狼疮肾炎终末期肾病患者肾移植临床分析

目的：探讨系统性红斑狼疮肾炎终末期肾病患者行肾移植术治疗的效果和可行性。方法：统计我院2004年1月～2008年12月间,原发病为终末期狼疮肾病的肾移植患者的临床资料和手术后随访情况进行分析。结果：4例患者均为女性,行移植手术时全身病情稳定,无狼疮活动;手术后均使用免疫抑制剂抗排斥反应;术后平均随访时间41.5个月;至今其中3例移植肾功能良好,未发生排异反应,1例移植肾功能异常者经移植肾病理活检证实为慢性排斥反应,4例均无狼疮肾病复发。结论：终末期狼疮肾病患者肾移植效果良好,肾移植治疗终末期狼疮肾病是有效和可行的。     

Cumulative Risk, Age at Onset, and Sex-Specific Differences for Developing End-Stage Renal Disease in Young Patients With Type 1 Diabetes: A Nationwide Population-Based Cohort Study

OBJECTIVE

This study aimed to estimate the current cumulative risk of end-stage renal disease (ESRD) due to diabetic nephropathy in a large, nationwide, population-based prospective type 1 diabetes cohort and specifically study the effects of sex and age at onset.

RESEARCH DESIGN AND METHODS

In Sweden, all incident cases of type 1 diabetes aged 0–14 years and 15–34 years are recorded in validated research registers since 1977 and 1983, respectively. These registers were linked to the Swedish Renal Registry, which, since 1991, collects data on patients who receive active uremia treatment. Patients with ≥13 years duration of type 1 diabetes were included (n = 11,681).

RESULTS

During a median time of follow-up of 20 years, 127 patients had developed ESRD due to diabetic nephropathy. The cumulative incidence at 30 years of type 1 diabetes duration was low, with a male predominance (4.1% [95% CI 3.1–5.3] vs. 2.5% [1.7–3.5]). In both male and female subjects, onset of type 1 diabetes before 10 years of age was associated with the lowest risk of developing ESRD. The highest risk of ESRD was found in male subjects diagnosed at age 20–34 years (hazard ratio 3.0 [95% CI 1.5–5.7]). In female subjects with onset at age 20–34 years, the risk was similar to patients'' diagnosed before age 10 years.

CONCLUSIONS

The cumulative incidence of ESRD is exceptionally low in young type 1 diabetic patients in Sweden. There is a striking difference in risk for male compared with female patients. The different patterns of risk by age at onset and sex suggest a role for puberty and sex hormones.Diabetic nephropathy is one of the most severe complications in patients with type 1 diabetes, leading to end-stage renal disease (ESRD) and the need for renal replacement therapy (dialysis and transplantation). Diabetic nephropathy is also a major predictor of cardiovascular morbidity and mortality in patients with type 1 diabetes (1). Although the incidence of type 1 diabetes has increased in children, and onset of disease occurs at younger age (2,3), a decrease in incidence of diabetic nephropathy and a longer duration from onset of diabetes to diabetic nephropathy and ESRD has been reported from dedicated centers (4). Recently, a follow-up of the Diabetes Control and Complications Trial–intensive treated type 1 diabetes case subjects showed a cumulative incidence of nephropathy of 9% at 30 years of diabetes duration compared with 25% in the conventionally treated group (5). A Finnish population-based study showed a cumulative incidence of ESRD of 7.8% after 30 years of diabetes duration (6). Next to Finland, Sweden has the highest incidence of childhood-onset diabetes reported worldwide (7), and since the 1980s Sweden has a strict nationwide childhood diabetes care program that includes intensive insulin treatment and home blood glucose monitoring to counteract development of late complications.Poor glycemic control and high blood pressure are the two most important risk factors in the initiation and development of diabetic nephropathy (8,9), but they are not sufficient for development of diabetic nephropathy and ESRD. Other factors, such as genetic susceptibility and growth and sex hormones, seem to contribute (10,11). Some studies (12–14) suggest that male sex is a risk factor for development of diabetic nephropathy and ESRD. Several studies (6,15,16) indicate that young age at onset of diabetes can prolong the time until development of microalbuminuria, diabetic nephropathy, ESRD, and other vascular complications. It has thus been suggested that puberty could promote the development of chronic diabetes complications due to deterioration of glycemic control, rapid growth, and hormonal changes (17,18). An increased risk for both hospitalization due to severe vascular complications and a higher mortality rate have also been found in patients with pubertal onset of diabetes compared with those with younger age at onset (19,20). If puberty is associated with increased risk of diabetic nephropathy, diabetes onset after that age would decrease diabetic nephropathy risk and approach the risk of prepubertal-onset cases.In the present study, we used data from two large, nationwide, population-based cohorts of young patients with type 1 diabetes for the following reasons:

• to estimate the cumulative incidence and long-term risk of ESRD after 30 years of type 1 diabetes with recommended intensive insulin treatment; and
• to study the effects of age at onset of diabetes and sex on these risks.

     

A Nationwide Population-Based Study of the Risk of Tuberculosis in Different Solid Organ Transplantations in Taiwan

Advances in immunosuppressants for solid organ transplantation (SOT) have improved prevention and treatment of acute rejection as well as reduced the risk of chronic graft damage. However, SOT recipients are prone to developing opportunistic infections because of their long-term immunosuppressed status. Tuberculosis (TB) is a serious opportunistic infection that is associated with increased morbidity and mortality in SOT recipients. However, nationwide population-based research specifically focused on the associations between kidney transplantation (KTx), liver transplantation (LTx), and heart transplantation (HTx), and subsequent TB infection is lacking. This study was conducted using Taiwan's National Health Insurance Research Database, which provided claims data for SOT recipients from 2000 to 2009. Clinical features, treatment, and outcomes were analyzed to determine the risk for TB after SOT. In total, 153 (3.2%) RTx, 19 (1.1%) LTx, and 26 (2.8%) HTx recipients became infected with TB. Compared with non-TB patients, HTx recipients with TB had significantly higher prevalence of older age (P = .037), hypertension (P < .001), and coronary artery disease (CAD) (P = .002). There were also greater percentages of male sex (P = .018), diabetes (P = .029), hyperlipidemia (P = .016), CAD (P < .001), and chronic obstructive pulmonary disease (COPD) (P < .001) in RTx recipients with TB than in those without. In conclusion, posttransplantation TB is a serious problem worldwide, and a high index of suspicion is warranted to ensure early diagnosis and prompt initiation of treatment for TB among SOT patients. In this preliminary study, KTx recipients had a higher risk of TB infection than LTx and HTx recipients, and the high-risk factors were male sex, diabetes, hyperlipidemia, CAD, and COPD. The use of optimal immunosuppressive agents to minimize acute rejection, monitoring of high-risk recipients, prompt diagnosis, and appropriate treatment are required for the management of TB infection in endemic areas such as Taiwan.     

Chronic Hemodialysis in End-Stage Lupus Nephritis: Changes of Clinical and Serological Activities

Abstract: The available data on the clinical and serological activities of systemic lupus erythematosus (SLE) in dialysis patients with end-stage lupus nephritis are limited. The clinical and serological parameters in 12 such patients prior to, at the onset of, and an average of 31 months after the institution of hemodialysis were retrospectively compared. One of the patients died of cardiopulmonary arrest within 1 week after institution of hemodialysis. All patients were clinically and serologically active prior to the onset of end-stage renal disease (ESRD). With the onset of ESRD, 2 of the 10 patients exhibited complete clinical and serological remission, and 2 patients showed clinical remission with persistent serological activity. After an average of 31 months on dialysis, the number of patients in total remission rose to 4 of 11, and the number of clinically inactive but serologically active patients was 1 of 11. Significant clinical and serological activities persisted in 6 of the 11 dialysis patients, requiring low dose steroid therapy in 3. The authors conclude that the clinical and serological activities of SLE decrease with the onset of ESRD and the institution of dialysis, leading to complete or partial remission in the majority of patients.     

Diabetes Mellitus and Increased Postoperative Risk of Acute Renal Failure After Hepatectomy for Hepatocellular Carcinoma: A Nationwide Population-Based Study

Background

This study aimed to determine the effects of diabetes mellitus (DM) on the risk of surgical mortality and morbidity in patients undergoing hepatectomy for hepatocellular carcinoma (HCC).

Methods

We identified 2,962 DM patients who underwent a hepatectomy for HCC from 2000 to 2010. The non-DM control cohort consisted of 2,962 patients who also received a hepatectomy during the same period. Age, sex, comorbidities, and year of admission were all matched between the 2 cohorts.

Results

The prevalence of preoperative coexisting medical conditions was comparable between the DM and non-DM cohorts, except the percentage of patients undergoing major hepatectomy (lobectomy; 18.1 % in the DM cohort vs. 20.4 % in the non-DM cohort; p = 0.02).The hazard ratio (HR) of 30-day postoperative mortality in the DM patients after hepatectomy was 1.17 [95 % confidence interval (CI) 0.75–1.84] after adjustment. The DM cohort exhibited a significantly higher risk of postoperative septicemia (adjusted hazard ratio, 1.45; 95 % CI 1.06–2.00) and acute renal failure (adjusted hazard ratio, 1.70; 95 % CI 1.01–2.84) compared with that of the non-DM cohort, but this higher risk was not associated with the increased risk of other major morbidities, including pneumonia, stroke, and myocardial infarction. Further analysis showed that major hepatectomy (lobectomy) in DM patients carried higher risks of septicemia and acute renal failure. In multiple regression models, preoperative diabetes-related comorbidities were not significantly associated with 30-day postoperative mortality.

Conclusions

DM is associated with a significantly high risk of septicemia and acute renal failure, but not with other major complications or mortality, after hepatectomy for HCC.     

Treatment and Outcome of Synchronous Colorectal Carcinomas: A Nationwide Study

Background

Synchronous colorectal carcinomas (CRC) occur in 1–8% of patients diagnosed with CRC. This study evaluated treatment patterns and patient outcomes in synchronous CRCs compared with solitary CRC patients.

Methods

All patients diagnosed with primary CRC between 2008 and 2013, who underwent elective surgery, were selected from the Netherlands Cancer Registry. Using multivariable regressions, the effects of synchronous CRC were assessed for both short-term outcomes (prolonged postoperative hospital admission, anastomotic leakage, postoperative 30-day mortality, administration of neoadjuvant or adjuvant treatment), and 5-year relative survival (RS).

Results

Of 41,060 CRC patients, 1969 patients (5%) had synchronous CRC. Patients with synchronous CRC were older (mean age 71 ± 10.6 vs. 69 ± 11.4 years), more often male (61 vs. 54%), and diagnosed with more advanced tumour stage (stage III–IV 54 vs. 49%) compared with solitary CRC (all p < 0.0001). In 50% of the synchronous CRCs, an extended surgery was conducted (n = 934). Synchronous CRCs with at least one stage II–III rectal tumour less likely received neoadjuvant (chemo)radiation [78 vs. 86%; adjusted OR 0.6 (0.48–0.84)], and synchronous CRCs with at least one stage III colon tumour less likely received adjuvant chemotherapy [49 vs. 63%; adjusted OR 0.7 (0.55–0.89)]. Synchronous CRCs were independently associated with decreased survival [RS 77 vs. 71%; adjusted RER 1.1 (1.01–1.23)].

Conclusions

The incidence of synchronous CRCs in the Dutch population is 5%. Synchronous CRCs were associated with decreased survival compared with solitary CRC. The results emphasize the importance of identifying synchronous tumours, preferably before surgery to provide optimal treatment.

     

Considerations in the Diagnosis and Treatment of Arrhythmias in Patients with End-Stage Renal Disease

Patients with ESRD have arrhythmias similar to those in patients without renal complications. It is unclear whether ESRD itself is a risk factor for the development of arrhythmias or whether it is simply a marker for other diseases which predispose to arrhythmias. Regardless, therapy can be undertaken but special caution is required because of metabolic alterations and drug interactions which can make antiarrhythmic therapy more risky than in the general population. With meticulous attention to detail, therapy can be provided safely.     

The Relationship between Volume and Outcome after Bariatric Surgery: A Nationwide Study in Taiwan

Background

This study purposed to explore the impact of hospital volume and surgeon volume on hospital resource utilization after bariatric surgery and to identify the predictors of length of stay (LOS) and hospital treatment cost in a nationwide population in Taiwan.

Methods

This population-based cohort study retrospectively analyzed 2,674 bariatric surgery procedures performed from 1997 to 2008. Hospitals were classified as low- and high-volume hospitals if their annual number of bariatric surgeries were <35 and ??35, respectively. Surgeons were classified as low- and high-volume surgeons if their annual number of bariatric surgeries were <15 and ??15, respectively. Hierarchical linear regression models were used to predict LOS and hospital treatment cost.

Results

The mean LOS was 7.67?days and the LOS for high-volume hospitals/surgeons was, on average, 28%/31% shorter than that for low-volume hospitals/surgeons. The mean hospital treatment cost was US$2,344.08, and the average hospital costs for high-volume hospitals/surgeons were 10%/13% lower than those for low-volume hospitals/surgeons. Advanced age, male gender, high Charlson co-morbidity index, and current treatment in a low-volume hospital, by a low-volume surgeon, and via open gastric bypass were significantly associated with long LOS and high hospital treatment cost (P?Conclusions The data suggest that annual surgical volume is the key factor in hospital resource utilization. The results improve the understanding of medical resource allocation for this surgical procedure and can help to formulate public health policies for optimizing hospital resource utilization for related diseases.     

Predictors of Remission and Relapse of Diabetes after Conventional Gastrectomy for Gastric Cancer: Nationwide Population-Based Cohort Study

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Association Between Attributed Cause of End-Stage Renal Disease and Risk of Death in Brazilian Patients Receiving Renal Replacement Therapy

Background. Studies conducted in several countries have indicated that the survival of patients undergoing renal replacement therapy (RRT) depends on the attributed cause of end-stage renal disease (ESRD). Objectives. This study was conducted to evaluate the association between attributed cause of ESRD and mortality risk in RRT patients in Brazil. Methods. We analyzed 88,881 patients from the Brazilian Ministry of Health Registry who were undergoing RRT between April 1997 and July 2000. Cox proportional hazards models were used to estimate the relative risk (RR) of death in patients with ESRD secondary to diabetes mellitus (DM), polycystic kidney disease (PKD), and primary glomerulopathies (GN) compared with a reference group comprised of patients with ESRD caused by hypertensive nephropathy. Patient's age, gender, and length of time (years) in RRT before inclusion in the registry (vintage) were included in the adjusted Cox model. Results. Compared with the reference group, the mortality risk was 27% lower in patients with PKD (RR = 0.73, 95% CI: 0.65–0.83, p< 0.0001); 29% lower in patients with GN (RR = 0.71, 95% CI: 0.68–0.74, p< 0.0001); and 100% greater in DM patients (RR = 2.00, 95% CI: 1.92–2.10, p< 0.0001). These relative risks remained statistically significant after adjustment for age, gender, and length of time in RRT before inclusion in the registry. Conclusions. Our data indicate that compared with the patients with hypertensive nephrosclerosis as attributed cause of ESRD, patients undergoing RRT in Brazil with idiopathic glomerulopathy and polycystic kidney disease have a lower risk of mortality, and patients with diabetes mellitus have a greater risk of mortality.     

A Population-Based Comparison of Adenocarcinoma of the Large and Small Intestine: Insights Into a Rare Disease

Background  

Because of its rarity, adenocarcinoma of the small intestine is frequently compared to adenocarcinoma of the colon, although the validity of this comparison is not known.     

Predicting Prostate Cancer Death with Different Pretreatment Risk Stratification Tools: A Head-to-head Comparison in a Nationwide Cohort Study

BackgroundNumerous pretreatment risk classification tools are available for prostate cancer. Which tool is best in predicting prostate cancer death is unclear.ObjectiveTo systematically compare the prognostic performance of the most commonly used pretreatment risk stratification tools for prostate cancer.Design, setting, and participantsA nationwide cohort study was conducted, including 154 811 men in Prostate Cancer data Base Sweden (PCBaSe) 4.0 diagnosed with nonmetastatic prostate cancer during 1998–2016 and followed through 2016.Outcome measurements and statistical analysisWe compared the D’Amico, National Institute for Health and Care Excellence (NICE), European Association of Urology (EAU), Genito-Urinary Radiation Oncologists of Canada (GUROC), American Urological Association (AUA), National Comprehensive Cancer Network (NCCN), and Cambridge Prognostic Groups (CPG) risk group systems; the Cancer of the Prostate Risk Assessment (CAPRA) score; and the Memorial Sloan Kettering Cancer Center (MSKCC) nomogram in predicting prostate cancer death by estimating the concordance index (C-index) and the observed versus predicted cumulative incidences at different follow-up times.Results and limitationsA total of 139 515 men were included in the main analysis, of whom 15 961 died from prostate cancer during follow-up. The C-index at 10 yr of follow-up ranged from 0.73 (95% confidence interval [CI]: 0.72–0.73) to 0.81 (95% CI: 0.80–0.81) across the compared tools. The MSKCC nomogram (C-index: 0.81, 95% CI: 0.80–0.81), CAPRA score (C-index: 0.80, 95% CI: 0.79–0.81), and CPG system (C-index: 0.78, 95% CI: 0.78–0.79) performed the best. The order of performance between the tools remained in analyses stratified by primary treatment and year of diagnosis. The predicted cumulative incidences were close to the observed ones, with some underestimation at 5 yr. It is a limitation that the study was conducted solely in a Swedish setting (ie, case mix).ConclusionsThe MSKCC nomogram, CAPRA score, and CPG risk grouping system performed better in discriminating prostate cancer death than the D’Amico and D’Amico-derived systems (NICE, GUROC, EAU, AUA, and NCCN). Use of these tools may improve clinical decision making.Patient summaryThere are numerous pretreatment risk classification tools that can aid treatment decision for prostate cancer. We systematically compared the prognostic performance of the most commonly used tools in a large cohort of Swedish men with prostate cancer. The Memorial Sloan Kettering Cancer Center nomogram, Cancer of the Prostate Risk Assessment score, and Cambridge Prognostic Groups performed best in predicting prostate cancer death. The use of these tools may improve treatment decisions.     

Treatment of End-Stage Renal Disease in Central and Eastern Europe: Overview of Current Status and Future Needs

The situation of end-stage renal disease (ESRD) patients in central and eastern Europe was very poor for many years during the so called socialistic era. Economical and political liberation resulted in the significant growth of renal replacement facilities in this region. The number of hemodialysis units increased significantly (56%) during the period 1990–1996, and the number of patients treated with this modality has risen by 75%. More dramatic progress was achieved in peritoneal dialysis. The number of units performing this method of renal replacement therapy (RTT) increased by 277% and the number of patients by more than 300%. Not only quantitative but also qualitative changes were observed. More modern hemodialysis machines installed in the vast majority of units allow for the performance of bicarbonate dialysis, controlled ultrafiltration, and sodium profile modeling. Also, a wider choice of biocompatible dialyzers has become available during the last few years. The number of centers performing renal transplantation has increased significantly, but the number of renal transplants has not followed this progress. Despite all the progress, further development of all RRT methods is necessary to achieve acceptance rates comparable to those observed in developed countries.     

Outcome Comparison Between Functional Ankle Instability Cases With and Without Anterior Ankle Impingement: A Retrospective Cohort Study

Functional ankle instability (FAI) and anterior ankle impingement (AAI) are likely to occur simultaneously. Nevertheless, how AAI affects ankle instability remains largely unknown. This study aimed to assess patients with FAI?+?AAI and those having FAI without AAI after arthroscopic synovectomy combined with the modified Broström procedure. Patients with chronic ankle instability who underwent surgery at the Huashan Hospital of Fudan University (China) from January 2010 to December 2015 were reviewed. Propensity score matching was performed (FAI?+?AAI: n?=?86; FAI without AAI: n?=?43). Ankle function was assessed by the American Orthopedic Foot and Ankle Society (AOFAS) and the Meislin criteria at 3 months, 1 year, and final follow-up. In the FAI?+?AAI group, AOFAS scores increased from 52.6 ± 7.2 to 78.6 ± 8.2, 84.2 ± 6.4, and 83.6 ± 11.3 at 3 months, 1 year, and last follow-up, respectively (p < .001). In the FAI without AAI group, AOFAS scores increased from 64.3 ± 10.5 to 85.2 ± 8.6, 91.4 ± 7.9, and 90.2 ± 9.8 at 3 months, 1 year, and last follow-up, respectively (p < .001; all p < .05 for differences between the 2 groups at each time point). The 2 groups showed similar scores based on the Meislin criteria (p?=?.38). Hypertrophic distal fascicle of the anteroinferior tibiofibular ligament showed lower AOFAS scores (all p < .05). Patients with FAI with or without AAI had improved outcomes with arthroscopic synovectomy combined with the modified Broström procedure; however, patients with combined FAI and AAI showed a relatively poorer outcome in comparison with those suffering from FAI alone, probably because of hypertrophic distal fascicle of the anteroinferior tibiofibular ligament.     

Refractory Hypertension and Anemia in End-Stage Renal Disease: An Unusual Manifestation of Kimura's Disease

Hypertension and anemia are common in uremic patients. This article describes a 35-year-old uremic Taiwanese who was admitted to our hospital with refractory hypertension and refractory anemia following chronic hemodialysis for more than two years. He was diagnosed with Kimura's disease finally. Refractory hypertension and refractory anemia were noted over two years before an enlarged inguinal lymph node was observed. The symptoms lead to the diagnosis of Kimura's disease. Unlike most cases, refractory hypertension and refractory anemia were first noted before the inguinal mass and eosinophilia were presented. The inflammatory parameters increased when the disease was active. Steroid treatment was conducted, and the symptoms including hypertension and anemia promptly decreased. To the authors' knowledge, this case is for first one in which Kimura's disease has induced refractory hypertension and anemia in an ESRD patient and in which these symptoms rapidly subsided following steroid treatment. The activity of Kimura's disease is closely related refractory hypertension, suggesting that inflammation may be involved in refractory hypertension and anemia in a dialytic patient with Kimura's disease.