Association of short-term blood pressure variability with cardiovascular mortality among incident hemodialysis patients

Objective: To investigate the association of short-term blood pressure variability (BPV) with cardiovascular mortality in hemodialysis (HD) patients, using a reliable index called average real variability (ARV), and to assess the factors associated with ARV in incident HD population.

Methods: A total of 103?HD patients were recruited, with 44-h ambulatory blood pressure monitoring performed after the midweek HD session. Systolic BPV was assessed by SD, coefficient of variation (CV), and ARV, respectively. Laboratory data were obtained from blood samples before the midweek HD. All patients were followed up for 24 months.

Results: According to the median of BPV indices, the comparisons between patients with the low and high values were conducted. Kaplan–Meier analysis showed the survival curves corresponding to median of SD and CV exhibit similar performance for the low and high groups (p?=?.647, p?=?.098, respectively). In contrast, patients with higher ARV had a lower survival rate than those with lower ARV (77.8% vs. 98.0%, p?=?.002). After adjustment for demographics and clinical factors, ARV (HR: 1.143; 95% CI: 1.022–1.279, p?=?.019) and high-sensitivity C-reactive protein (HR: 1.394; 95% CI: 1.025–1.363, p?=?.021) were associated with increased risk of cardiovascular mortality in HD patients. Age and interdialytic weight gain (IDWG) were related factors for ARV (β?=?0.065, p?=?.005; β?=?0.825, p?=?.003, respectively).

Conclusions: Greater ARV was independently associated with increased risk of cardiovascular mortality in HD patients. Age and IDWG were independent related factors for ARV.     

Impact of acute kidney injury on renal allograft survival

Background: Acute kidney injury (AKI) is one of the major determinants of graft survival in kidney transplantation (KTx). Renal Transplant recipients are more vulnerable to develop AKI than general population. AKI in the transplant recipient differs from community acquired, in terms of risk factors, etiology and outcome. Our aim was to study the incidence, risk factors, etiology, outcome and the impact of AKI on graft survival.

Methods: A retrospective analysis of 219 renal transplant recipients (both live and deceased donor) was done.

Results: AKI was observed in 112 (51.14%) recipients, with mean age of 41.5?±?11.2 years during follow-up of 43.2?±?12.5 months. Etiologies of AKI were infection (47.32%), rejection (26.78%), calcineurin inhibitor (CNI) toxicity (13.39%), and recurrence of native kidney disease (NKD) (4.46%). New Onset Diabetes After Transplant (NODAT) and deceased donor transplant were the significant risk factors for AKI. During follow-up 70.53% (p?=?.004) of AKI recipients progressed to chronic kidney disease (CKD) in contrast to only 11.21% (p?=?.342) of non AKI recipients. Risk factors for CKD were AKI within first year of transplant (HR: 7.32, 95%CI: 4.37–15.32, p?=?.007), multiple episodes of AKI (HR: 6.92, 95%CI: 3.92–9.63, p?=?.008), infection (HR: 3.62, 95%CI: 2.8–5.75, p?=?.03) and rejection (HR: 9.92 95%CI: 5.56–12.36, p?=?.001).

Conclusion: Renal transplant recipients have high risk for AKI and it hampers long-term graft survival.     

Urinary protein and renal prognosis in idiopathic membranous nephropathy: a multicenter retrospective cohort study in Japan

Background: Several studies have revealed a relationship between proteinuria and renal prognosis in idiopathic membranous nephropathy (IMN). The benefit of achieving subnephrotic proteinuria (<3.5?g/day), however, has not been well described.

Methods: This multicenter, retrospective cohort study included 171 patients with IMN from 10 nephrology centers in Japan. The relationship between urinary protein over time and a decrease of 30% in estimated glomerular filtration rate (eGFR) was assessed using time-dependent multivariate Cox regression models adjusted for clinically relevant factors.

Results: During the observation period (median, 37?months; interquartile range, 16–71?months), 37 (21.6%) patients developed a 30% decline in eGFR, and 2 (1.2%) progressed to end-stage renal disease. Time-dependent multivariate Cox regression models revealed that lower proteinuria over time were significantly associated with a lower risk for a decrease of 30% in eGFR (primary outcome), adjusted for clinically relevant factors. Complete remission (adjusted hazard ratio [HR], 0.005 [95%CI, 0.0–0.09], p?p?=?.002), and 1.0 to 3.5?g/day (ICR II) (adjusted HR, 0.12 [95%CI, 0.02–0.64], p?=?.013) were significantly associated with avoiding a 30% decrease in eGFR, compared to that at no remission.

Conclusions: Attaining lower proteinuria predicts good renal survival in Japanese patients with IMN. This study quantifies the impact of proteinuria reduction in IMN and the clinical relevance of achieving subnephrotic proteinuria in IMN as a valuable prognostic indicator for both the clinician and patient.     

Total parathyroidectomy versus total parathyroidectomy with autotransplantation for secondary hyperparathyroidism: systematic review and meta-analysis

Background: Total parathyroidectomy (tPTX) and total parathyroidectomy with autotransplantation (tPTX?+?AT) are effective and inexpensive treatments for secondary hyperparathyroidism (sHPT), but we do not know which one is the optimal approach. Therefore, we undertook a meta-analysis to compare the safety and efficacy of these two surgical procedures.

Methodology: Studies published in English on PubMed, Embase and the Cochrane Library from inception to 27 September 2016 were searched systematically. Eligible studies comparing tPTX with tPTX?+?AT for sHPT were included and Review Manager v5.3 was used.

Results: Eleven studies were included in this meta-analysis. Ten cohort studies and one randomized controlled trial (RCT) involving 1108 patients with sHPT were identified. There was no significant difference in the prevalence of surgical complications (relative risk [RR], 1.71; 95% confidence interval [CI], 0.77–3.79; p?=?.19), all-cause mortality (RR, 0.68; 95% CI, 0.33–1.39; p?=?.29), sHPT persistence (RR, 3.81; 95% CI, 0.56–25.95; p?=?.17) or symptomatic improvement (RR, 1.02; 95% CI, 0.91–1.13; p?=?.79). tPTX could reduce the risk of sHPT recurrence (RR, 0.19; 95% CI, 0.09–0.41; p?p?=?.01) compared with tPTX?+?AT. Simultaneously, tPTX increased the risk of hypoparathyroidism (RR, 2.63; 95% CI, 1.06–6.51; p?=?.04).

Conclusions: We found tPTX and tPTX?+?AT to be useful methods for sHPT treatment. tPTX was superior for reducing the risk of sHPT recurrence and reoperation than tPTX?+?AT but, due to a lack of high statistical-power RCTs, comparative studies will be needed in the future.     

Prognostic impact of recurrences in patients with electrical storm

Objectives. The study sought to assess the prognostic impact of recurrences of electrical storm (ES-R) on mortality, rehospitalization and major adverse cardiac events (MACE). Background. Data on the prognostic impact of ES-R is rare. Methods. All consecutive ES patients with an implantable cardioverter defibrillator (ICD) were included retrospectively from 2002 to 2016. Patients with ES-R were compared to patients without ES-R. The primary endpoint was all-cause mortality, secondary endpoints were in-hospital mortality, rehospitalization and MACE. Results. A total of 87 consecutive ES patients with an ICD were included, of which 26% presented with ES-R at 2.5 years of follow-up. ES-R patients revealed lower LVEF compared to non-ES-R patients (91% vs. 61%; p?=?.081). There was a numerically higher rate of the primary endpoint of all-cause mortality at 2.5 years (50% vs. 32%; log-rank p?=?.137). Furthermore, ES-R was associated with increasing rates of rehospitalization (64% vs. 37%; p?=?.031; HR 1.985; 95% CI 1.025–3.845; log-rank p?=?.042), especially of acute heart failure (32% vs. 12%; p?=?.001; HR 3.262; 95% CI 1.180–9.023; log rank p?=?.023). MACE were higher in ES-R patients (55% vs. 35%; p?=?.113; log rank p?=?.141). ES patients with LVEF ≤35% were 12.4 times more likely to develop ES-R (HR 12.417; 95% CI 1.329–115.997; p?=?.027). Conclusion. At long-term follow-up of 2.5 years, ES-R was associated with numerically higher rates of long-term all-cause mortality and significantly higher rates of rehospitalization due to acute heart failure. LVEF ≤35% was associated with increased risk of ES-R.

Condensed Abstract

This study examined retrospectively the impact of recurrences of electrical storm (ES-R) on survival in 87 patients. ES-R was associated with numerically higher long-term all-cause mortality, whereas significantly higher rates of rehospitalization, respectively of acute heart failure were observed.

• Highlights

• ES-R is associated with numerically higher rates of all-cause mortality at long-term follow-up.

• ES-R is associated with significantly higher rates of rehospitalization and numerically higher rates of MACE at long-term follow-up, mainly due to acute heart failure.

• Patients with LVEF ≤35% were 12.4 times more likely to develop ES-R.

     

ST2 in heart failure with preserved and reduced ejection fraction

Objectives. Soluble suppression of tumorigenecity 2 (sST2) is prognostic in acute and chronic heart failure with reduced ejection fraction (HFrEF) but less studied in HF with preserved EF (HFpEF). We evaluated sST2 concentrations, correlations with biomarkers and echocardiographic measures of diastolic and systolic function, and associations with outcomes in HFpEF and HFrEF. Design and results. A total of 193 subjects from three different cohorts were included. Eighty-six HFpEF patients were obtained from the Karolinska Rennes (KaRen) study, 86 patients with HFrEF were recruited from referrals to Karolinska University Hospital for advanced assessment of HF, and 21 controls were included (ClinicalTrials.gov Identifier for KaRen: NCT01091467). HFrEF and controls cohorts did not have ClinicalTrials.gov registrations. sST2 was lower in HFpEF, median (interquartile range); 23 (17–31) compared to HFrEF; 35 (23–52) µg/L, p?_s=0.392, p?_s=0.466, p?_s=0.276, p?=?.019) but not to E/E´, nor to left ventricular mass index. sST2 was in HFpEF associated with the composite endpoint of death or HF hospitalization, adjusted hazard ratio (HR) per log increase in sST2 6.62, 95% confidence interval (CI) 1.04–42.28, p?=?.046, and in HFrEF death, heart transplant or left ventricular assist systems; 3.51, 95% CI 1.05–11.69, p?=?.041. Conclusions. In patients with HFpEF compared to HFrEF, crude levels of sST2 were lower but potentially more strongly associated with outcomes. The lower levels of sST2 in HFpEF than in HFrEF may reflect lower degrees of fibrosis, but the potentially stronger association with outcomes may reflect a greater prognostic importance of progressive fibrosis and as such a greater potential for intervention. In conclusion; this study adds to the evidence of sST2 as prognostic marker in both HFpEF and HFrEF.

Trial registration: ClinicalTrials.gov identifier: NCT01091467.     

Recurrence after pulmonary vein isolation is associated with low contact force

Objectives. Recurrent arrhythmia after pulmonary vein isolation (PVI) by radiofrequency (RF) ablation in patients with atrial fibrillation (AFIB) remains a significant challenge. Using contact force (CF) sensing ablation catheters, we aimed to identify procedure related parameters associated with recurrence after de-novo PVI in patients with AFIB. Methods. Consecutive patients undergoing a de-novo PVI procedure (n?=?120, 63% paroxysmal and 37% persistent AFIB) employing a force-sensing ablation catheter were included. A clinical control including electrocardiogram and 120?hour of Holter-recording at 12-months was performed in all patients. Recurrence was defined as any documented AFIB or atrial flutter more than 30?seconds on Holter-recording after an initial blanking period of three months. Results. Recurrence occurred in 44 patients (37%). Mean CF was lower in patients with recurrent arrhythmia (22.2?±?9.5 vs. 28.8?±?9.3?g, p?p?=?.03), and higher percentage of ablation time with a CF <10 grams (OR 1.1 (95% CI 1.0–1.1), p?=?.004) were both associated with recurrence in two distinct models. Dragging during ablation compared with point-by-point ablation technique was associated with recurrence in both models (OR 19.2 (95% CI 2.9–130.0), p?=?.002, and OR 21.7 (95% CI 2.7–176.2), p?=?.004). Conclusions. Low CF and dragging during ablation as compared with point-by-point ablation technique were associated with recurrent arrhythmia in patients with AFIB undergoing de-novo PVI by RF ablation.     

The predictive value of the product of contrast medium volume and urinary albumin/creatinine ratio in contrast-induced acute kidney injury

Preexisting renal impairment and the amount of contrast media are the most important risk factors for contrast-induced acute kidney injury (CI-AKI). We aimed to investigate whether the product of contrast medium volume and urinary albumin/creatinine ratio (CMV?×?UACR) would be a better predictor of CI-AKI in patients undergoing nonemergency coronary interventions. This was a prospective single-center observational study, and 912 consecutive patients who were exposed to contrast media during coronary interventions were investigated prospectively. CI-AKI is defined as a 44.2?μmol/L rise in serum creatinine or a 25% increase, assessed within 48?h after administration of contrast media in the absence of other causes. Fifty patients (5.48%) developed CI-AKI. The urinary albumin/creatinine ratio (UACR) (OR?=?1.002, 95% CI?=?1.000–1.003, p?=?.012) and contrast medium volume (CMV) (OR?=?1.008, 95% CI?=?1.001–1.014, p?=?.017) were independent risk factors for the development of CI-AKI. The area under the ROC curve of CMV, UACR and CMV?×?UACR were 0.662 (95% CI?=?0.584–0.741, p?p?p?相似文献   

Meta-analysis of vitamin D supplementation in the treatment of chronic heart failure

Objectives. We performed a meta-analysis to determine whether vitamin D supplementation is beneficial in patients with chronic heart failure (CHF). Design. Meta-analysis of randomised controlled trials. Results. Vitamin D supplementation in patients with CHF improved health-related quality of life and C-reactive protein levels [weighted mean difference (WMD): 6.75, 95% confidence interval (CI): 2.87 to 10.64, p?p?=?.007]. However, this supplementation was not superior to conventional treatment in terms of mortality, changes in left ventricular ejection fraction (ΔLVEF), N-terminal pro-B-type natriuretic peptide or B-type natriuretic peptide levels, and 6-minute walk distance (risk ratio: 1.11, 95% CI: 0.79 to 1.57, p?=?.53; WMD: 2.56, 95% CI: ?2.18 to 7.31, p?=?.29; SMD: ?0.18, 95% CI: ?0.42 to 0.06, p?=?.15; WMD: ?23.30, 95% CI: ?58.31 to 11.72, p?=?.19). In contrast, ΔLVEF significantly improved (WMD: 6.75, 95% CI: 4.16 to 9.34, p?Conclusions. Vitamin D supplementation decreases serum levels of inflammatory markers and improves quality of life in CHF patients. Pooled analysis of vitamin D supplementation did not show reduced mortality or improved left ventricular function perhaps because of excessive increase in plasma 25-hydroxyvitamin D and calcium levels. Future studies should pay attention to vitamin D and calcium levels achieved.     

Effects of far infrared therapy on arteriovenous fistulas in hemodialysis patients: a meta-analysis

Background: Far infrared (FIR) therapy may have a beneficial effect on maturity and function of arteriovenous fistulas (AVFs) in hemodialysis (HD) patients. Therefore, we performed this pooled analysis to assess the protective effects of FIR therapy in HD patients.

Methods: The randomized controlled trials (RCTs) and quasi-RCTs of FIR therapy for HD patients were searched from multiple databases. Relevant studies were screened according to the predefined inclusion criteria. The meta-analyses were performed using RevMan 5.2 software (The Cochrane Collaboration, Oxford, UK).

Results: Meta-analysis showed that FIR therapy could significantly increase the vascular access blood flow level (MD, 81.69?ml/min; 95% CI, 46.17–117.21; p?p?p?p?p?Conclusions: FIR therapy can reduce AVFs occlusion rates and needling pain level, while significantly improve the level of vascular access blood flow, AVFs diameter and the primary AVFs patency.     

Emotional management and biological markers of dietetic regimen in chronic kidney disease patients

The aim of the study was to investigate the association between psychological characteristics and biological markers of adherence in chronic kidney disease patients receiving conservative therapy, hemodialysis, peritoneal dialysis (PD), or kidney transplantation.

Seventy-nine adult patients were asked to complete the following questionnaires: Toronto Alexithymia scale, Snaith–Hamilton Pleasure Scale, and Short Form Health Survey. Biological markers of adherence to treatment were measured.

Peritoneal dialysis patients showed a lower capacity to feel pleasure from sensorial experience (p?=?.011) and a higher values of phosphorus compared to the other patients’ groups (p?=?.0001).

The inability to communicate emotions was negatively correlated with hemoglobin levels (r?=??(0).69; p?=?.001) and positively correlated with phosphorus values in the PD patients (r?=?.45; p?=?.050).

Findings showed higher psychological impairments and a lower adherence to the treatment in PD patients and suggest the implication of emotional competence in adherence to treatment.     

Completeness of pathology reports in stage II colorectal cancer

Introduction: The completeness of the pathological examination of resected colon cancer specimens is important for further clinical management. We reviewed the pathological reports of 356 patients regarding the five factors (pT-stage, tumor differentiation grade, lymphovascular invasion, tumor perforation and lymph node metastasis status) that are used to identify high-risk stage II colon cancers, as well as their impact on overall survival (OS).

Methods: All patients with stage II colon cancer who were included in the first five years of the MATCH study (1 July 2007 to 1 July 2012) were selected (n?=?356). The hazard ratios of relevant risk factors were calculated using Cox Proportional Hazards analyses.

Results: In as many as 69.1% of the pathology reports, the desired information on one or more risk factors was considered incomplete. In multivariable analysis, age (HR: 1.07, 95%CI 1.04–1.10, p?p?=?.003) and well (HR 0.11, 95%CI 0.01–0.89, p?=?.038) differentiated tumors were significantly associated with OS.

Conclusions: Pathology reports should better describe the five high-risk factors, in order to enable proper patient selection for further treatment. Chemotherapy may be offered to stage II patients only in select instances, yet a definitive indication is still unavailable.     

Clinical outcome after progressing to frontline and second-line Anti–PD-1/PD-L1 in advanced urothelial cancer

BackgroundImmune checkpoint inhibitors (ICIs) are approved for first-line (cisplatin unfit, PD-L1+) and platinum-refractory urothelial carcinoma (UC). Still, most patients experience progressive disease (PD) as the best response. Although higher response rates to subsequent systemic treatment (SST) have been described, post-PD outcome data are scarce.ObjectiveTo examine the outcome of UC patients who received SST and no SST after progressing to ICIs.Design, setting, and participantsA retrospective analysis of UC patients progressing to frontline or later-line anti–PD-1/PD-L1 therapy in 10 European institutions was conducted between March 2013 and September 2017.InterventionPost-PD management as per standard practice.Outcome measurements and statistical analysisOverall survival (OS) was analyzed with a Kaplan-Meier model. Cox regression was used for multivariate analysis (MV). Impact of SST on OS was examined with a time-varying covariate model.Results and limitationsA total of 270 UC patients with PD to ICIs (69 frontline, 201 later line) were analyzed. Of the patients, 57% of frontline-ICI-PD and 34% of later-line-ICI-PD patients received SST, and SST had an impact on OS in MV (frontline: hazard ratio [HR] 0.22, 95% confidence interval [CI] 0.10–0.51, p < 0.001; later line: HR 0.22, 95% CI 0.13–0.36, p < 0.001). In the frontline-ICI-PD group, median OS with and without SST was 6.8 mo (95% CI 5.0–8.6) and 1.9 mo (95% CI 0.9–3.0), respectively. High disease burden (three or more metastatic sites: HR 2.49, p = 0.03; simultaneous liver/bone metastases: HR 3.93, p = 0.03) predicted worse survival. In later-line-ICI-PD group, response to ICIs (HR 0.37, p = 0.03), longer exposure to ICIs (HR 0.89, p = 0.002), and bone metastasis (HR 2.42, p < 0.001) predicted survival. The retrospective nature of this study and a lack of certain parameters limit the interpretation of our analysis.ConclusionsPatients progressing to frontline ICIs are at risk of early death, excluding them from experiencing potential benefit from chemotherapyPatient summaryOur analysis suggests that outcomes after failing immunotherapy are poor, particularly in UC patients who received no prior chemotherapy.     

Characteristics of patients with coexisting IgA nephropathy and membranous nephropathy

Background: Coexistence of IgA nephropathy (IgAN) and membranous nephropathy (MN) in the same patient is rare. Few studies have reported the clinical and pathological features of patients with combined IgAN and MN (IgAN–MN).

Methods: The clinico-pathological features, levels of galactose-deficient IgA1 (Gd-IgA1) and autoantibodies against M-type transmembrane phospholipase A₂ receptor (anti-PLA₂R) in sera were compared among IgAN–MN, IgAN, and MN patients.

Results: Twenty-six patients with biopsy-proven IgAN–MN were enrolled. The mean age at biopsy was 43.6?±?15.9?years, and 65.4% were male. Proteinuria and estimated glomerular filtration rate (eGFR) levels in patients with IgAN–MN were similar to that of MN patients. Compared with the IgAN patients, IgAN–MN patients showed a higher median proteinuria level (4.3 vs. 1.2?g/day, p?2, p?p?=?.801). Percentage of IgAN–MN patients with detectable serum levels of anti-PLA₂R was lower than that of MN patients (38.5% vs. 68.6%, p?=?.011).

Conclusions: IgAN–MN patients display similar clinical features to MN patients and milder pathological lesions than IgAN patients. IgAN–MN patients have similar levels of Gd-IgA1 to those of IgAN patients, and a lower proportion of anti-PLA₂R than MN patients.     

Risk factors of severe peritoneal sclerosis in chronic peritoneal dialysis patients

Peritoneal dialysis (PD) offers the healthiest way for starting renal replacement therapy (RRT) in End Stage Renal Disease patients, however exposes long-term PD patients to a dangerous complication named encapsulating peritoneal sclerosis (EPS). In this study, we searched for possible risk factors of EPS. Data were collected from two PD centers covering period 1995–2012 and comprised 464 patients. Control group defined as PD patients stayed on PD >42 month (n?=?122), and case group was 12 confirmed EPS patients. Associations were analyzed using linear regression analysis. Prevalence and incidence of EPS were 2.59% and 8.9% with an incidence of 0.7% patient-years, respectively. The age at start of PD in EPS patients (32.75?±?10.8 year) was significantly lower compared with control group (49.61?±?16.18 year, p?=?.0001). The mean duration of PD in EPS and control group were 2494.4?±?940.9 and 1890.2?±?598.8 days (p?=?.002). Control group had 145 episodes of peritonitis during total duration of 7686 patient months (peritonitis rate of 1/53). This was 1/26 with a total 38 episodes of peritonitis during the total duration of 997 patient months (p?=?.01) for EPS group. In regression analysis, PD duration, age at PD start and duration of Ultrafiltration failure (UFF) were associated with EPS. Longer time being on PD, younger age, and higher UFF duration were the risk factors for EPS development.     

Use of renal replacement therapy after out-of-hospital cardiac arrest in Denmark 2005–2013

Abstract

Objectives: Renal replacement therapy (RRT) is used to treat acute kidney injury as part of multi organ failure. Use and prognostic implications after out-of-hospital cardiac arrest (OHCA) is not well known.

This study aims to assess incidence and use of RRT and whether RRT post-arrest was associated with 30-day mortality in Denmark in the years 2005–2013. Methods: The Danish Cardiac Arrest Registry holds information on all OHCA patients in Denmark from 2005 to 2013. We identified 3,012 one-day survivors of OHCA ≥18 years, with presumed cardiac aetiology of arrest, admitted to ICU without previous RRT. Change in use of RRT during the study period was assessed using competing risk analysis. Mortality was assessed with Cox regression. Results: On average, RRT was performed in 6% of the patient population with an average annual 1% increase, HR: 1.01, CI: 0.95–1.07, p?=?.69. Hazard of RRT was lower in patients receiving bystander cardiopulmonary resuscitation (CPR) (p?<?.001), patients with a shockable primary rhythm (p?=?.009) and elderly patients (p?=?.03). Socioeconomic factors did not influence hazard of RRT, but patients admitted to tertiary centres had higher hazard of RRT (p?=?.009).

Use of RRT was associated with increased mortality in multivariate Cox regression (HR: 1.28, CI: 1.06–1.55, p?=?.01). Conclusion: Use of RRT as part of post resuscitation care following OHCA did not increase from 2005 to 2013; use was more common in tertiary centres and in patients with negative prehospital predictors (no bystander CPR, non-shockable rhythm). RRT was associated with increased mortality.     

Aspirin plus clopidogrel versus aspirin mono-therapy for ischemic stroke: a meta-analysis

Objectives. Stroke is a common condition after a transient ischemic attack (TIA) or minor ischemic stroke (IS). Adding clopidogrel to aspirin may yield more beneficial outcomes than aspirin mono-therapy; meanwhile, the risk of bleeding in the acute phase remains poorly understood. Therefore, there is increasing emphasis on the risks and benefits of clopidogrel with aspirin compared with aspirin mono-therapy in an effort to treat TIA/IS. Design. We searched several electronic databases, including PubMed, Cochrane, and Embase, to identify eligible randomized controlled trials (RCTs) based on the index words comparing dual-antiplatelet therapy to aspirin mono-therapy for secondary stroke prevention updated to December, 2018. Results. A total of 11 RCTs met our inclusion criteria. The pooled analysis showed that clopidogrel plus aspirin was associated with a trend toward a reduction in recurrent IS (RR?=?0.72, 95%CI?= 0.65–0.81, p?p?=?.09) than aspirin mono-therapy. There were differences in bleeding episodes (RR?=?1.81, 95%CI?=?1.65–1.99, p?p?=?.0005), or mild bleeding (RR?=?2.25, 95%CI?=?1.54–3.31, p?p?=?.09). Conclusions. The addition of clopidogrel to aspirin for patients with TIA or IS appeared to significantly reduce the risk of IS recurrence with a possible increase in the risk of bleeding compared with aspirin alone.     

Incisional Hernia Repair of Medium- and Large-Sized Defects: Laparoscopic IPOM Versus Open SUBLAY Technique

Background: Small incisional hernias can be repaired laparoscopically with low morbidity and reasonable recurrence rates. The aim of this study was to compare laparoscopic with open technique in medium- and large-sized defects regarding postoperative complications and recurrence rates.

Methods: Between 2012 and 2016, 102 patients with medium- or large-sized defects according to EHS classification underwent incisional hernia repair. Patients’ characteristics, hernia size and postoperative complications were prospectively recorded. In October 2016, eligible patients were assessed for recurrence.

Results: About 31 patients underwent laparoscopic IPOM and 71 patients open SUBLAY repair. Morbidity rate was significantly lower in IPOM group than in SUBLAY group (19% versus 41%; p?=?.028). Postoperative complications according to Clavien–Dindo classification were significantly lower in the IPOM group (p?=?.021). Duration of surgery (88 versus 114?min; p?=?.009) and length of hospital stay (five versus eight days; p?<?.001) were significantly shorter for IPOM than for SUBLAY. 71 patients were available for follow-up. Recurrence rates showed no significant difference between study groups (13% versus 7%, p?=?.508).

Conclusions: Laparoscopic repair in medium- and large-sized defects is a feasible and safe approach. IPOM compared to SUBLAY significantly reduces postoperative complications and hospital stay; recurrence rates are comparable.     

Effect of permanent pacemaker on mortality after transcatheter aortic valve replacement

Objectives. Transcatheter aortic valve implantation (TAVI) is an established treatment for high-grade aortic valve stenosis in patients found unfit for open heart surgery. The method may cause cardiac conduction disorders requiring permanent pacemaker (PPM) implantation, and the long-term effect of PPM implantation remains ambiguous. Design One hundred sixty-eight patients who underwent TAVI from 2008 to 2012 were included. Patient characteristics, ECGs and PPM data were collected through medical records. Kaplan–Meier plots and Cox regression analysis were performed. Results. Forty subjects were excluded, leaving 128 patients for final inclusion. 41 (32%) received a PPM (mean age 82 vs. 80 in patients without PPM, p?=?.06) within 30 days of the TAVI procedure. Median follow-up was ～4 years and 37 (29%) died. One-year mortality was 14% for non-PPM patients vs. 2% in PPM patients, and mortality at 5yrs 70% vs. 54%, respectively. Kaplan–Meier survival analysis showed higher mortality in patients without PPM (p?=?.008). In multivariate survival analysis significant variables were: No PPM (HR 2.6; CI 1.1–6.2; p?=?.03), chronic obstructive pulmonary disease (HR 2.4; CI 1.2–5.0; p?=?.02) and either pre- or post-procedural chronic or paroxystic atrial fibrillation (HR 2.3; CI 1.2–4.7; p=?.02). Conclusion. TAVI-patients with a PPM had better survival than patients in whom a PPM was not implanted.     

The effect of histopathologic and clinical features on allograft survival in renal transplant patients with antibody-mediated rejection

Background: Antibody-mediated rejection is a frequent cause of graft failure; however, prognostic indications of this complication have not been well defined. The aim of this study was to evaluate the association of histopathological and clinical features and to determine the effect of these findings on allograft survival in patients with AMR.

Methods: Fifty-two patients suffered from AMR (30 male; mean age 39?±?11 years) were included in the study. Data were investigated retrospectively and graft survival was analyzed. All transplant biopsies were evaluated according to Banff 2009 classification.

Results: Of the 52 cases, 45 were transplanted from living-donors. Twenty-one patients were diagnosed in the first 3-months after transplantation. Graft survival was 65% at 12 months and 54% at 36 months. Mean serum creatinine at time of biopsy was 3.8?±?3.6?mg/dL. Thirty-five of the 52 cases showed diffuse C4d positivity, 12 cases showed focal and 5 remained C4d negative. One of the patients died, 13 experienced graft loss and 38 survived with functioning grafts. Serum creatinine levels at time of biopsy were correlated with graft survival (p?=?.021: OR?=?1.10: 95 % CI?=?1.015–1.199). In terms of the impact of pathological findings; tubulitis (p=.007: OR?=?2.62: 95 % CI?=?1.301–5.276), intimal arteritis (p=.017: OR?=?2.85: 95% CI?=?1.205–6.744) and interstitial infiltration (p=.004: OR?=?3.37: 95% CI?=?1.465–7.752) were associated with graft survival.

Conclusions: Serum creatinine at time of biopsy, tubulitis, intimal arteritis and interstitial infiltration were significantly associated with graft survival. Antibody-mediated rejection is associated with reduced long-term graft survival.