routine treatment and no PTX, or the study group (n?=?140), with routine treatment and PTX, 400?mg/tid from 24?h before to 24?h after coronary angioplasty. Serum creatinine was measured before and 2?days after the procedure. The primary end point was the occurrence of CIN within 48?h.

Results

The control and PTX groups were comparable in the overall predicted risk of CIN. Also, the type and volume of the contrast agent were not significantly different between the two groups. Following angioplasty, CIN occurred in 20 (13.69%) patients in the control group and in 12 (8.5%) patients in the study group; the difference was not statistically significant (P?=?0.17). Additionally, there was no mortality and need for hemodialysis in either group.

Conclusion

In angioplasty patients, the prophylactic oral use of PTX could be recommended for CIN prevention, although no statistically significant protective effect was documented.     

Different interventions in preventing contrast-induced nephropathy after percutaneous coronary intervention

Background

This study aimed to observe the preventive potential of different hydration solutions on contrast-induced nephropathy (CIN) after percutaneous coronary intervention.

Methods

We initially screened 627 patients who were admitted to the Division of Cardiology, Beijing Anzhen Hospital between October 2010 and October 2011. The research subjects were randomly divided into four groups and were given: normal physiological saline (PS), sodium bicarbonate (SB), oral administration of PS + N-acetylcysteine (NAC) (PS + NAC), or oral administration of SB + NAC (SB + NAC). These patients were administered a hypotonic nonionic contrast agent, and the incidence of CIN in each group was observed.

Results

The total incidence rate of CIN was 4.47 %, while the CIN incidence rates in the PS group, the SB group, the PS + NAC group and the SB + NAC group were 3.11, 5.03, 4.46 and 5.33 %, respectively. The differences between these groups were not statistically significant (P = 0.238), and for patients with diabetes and/or renal dysfunction, the incidence rates of CIN among the four groups did not show statistically significant differences (P = 0.238, 0.156, 0.287).

Conclusion

Use of PS, SB, and NAC caused no significant reduction in the incidence of CIN, but in high-risk patients with diabetes and/or renal dysfunction, SB + NAC might be superior to the application of isotonic crystalloid solution.     

Impact of anemia on contrast-induced nephropathy (CIN) in patients undergoing percutaneous coronary interventions

Background

The aim of the present study was to assess the influence of anemia on the risk of developing contrast-induced nephropathy after percutaneous coronary angioplasty.

Methods

Serum creatinine values were measured before and within 48 h after the administration of contrast agents. Contrast-induced nephropathy (CIN) was defined as an increase of ≥0.5 mg/dl or ≥25 % in serum creatinine concentration over baseline within 48 h after administration. Anemia was defined as hemoglobin <120 g/l in women and <130 g/l in men.

Results

Among the 1,026 patients studied, 32 (3.1 %) developed CIN after procedure. CIN occurred in 6.3 % of the anemic patients and in 2.2 % of the non-anemic patients (P < 0.01). The incidence of CIN increased with decreasing of baseline estimated glomerular filtration rate (eGFR) in both the anemia and non-anemia groups. In patients with baseline eGFR <30 ml/min, a high proportion of both anemic and non-anemic patients experienced CIN (24.6 vs. 17.5 %). When baseline eGFR was 30–59 ml/min, the incidence of CIN in anemic patients was twofold higher than in non-anemic patients (7.9 vs. 3.8 %; P < 0.05). Multivariate logistic regression analysis found that baseline eGFR and baseline hemoglobin were independent predictors of CIN.

Conclusion

Anemia is associated with a higher incidence of CIN in patients with moderate renal dysfunction. Patients with both preexisting renal insufficiency and anemia are at high risk of CIN. Baseline eGFR and baseline hemoglobin are independent predictors of CIN.     

The efficacy of probucol combined with hydration in preventing contrast-induced nephropathy in patients with coronary heart disease undergoing percutaneous coronary intervention: a multicenter,prospective, randomized controlled study

Purpose

To investigate the preventive effect of probucol combined with hydration on contrast-induced nephropathy (CIN) in patients with coronary heart disease undergoing percutaneous coronary intervention (PCI).

Methods

A total of 641 patients undergoing PCI were randomly assigned to either a probucol group (probucol 500 mg twice daily and hydration; n = 321) or a control group (hydration only; n = 320). The primary endpoint was the incidence of CIN, defined as an increase in serum creatinine (Scr) by ≥ 44.2 μmol/L or ≥ 25% within 72 h after the administration of contrast agent. Secondary endpoints were changes in Scr, cystatin-C (Cys-C), creatinine clearance rate (Ccr), C-reactive protein (CRP), superoxide dismutase (SOD), and glutathione (GSH) within 72 h, and major adverse events during hospitalization or the 14-day follow-up period.

Results

The incidence of CIN was 4.0% (13/321) in the probucol group and 10.9% (35/320) in the control group. The probucol group had lower Cys-C and higher Ccr at 48 and 72 h after PCI compared with the control group. At 48 and 72 h following the operation, Cys-C and CRP were lower in the probucol group compared with the control group, but Ccr, SOD, and GSH were higher. There were no differences in the incidence of major adverse events during hospitalization or the 14-day follow-up between the groups. Multivariate logistic regression analysis showed that probucol was an independent protective factor for CIN.

Conclusions

Probucol combined with hydration more effectively decreased the incidence of CIN in patients with coronary heart disease undergoing PCI compared with hydration alone.

     

Retrospective analysis of factors predicting end-stage renal failure or death in patients with microscopic polyangiitis with mainly renal involvement

Background

The aim of this study was to identify risk factors for end-stage renal failure (ESRF) or death in Japanese patients with microscopic polyangiitis (MPA) with renal involvement.

Methods

From 54 consecutive patients with systemic vasculitis based on Watt’s algorithm, we retrospectively analyzed 39 MPA patients with renal involvement, including 19 (48.7 %) with renal-limited vasculitis.

Results

Thirty-three of 39 patients (84.6 %) demonstrated rapidly progressive glomerulonephritis, and 13 (33.3 %) developed ESRF; 8 of 13 required dialysis within 1 week. Thirteen (33.3 %) died during follow-up of more than 12 months, and 7 died during the first 6 months, mainly because of opportunistic infections. Overall survival at 6 and 12 months was 79.5 and 71.1 %, respectively. Serum creatinine levels did not differ significantly between survivors and non-survivors (P = 0.092). The mean Birmingham Vasculitis Activity Score, version 3 (BVAS v.3), was 16.2 ± 6.5, with a renal subscore of over 12 points in 82.1 %, and BVAS v.3 was marginally higher in non-survivors than survivors (P = 0.045). An age- and sex-adjusted Cox proportional hazards analysis demonstrated that neither the serum creatinine level (P = 0.277) nor BVAS v.3 (P = 0.188) at initial diagnosis was a risk factor for overall survival. The baseline serum creatinine cutoff value for discriminating between ESRF and non-ESRF was 4.6 mg/dl, with a sensitivity and specificity of 92.3 and 84.6 %, respectively.

Conclusions

Survival rates do not relate to ESRF in MPA patients with mainly renal involvement. Although patients with ESRF required regular hemodialysis, longer survival can be achieved.     

Pathologic evaluation of non-neoplastic renal parenchyma in partial nephrectomy specimens

Purpose

This study aimed to identify non-neoplastic pathologic changes in partial nephrectomy specimens of patients without a known history of medical comorbidities. Routine analysis of this tissue may allow the clinician to identify subclinical renal disease.

Methods

We retrospectively reviewed our database of patients who underwent open partial nephrectomy for a small renal mass. Non-neoplastic tissue of partial nephrectomy specimens of patients without a known history of chronic kidney disease, diabetes mellitus, hypertension, or coronary artery disease was evaluated for glomerular, interstitial, and vascular pathologic changes.

Results

A rim of non-neoplastic tissue was adequate for pathologic evaluation in 91.8% of specimens. A total of 45 patients were studied with a median age of 52.0 years. Atherosclerosis was the most commonly identified pathologic finding in 9 (20%) patients, followed by mesangial expansion and interstitial fibrosis, each found in 8 (17.8%) patients. Linear regression found interstitial fibrosis to be the only pathologic lesion associated with preoperative serum creatinine (coefficient = 0.697, P = 0.001). Male gender was also associated with a higher preoperative creatinine (coefficient = 0.270, P = 0.034). Postoperative serum creatinine was not associated with any of the examined lesions.

Conclusions

Current surgical techniques provide adequate non-neoplastic tissue for pathologic evaluation. We observed a striking degree of pathologic disease in patients without a known history of medical comorbidities. Routine inspection of the non-neoplastic parenchyma of partial nephrectomy specimens should be performed as it can alert the clinician to presence subclinical renal disease allowing for medical intervention.     

The effectiveness of N-acetylcysteine in preventing contrast-induced nephropathy in patients undergoing contrast-enhanced computed tomography: a meta-analysis of randomized controlled trials

Background

N-Acetylcysteine (NAC) is reported to have potential for preventing of contrast-induced nephropathy (CIN) in patients undergoing coronary angiography. However, the effectiveness of NAC in preventing CIN in patients undergoing contrast-enhanced computed tomography (CT) is still controversial. We conducted a meta-analysis of relevant randomized controlled trials (RCTs) to further examine this issue.

Methods

RCTs were identified by computerized searching in PubMed, EMBASE, SCOPUS, and Cochrane databases. Two reviewers independently assessed the methodological quality of each study. A meta-analysis was performed to evaluate the effectiveness of NAC in preventing CIN in patients undergoing CT. The primary outcome was the incidence of contrast-induced nephropathy, and the requirement for dialysis. The secondary outcome was the change of serum creatinine.

Results

Six randomized controlled trials were identified with a total of 496 patients meeting the criteria for this study. Prophylactic administration of NAC in patients with serum creatinine above 1.2 mg/dL undergoing contrast-enhanced CT, along with hydration, reduced the risk of CIN (relative risk 0.20; 95 % confidence interval: 0.07–0.57). Requirement for dialysis was not significantly different between the NAC group and the control group.

Conclusions

This review provides evidence of the efficacy of NAC in preventing the incidence of CIN and recommends that NAC be more widely used in high-risk patients undergoing contrast-enhanced CT. On the basis of the evidence reviewed, further research involving large RCTs may be warranted.     

The effect of withdrawal of ACE inhibitors or angiotensin receptor blockers prior to coronary angiography on the incidence of contrast-induced nephropathy

Background

The effect of continuing or discontinuing chronic angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) therapy prior to coronary angiography on the incidence of contrast-induced nephropathy (CIN) is not clear. We undertook a randomized trial to evaluate the effect of withdrawing ACEIs or ARBs 24 h prior to coronary angiography on the incidence of CIN associated with coronary angiography.

Methods

A total of 220 patients with chronic kidney disease (CKD) stages 3–4 (glomerular filtration rate 15–60 ml/min/1.73 m²) on ACEI or ARB therapy were randomized before angiography to either ACEI/ARB continuation group or discontinuation group. A third group of patients with CKD stages 3–4 but not on angiotensin blockade therapy were also followed. The primary outcome measure was the incidence of CIN defined by a rise in serum creatinine by 25% or 0.5 mg/dl (44 μmol/l) from baseline.

Results

There was no statistically significant difference in the incidence of CIN between the three groups (P = 0.66). The incidences were 6.2%, 3.7%, and 6.3% for the continuation, discontinuation, and angiotensin blockade naïve group, respectively. There was also no significant difference found between the groups in mean serum creatinine and glomerular filtration rate values at baseline and post contrast administration.

Conclusion

Withholding ACEIs and ARBs 24 h before coronary angiography does not appear to influence the incidence of CIN in stable patients with CKD stages 3–4.     

Long-term observations of clinicopathological characteristics and outcome of Japanese patients with pauci-immune crescentic glomerulonephritis

Background

The clinicopathological characteristics and outcome with pauci-immune crescentic glomerulonephritis (CreGN) are presumed to vary over time. We examined the characteristics and outcome of Japanese patients with CreGN according to the treatment periods.

Patients and methods

From 1968 to 2011, we examined a total of 102 patients diagnosed with pauci-immune CreGN by renal biopsy. The patients were divided into three groups according to the treatment periods—Group I (1968–1988, n = 18), Group II (1989–2001, n = 37; when the nationwide survey of rapidly progressive glomerulonephritis [RPGN] was performed in Japan), and Group III (2002–2011, n = 47; after publication of the Japanese guideline for RPGN).

Results

There were no significant differences in blood pressure, renal function or anti-neutrophil cytoplasmic antibody titer between groups. On the other hand, the rate of crescent formation and degree of interstitial inflammatory cell infiltration were decreased in Group III. Serum creatinine (<3.0, 3.0–6.0, ≥6.0 mg/dL) and crescent formation (<30, 30–50, 50–80, ≥80 %) were significant renal prognostic factors in Group III [serum creatinine: hazard ratio (HR) 4.79, 95 % confidence interval (CI) 1.43–16.1, P = 0.011; crescent formation: HR 2.86, 95 % CI 1.06–7.73, P = 0.039]. Furthermore, renal survival rate of patients with crescent formation <50 % and patient survival rate of patients with serum creatinine <3 mg/dL were improved in Group III.

Conclusion

Patients with CreGN were diagnosed in the early phase of crescent formation and outcome has improved in recent years.     

Comparison between the effects of intraoperative human albumin and normal saline on early graft function in renal transplantation

Purpose

The aim of the current study was to compare the effects of intraoperative infusion of 20 % human albumin versus 0.9 % normal saline on early and late graft function in renal transplantation.

Methods

This prospective, randomized study was conducted on 44 patients with end-stage renal disease undergoing kidney transplantation. Patients were 32 males (72.7 %) and 12 females (27.3 %) with a mean age of 54.35 ± 11.15 years (range 20–58 years). Patients with cardiac disease and liver dysfunction were excluded from the study. Twenty-two of the 44 patients were given intraoperative intravenous infusion of 20 % human albumin with 0.9 % normal saline (albumin group), and the remaining 22 patients received intraoperative intravenous infusion of 0.9 % normal saline alone (saline group), as part of the intraoperative fluid hydration to keep central venous pressure between 10 and 15 mm of Hg.

Results

There was no statistically significant difference in mean intravenous fluid volume infused until the end of surgery between the saline group and the albumin group (P = 0.8326). Time of onset of diuresis and total intraoperative urine output were statistically insignificant between the two groups (P = 0.6255, P = 0.9231, respectively). Post-transplant serum creatinine on day 1, 3 and 5 between the albumin and saline groups were comparable (P = 0.8998, P = 0.7257, P = 0.8092, respectively). Post-transplant urine output on day 1, 3 and 5 between the albumin and saline groups were also comparable (P = 0.653, P = 0.9075, P = 0.946, respectively). Mean postoperative weight gain was higher in the saline group compared with the albumin group, but was not statistically significant (P = 0.6348).

Conclusions

This study revealed that the use of 20 % human albumin as an intraoperative volume expander provides no more benefit than the use of 0.9 % normal saline in terms of immediate graft function in living donor renal transplantation.     

Prevention of contrast-induced nephropathy with prostaglandin E1 in high-risk patients undergoing percutaneous coronary intervention

Purpose

Contrast-induced nephropathy (CIN) is an important complication in the use of iodinated contrast media. The present study aimed to assess the safety and efficacy of prostaglandin E₁ (PGE₁) in prevention of CIN in patients with high-risk factors undergoing percutaneous coronary intervention (PCI).

Methods

The study group consisted of 163 patients who had undergone a coronary intervention procedure between January 1, 2012 and October 31, 2012. Study participants were randomly assigned to either the PGE₁ group (82 patients) or the control group (81 patients). Patients in the PGE₁ group received PGE₁ intravenous infusion of 20 ng/kg/min for 6 h before and after the administration of contrast media. The control group received 0.9 % sodium chloride solution for routine hydration only. A nonionic, low-osmolality contrast agent was used in our laboratory at this time. Serum creatinine (Scr) values and estimated glomerular filtration rate were measured before and within 48 h of the administration of contrast agents. CIN was defined as an increase of ≥0.5 mg/dL or ≥ a 25 % increase in Scr concentrations over baseline within 48 h of angiography.

Results

The amount of contrast agent administered was similar for the PGE₁ and control groups (156 ± 63 vs. 161 ± 68 mL, P > 0.05). The incidence of CIN was lower in the PGE₁ group than in the control group (3.7 vs. 11.1 %, P < 0.05). No serious adverse effects were observed.

Conclusions

In patients with high-risk factors undergoing PCI, the use of PGE₁ for prevention of CIN is safe and efficacious.     

Effect of continuous positive airway pressure on serum cystatin C among obstructive sleep apnea syndrome patients

Purpose

The purpose of the present study was to evaluate the influence of continuous positive airway pressure (CPAP) on serum cystatin C, a novel biomarker of early renal impairment, among obstructive sleep apnea (OSA) patients.

Materials and methods

Newly diagnosed severe OSA patients who treated with CPAP for 3 months were enrolled from two sleep laboratories. Serum biomarkers of renal impairment, cystatin C, creatinine and estimated glomerular filtration rate (eGFR), were detected before and after CPAP treatment.

Results

A total of 39 severe OSA patients were enrolled, 29 (74.4 %) were male, and mean age was 51.2 ± 12.2 years. After CPAP treatment, there were no changes of creatinine and eGFR (77.80 ± 20.00 vs. 75.3 ± 16.60 and 98.69 ± 31.74 vs. 100.20 ± 28.30, all p > 0.05), but cystatin C declined significantly (0.87 ± 0.18 vs. 0.77 ± 0.21, p = 0.000).

Conclusion

CPAP can decrease cystatin C levels among severe OSA patients and may prevent the latent renal impairment.     

Induction of cold ischemia in patients with solitary kidney using retrograde intrarenal cooling: 2-year functional outcomes

Purpose

Renal hypothermia is commonly utilized during nephron sparing surgery to minimize ischemic tissue damage. We propose a method to induce renal hypothermia using continuous retrograde irrigation of iced saline via dual-lumen ureteral catheter. We will report results in an ex vivo porcine model followed by clinical outcomes in a series of patients with solitary kidney undergoing robotic-assisted laparoscopic partial nephrectomy (RALPN).

Materials and methods

First, we performed temperature measurements during retrograde renal cooling in a porcine model before investigating the technique in humans. In porcine experiments, renal cortical temperature measurements (n = 270) were recorded during retrograde infusion of ice-cold saline via a 10-Fr dual-lumen ureteral catheter placed in ureter. Subsequently, a series of patients (n = 10) undergoing RALPN with a solitary kidney had concomitant intra-operative retrograde renal cooling. A 10-Fr dual-lumen ureteral catheter was placed at initiation of anesthesia and cold saline initiated prior to renal artery clamping.

Results

Porcine cortical temperature reached the target temperature (≤20 °C) within an average of 203 s of retrograde irrigation. In the clinical series, patients’ mean preoperative creatinine was 1.16 mg/dL (GFR = 60). At a median follow-up of 10 months (range 1–27 months), postoperative creatinine was 1.50 mg/dL (GFR = 41.28). Average clamp time was 19.4 min. All patients had negative surgical margins.

Conclusions

Retrograde irrigation is a technically feasible method to induce cold ischemia, which may provide an additional protective effect of renal function in patients who have a solitary kidney undergoing surgery via a minimally invasive approach.     

Inverse correlation between left ventricular end-diastolic pressure and contrast-induced nephropathy in patients undergoing percutaneous coronary intervention

Background

There is a rising incidence of contrast-induced nephropathy (CIN), which is defined as either a 25% relative increase or an absolute increase of 0.5 mg/dL (44.2 µmol/L) in the serum creatinine (Scr) level at 48–72 h after administration of iodinated contrast media (CM). We investigated the relationship between left ventricular end-diastolic pressure (LVEDP) and CIN in patients undergoing percutaneous coronary intervention (PCI).

Methods

A total of 431 consecutive patients with coronary artery disease undergoing PCI were divided into four groups based on LVEDP quartile cut-off points. Enrolled patients were given continuous intravenous infusion of normal saline starting 4 h before PCI and lasting 24 h. At the end of hydration administration, 20 mg furosemide was slowly injected intravenously. Serum creatinine (Scr), creatinine clearance rate (Ccr), and glomerular filtration rate (GFR) were detected before and after PCI.

Results

There were significant differences in the incidences of CIN in the four groups: 10.25% in the Q1 group, 5.55% in the Q2 group, 5.31% in the Q3 group, and 1.06% in the Q4 group (P?<?0.05). With increasing LVEDP, the incidence of CIN decreased significantly (OR 0.581, 95% CI 0.367–0.920). Received operating characteristic curve analysis of the predictive value of LVEDP for CIN produced area under the curve values was 0.641, with a sensitivity of 74.1% and specificity of 48%. The optimal LVEDP cut-off for the occurrence of CIN was 14.5 mmHg.

Conclusions

LVEDP correlated inversely with CIN in patients undergoing PCI.

     

The effects of tolvaptan on patients with severe chronic kidney disease complicated by congestive heart failure

Background

Tolvaptan, a diuretic with a new mechanism of action, selectively binds to the vasopressin V2 receptor and inhibits reabsorption of water. Its effect on heart failure is proven, but its benefit for patients with chronic kidney disease (CKD) has not been not confirmed. In this study, we examined the effect of tolvaptan on patients with severe CKD.

Methods

We analyzed patients with stage 4 or higher CKD who had congestive heart failure that was resistant to existing diuretics. The patients were administered an initial tolvaptan dose of 7.5 mg/day. We assumed urine volume and urine osmolality to be the main effective endpoint and recorded free water clearance, serum osmolality, serum creatinine (Cr) level, and adverse events.

Results

There was no instance of clinically significant hypernatremia. The urine volume increased significantly (P < 0.0001), as did the urine osmolality (P = 0.0053). Free water clearance showed a tendency to increase, although the difference was not statistically significant. The serum creatinine level did not change significantly, and there was no clear effect on renal function. However, in patients with stage 5 CKD, the serum creatinine level decreased significantly (n = 5, P = 0.0435). There were no adverse events.

Conclusion

We confirmed that tolvaptan has a diuretic effect in patients with both severe CKD and congestive heart failure without causing either clinically significant hypernatremia or an adverse effect on renal function. Tolvaptan is an effective diuretic for patients with CKD.     

Bilateral synchronous sporadic renal masses: intermediate functional and oncological outcomes at a single institution

Purpose

To review the intermediate term oncologic and functional outcomes after the surgical management of bilateral renal masses (BRM).

Materials and methods

After obtaining Institutional Review Board approval, the Tulane renal surgery database (n = 890 patients) was queried for patients presenting with synchronous bilateral enhancing renal masses (n = 30 renal units). We performed a retrospective chart review evaluating oncologic and functional outcomes, specifically with respect to local recurrence and metastatic disease. We also reviewed changes in glomerular filtration rates.

Results

Of the 30 renal units were operated on for BRM concerning for renal cell carcinoma, 25 kidneys harbored malignancy (83.3 %). The average tumor size was 3.35 cm. Treatment of each kidney was staged; average time period to treatment of contralateral side was 3.5 months. Estimated GFR (eGFR) for these same pre-operative patients was 59 ml/min/1.73 m² (range 25–89). The average creatinine after treatment of one kidney was available for all patients and was 1.5 (range 0.7–2.8), with an average eGFR of 51.8 (range 29–87). The average creatinine after the second operation for these same 15 patients was 1.79 (range 0.9–3.7) with an average GFR of 41.9 (range 17–78). No patient had to undergo temporary dialysis. An average change in GFR after the second, contralateral procedure on the kidney was 17.07 mg/dl. Average oncologic follow-up was 608 days. Excluding two patients who presented with metastatic disease, the average recurrence-free survival was 92.8 %.

Conclusion

Our data continue to underscore the need for nephron sparing surgery (NSS), especially in the setting of BRM. The average decline in GFR of 28.9 % after treatment of both kidneys and renal cell carcinoma recurrence-free rate of 92.3 % further support the efficacy of NSS in these patients.     

Lateral Incisional Hernia After Renal Transplantation: A Comparative Study

Background

Because of the lack of published data and the relative rarity of lateral incisional hernias (LIHs), especially after renal transplantation, mesh repair of LIH remains a challenge for surgeons. The aim of the present study was to evaluate the outcomes of LIH treated by mesh repair after renal transplantation.

Methods

All consecutive patients who had undergone LIH mesh repair after renal transplantation were compared with patients who had undergone LIH mesh repair without renal transplantation. Demographic data, incisional hernia characteristics, operative data, and postoperative outcomes were prospectively recorded. Early complications and recurrence rates were evaluated.

Results

Altogether, 112 patients were treated for LIH with mesh repair. Among these patients, 61 (54.4 %) underwent LIH after renal transplantation. The early complications were similar for the patients with and without renal transplantation (24.5 vs. 23.5 %, respectively; p = 0.896). The recurrence rates also were similar for the patients with and without renal transplantation (9.8 vs. 9.8 %, respectively; p = 1).

Conclusions

Mesh graft repair is feasible in patients with LIH after renal transplantation. Postoperative complications and recurrences were not more frequent in renal transplantation patients than in those without renal transplantation.     

Alprostadil plays a protective role in contrast-induced nephropathy in the elderly

Purpose

To evaluate the protective effects of alprostadil on contrast-induced nephropathy (CIN) in elderly patients.

Methods

We randomized 370 patients into the control or alprostadil group. The patients in the control group were injected with 100 ml sterile saline and the patients in the alprostadil group with alprostadil (0.4 μg/kg/day) in 100 ml sterile saline before and after iohexol-enhanced (100 ml) computed tomography (CT). Serum creatinine (Scr), blood urea nitrogen (BUN), cystatin C (CysC), and creatinine clearance (Ccr) were analyzed or calculated. ΔScr and ΔCysC were determined by the changes between baseline and highest Scr and CysC levels. The standard for CIN was a postdose Scr increase >44.2 μmol/l or >25 % over baseline.

Results

In the control group, peak Scr (P < 0.05) and ΔScr (P < 0.01) were higher than those in the alprostadil group. The postdose CysC at 24 h (P < 0.05), 48 h (P < 0.05), and 72 h (P < 0.05), peak CysC (P < 0.01), and ΔCysC (P < 0.05) in the control group were higher than those in the alprostadil group. The incidence of CIN in the control group was 22.2 %, which was higher than in the alprostadil group (9.1 %, P < 0.01). Subgroup analyses in patients with advanced age (≥80 years), concomitant hypertension or diabetes, and abnormal baseline renal function (Ccr ≤60 ml/min) showed that the alprostadil group had lower ΔScr and ΔCysC than the control group after contrast-enhanced CT examination in all four subgroups (P < 0.05 or P < 0.01).

Conclusions

In this cohort of older patients undergoing contrast CT, the use of alprostadil reduced the incidence of CIN.     

The method of GFR determination impacts the estimation of cisplatin eligibility in patients with advanced urothelial cancer

Objectives

To determine GFR with different methods in patients with first-line chemotherapy for advanced urothelial cancer (UC) and to evaluate the impact of these methods on the estimation of cisplatin eligibility.

Methods

A database was built retrospectively containing all patients receiving first-line chemotherapy for UC between 2001 and 2012 in one German high-volume center. GFR was calculated with the methods by Cockcroft–Gault (CG), MDRD and CKD-EPI. Measurements of creatinine clearance with timed urine collections were registered.

Results

A total of 166 patients were included. All methods of renal function determination yielded consistent results in terms of cisplatin eligibility for 134 patients (80.7 %) and disagreeing results for 32 patients (19.3 %). Twenty-two of these 32 patients with borderline GFR received cisplatin-based chemotherapy. Fifteen of these 22 patients completed at least three cycles. The mean GFR in the mentioned 32 patients was 51.3, 56.2 and 54.2 ml/min with the method by CG, MDRD and CKD-EPI. Three, ten and four patients were estimated cisplatin-eligible with either method. There was a good correlation between MDRD and CKD-EPI (r ² = 0.92). CG tended to underestimate GFR compared to both MDRD and CKD-EPI. Measurements of creatinine clearance showed a wide distribution in comparison with MDRD (r ² = 0.002).

Conclusions

The method used to determine GFR influences the estimation of cisplatin eligibility in a subset of UC patients. MDRD and CKD-EPI formulas seem most valuable, while CG tends to underestimate renal function. Using a strict cutoff of 60 ml/min may unnecessarily preclude cisplatin in some patients.     

Long-term renal outcome and complications in South Africans with proliferative lupus nephritis

Aim

To report the long-term outcome and complication profile of South African patients with proliferative lupus nephritis (PLN).

Methods

A retrospective review of 66 patients with biopsy-proven PLN [58 diffuse proliferative LN (Class IV) and 8 focal proliferative LN (Class III)] under our care from January 1995 to December 2009 was done.

Results

Thirty-three (50 %) patients reached the composite end point of doubling of serum creatinine, end-stage renal disease (ESRD) or death. The 5-, 10- and 15-year cumulative event-free survival rates were 54, 34 and 27 %, respectively. Variables associated with the composite end point were simultaneous diagnosis of SLE and LN (p = 0.048); elevated serum creatinine at onset (p = 0.009); elevated systolic blood pressure (SBP) (p < 0.001) and elevated diastolic blood pressure (DBP) (p < 0.001) on follow-up; and non-remission following induction therapy (p < 0.001). The 5-, 10- and 15-year renal survival rates in our patients were 63, 52 and 52 %, respectively. Hypertension at onset of LN (p = 0.037), nephrotic-range proteinuria (p = 0.033), eGFR < 60 ml/min/1.73 m² (p = 0.013) and lack of remission following induction therapy (p < 0.001) were all associated with development of end-stage renal disease (ESRD). Elevated SBP on follow-up (95 % CI 1.03–1.34, p = 0.017) was the only factor associated with composite end point while failure to achieve remission following induction therapy was the only factor associated with ESRD on multivariate analysis. Thirty-five (53 %) patients developed complications with persistent leukopenia, gastritis, sepsis, tuberculosis (TB) and herpes zoster being the leading complications. Ovarian failure occurred in 4 (11 %) patients.

Conclusion

The 5-, 10 and 15-year event-free survival rates were 54, 34 and 27 % and failure to achieve remission following induction therapy predicted poor renal survival on multivariate analysis.