Estimated glomerular filtration rate and daily amount of urinary protein predict the clinical remission rate of tonsillectomy plus steroid pulse therapy for IgA nephropathy

Background

This retrospective study was designed to estimate the clinical remission (CR) rate of tonsillectomy plus steroid pulse (TSP) therapy in patients with IgA nephropathy.

Methods

Based on 292 of 302 patients with IgA nephropathy treated at 11 Japanese hospitals, we constructed heat maps of the CR rate at 1 year after TSP with the estimated glomerular filtration rate (eGFR), grade of hematuria, pathological grade, number of years from diagnosis until TSP, and age at diagnosis on the vertical axis and the daily amount of urinary protein (urinary protein) on the horizontal axis. We compared subgroups usinge Student’s t test, the chi-square test with Yates correction, or Fisher’s exact probability test.

Results

The first heat map of eGFR and urinary protein showed that the CR rate was 71 % (CR vs. non-CR, 96 vs. 40) in patients with eGFR greater than 30 ml/min/1.73 m² and 0.3–1.09 g/day of urinary protein. However, the CR rate in patients with more than 1.50 g/day of urinary protein was approximately 30 %. The second heat map of grade of hematuria and urinary protein revealed that the CR rate is 72 % (CR vs. non-CR, 93 vs. 37) in patients with more than 1+ hematuria and 0.3–1.09 g/day of urinary protein; however, it was 28.6 % in patients with no hematuria. The third heat map of pathological grade and urinary protein demonstrated that the highest CR rate was 83 % (CR vs. non-CR, 52 vs. 11) in patients with pathological grade I or II disease and less than 1.09 g/day of urinary protein, as opposed to 22 % (CR vs. non-CR, 9 vs. 32) in patients with pathological grade III or IV disease and more than 2.0 g/day of urinary protein. The fourth heat map of the number of years from diagnosis until TSP and urinary protein revealed that the former did not influence the CR rate in patients with less than 1.09 g/day of urinary protein. However, in patients with more than 1.10 g/day of urinary protein, the CR rate of the subgroup with less than 6 years was 43 % (CR vs. non-CR; 23 vs. 54) compared to 23 % (CR vs. non-CR, 11 vs. 48; P = 0.01) in the subgroup with more than 6 years. The fifth heat map of age at diagnosis and urinary protein showed that the CR rate is approximately 72 % (CR vs. non-CR, 73 vs. 28) in patients older than 19 years at diagnosis with 0.3–1.09 g/day of urinary protein.

Conclusions

The daily amount of urinary protein is an important predictor of the CR rate after TSP in IgA nephropathy patients. Heat maps are useful tools for predicting the CR rate associated with TSP.     

Measurements of serum cystatin C concentrations underestimate renal dysfunction in pediatric patients with chronic kidney disease

Background

In our clinical experience, cystatin C (CysC) concentrations are not as high as expected in patients with chronic kidney disease (CKD) and high-stage renal dysfunction. We therefore investigated whether measurements of serum CysC result in an underestimation of renal dysfunction in pediatric patients with CKD.

Methods

Glomerular filtration rate (GFR) was estimated from serum creatinine (Cr) concentration, using the equation Cr-GFR (%)?=?[0.30?×?body length (m)/serum Cr]?×?100; and from serum CysC concentration, using the equation Cys-GFR (%)?=?(0.70/serum CysC)?×?100. We investigated the relationship between GFR estimated by these 2 equations. Patients aged 2??2?years were assorted into 5 groups, based on GFR-Cr categories of <12.5, ??2.5 to <25, ??5 to <50, ??0 to <75, and ??5%, and GFR-CysC/GFR-Cr ratios were compared in these 5 groups.

Results

The median GFR-CysC/GFR-Cr ratio in groups of patients with GFR-Cr of <12.5, ??2.5 to <25, ??5 to <50, ??0 to <75, and ??5% were 2.28, 1.48, 1.22, 1.18 and 0.98, respectively, with statistically significant differences between any two groups (p?Conclusion Measurements of serum CysC concentrations lead to underestimation of renal dysfunction in pediatric patients with CKD.     

Glomerular filtration rate is related to severity of obstructive coronary artery disease in patients undergoing coronary angiography

Purpose

Chronic kidney disease is independently associated with an increased risk of cardiovascular events; however, the relationship between the glomerular filtration rate (GFR) and coronary artery disease (CAD) in patients undergoing coronary angiography has yet to be fully elucidated.

Methods

This retrospective study enrolled a total of 7968 patients who underwent diagnostic coronary artery catheterization [mean age?=?54.8?±?10.6?years, 74.4% males] and did not have any previous history of coronary revascularization, diabetes mellitus, hypertension, end-stage renal disease treated by dialysis or renal transplantation, and were not taking diuretics or drugs acting on renin angiotensin system. The severity of CAD was defined as the number of coronary arteries with a luminal stenosis ??50% on the angiogram, and the GFR was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI).

Results

There were 2133 (26.8%) patients with GFR????90?ml/min/1.73?m², 4574 (57.4%) patients with 60????GFR?2, 1073 (13.5%) with 45????GFR?2 and 181 (2.3%) with 15?2. After adjustment for traditional cardiovascular risk factors (age, sex, dyslipidemia, low to high-density lipoprotein ratio, smoking status, and family history), the GFR showed a significant association with the severity of CAD and remained a significant predictor of CAD (Odds Ratio raised from 1.1 in patients with 60????GFR?2 to 1.8 in patients with 15?2).

Conclusions

A reduced kidney function, even mildly, is significantly associated with CAD severity, independently of other traditional CAD risk factors.     

Overweight and obesity accelerate the progression of IgA nephropathy: prognostic utility of a combination of BMI and histopathological parameters

Background

Although more than 40?years have passed since IgA nephropathy (IgAN) was first reported, predicting the renal outcome of individual IgAN patients remains difficult. Emerging epidemiologic evidence indicates that overweight and obesity are risk factors for end-stage renal disease. We aimed to elucidate the outcome of overweight IgAN patients and improve our ability to predict the progression of IgAN based on a combination of body mass index (BMI) and histopathological parameters, including maximal glomerular area (Max GA).

Methods

Forty-three adult IgAN patients whose estimated glomerular filtration rate was ≥50?ml/min/1.73?m² were enrolled in this study. Renal biopsy specimens were evaluated according to the Oxford classification of IgAN. A Kaplan–Meier analysis and the multivariate Cox proportional hazards method were used to evaluate 10-year kidney survival and the impact of covariates. The ability of factors to predict the progression of IgAN was evaluated by their diagnostic odds ratio (DOR).

Results

A BMI ≥25?kg/m² was found to be an independent predictor of a ≥1.5-fold increase in serum creatinine value (DOR 7.4). The combination of BMI ≥25?kg/m², Max GA ≥42,900?μm², and presence of mesangial hypercellularity (Oxford M1) optimally raised predictive power for disease progression of IgAN (DOR 26.0).

Conclusion

A combination of BMI ≥25?kg/m², the Oxford classification M1, and a Max GA ≥42,900?μm² can serve as a predictor of long-term renal outcome of IgAN.     

Spontaneous remission in children with IgA nephropathy

Background

Some patients with IgA nephropathy (IgAN) achieve spontaneous remission even when not receiving medication. However, details on such remissions remain unknown. The aim of our study was to clarify this information in the clinical setting of childhood IgAN with minor glomerular abnormalities or focal mesangial proliferation (MGA/FMP).

Methods

This study was a retrospective analysis of 96 children with MGA/FMP who did not receive medication from among the 555 patients with newly diagnosed childhood IgAN treated between January 1972 and December 2000. The Kaplan?CMeier method and Cox proportional hazard model were used for the analysis.

Results

Of the 96 pediatric patients who did not receive medication, 57 (59.4?%) achieved spontaneous remission. The cumulative spontaneous remission rates among these patients were 57.5? and 77.4 % at 5?and 10 years, respectively, from onset. The mean time from onset to remission was 5.9?±?0.4?years. Clinical and histological findings were similar between the remission and non-remission groups. Of the 57 patients with spontaneous remissions, ten (17.5?%) also developed a recurrence of urinary abnormalities. The cumulative recurrence-free rates were 79.9?and 67.9 % at 5 and 10?years, respectively, after remission.

Conclusions

The spontaneous remission rate in childhood IgAN with MGA/FMP was higher than expected. Our results suggest that physicians should consider the potential for spontaneous remission and refrain from very aggressive treatment in IgAN patients with MGA/FMP.     

Significance of tonsillectomy combined with steroid pulse therapy for IgA nephropathy with mild proteinuria

Background

Medical intervention for patients with IgA nephropathy and mild proteinuria (<1.0 g/day) is controversial, and the effectiveness of tonsillectomy plus steroid pulse therapy (TSP) for such patients remains obscure.

Methods

Among 323 patients in our multicenter cohort study, 79 who had mild proteinuria (0.4–1.0 g/day) at diagnosis were eligible to participate in this study. We compared the clinicopathological findings at diagnosis, a decline in renal function defined as a 50 or 100 % increase in serum creatinine (sCr) and clinical remission (CR) defined as the disappearance of hematuria and proteinuria (<0.3 g/day) among groups given TSP (n = 46), steroid therapy (ST) (n = 9), and non-ST (n = 24). Factors contributing to CR were also evaluated using multivariate analysis.

Results

Background factors at diagnosis including age, ratio (%) of patients with hypertension, sCr, proteinuria, and histological severity did not significantly differ among the groups. Only two patients each in the TSP (4.3 %) and non-ST (8.3 %) groups achieved a 50 % increase in sCr during a mean follow–up period of 4.7 years. At the final observation, 71.7, 44.4, and 41.7 % of patients in the TSP, ST, and non-ST groups, respectively, achieved CR (p = 0.032). Cox proportional hazards models revealed that TSP led to CR more effectively than non-TSP by a factor of about threefold (hazard ratio, 2.74; p = 0.008).

Conclusion

TSP therapy has potential for inducing CR in patients with IgAN and mild proteinuria (<1.0 g/day).

     

Gene polymorphisms contributing to hypertension in immunoglobulin A nephropathy

Background

Hypertension, which is affected by genetic and environmental factors, is one of the major risk factors for chronic kidney disease. Identification of the genetic factor contributing to hypertension in patients with chronic kidney disease may potentially refine a therapeutic strategy.

Methods

In the present multicenter cross-sectional study, 240 patients were eligible (aged 15?C50?years with urinary protein ??0.25?g/day) out of 429 patients who were diagnosed as having immunoglobulin (Ig) A nephropathy (IgAN) by renal biopsy between 1990 and 2005 and enrolled in our previous study, PREDICT-IgAN. The outcome was hypertension defined as ??140 and/or ??90?mmHg of systolic and diastolic blood pressure and/or use of antihypertensives at renal biopsy. We assessed associations between hypertension and 28 polymorphisms with the frequency of minor genotype ??10% among 100 atherosclerosis-related polymorphisms using the Chi-squared test in dominant and recessive models. We identified polymorphisms associated with hypertension in multivariate logistic regression models.

Results

Baseline characteristics: hypertension 36.3%. Among 28 polymorphisms, the Chi-squared test revealed that CD14 (-159CC vs CT/TT, P?=?0.03) and ACE (DD vs DI/II, P?=?0.03) were significantly associated with hypertension after Bonferroni correction. Multivariate logistic regression models revealed that CD14 -159CC [vs CT/TT, odds ratio (OR) 3.58 (95% confidence interval (CI) 1.66?C7.63)] and ACE DD [vs DI/II, OR 4.41 (95% CI 1.80?C10.8), P?=?0.001] were independently associated with hypertension.

Conclusions

CD14 C-159T and ACE I/D contributed to hypertension in patients with IgAN.     

Wachstumsprothesen zur Rekonstruktion von Defekten der unteren Extremit?ten beim Kind

Objective

Bone defect reconstruction with growing prostheses after resection of malignant bone tumors using the technique of extendable prostheses.

Indications

Limb salvage surgery after resection of primary malignant bone tumors in the growing skeleton for expected leg length deficiencies >?4?cm.

Contraindications

Palliative tumor resection, infection, systemic metastases at the time of diagnosis, social contraindications, lack of compliance of the patient and/or family.

Surgical technique

Wide resection of the tumor with resection of the biopsy location. Reconstruction with the growing prosthesis. Planned lengthening operations.

Postoperative management

Mobilization with crutches, weight bearing or partial weight bearing according the prosthesis?? fixation. Chemotherapy as defined in the chemotherapy protocol. Planned minimally invasive lengthening or noninvasive lengthening according to the type of growing module.

Results

Since 1969, more than 8,632?patients have been registered in the Vienna Bone and Soft Tissue Tumor Registry. Of these, 691?patients suffered from osteosarcoma and 243 from Ewing??s sarcoma. A total of 513?patients were <?18?years of age (54.4%). Since 1987, 71?patients have been treated with growing prostheses: 13?patients died of disease, and 44?patients reached maturity. The overall 5- and 10-year survival were 84% and 77%, respectively. The patient group consisted of 26?girls and 18?boys, mean age at surgery 10?±?3?years. The diagnosis was 34?osteosarcoma and 10?Ewing??s tumors. The patients had a mean of 4?±?3 elongation procedures to reach an elongation of 72.5?±?53.45?mm. The average elongation per procedure was 14.83?±?4.6?mm.     

Significance of docetaxel-based chemotherapy as treatment for metastatic castration-resistant prostate cancer in Japanese men over 75?years old

Objectives

The objective of this study was to evaluate the significance of docetaxel-based chemotherapy in elderly Japanese men with metastatic castration-resistant prostate cancer (CRPC).

Materials and methods

This study included a total of 159 consecutive patients aged ??75?years with mCRPC who were treated with docetaxel-based chemotherapy. The efficacy and tolerability of this therapy were retrospectively analyzed.

Results

In these 159 patients, the median age and prostate-specific antigen (PSA) level before docetaxel-based chemotherapy were 78?years and 44.0?ng/ml, respectively. Of these patients, 42 (26.4?%) and 117 (73.6?%) received docetaxel as a weekly (30?mg/m²) and 3-weekly (70?mg/m²) regimen, respectively, and estramustine was administered combining with docetaxel in 77 (48.4?%). Following docetaxel-based chemotherapy, PSA declined in 118 patients (74.3?%), including 87 (54.6?%) achieving a PSA decline ??50?%, and the median progression-free survival and overall survival (OS) were 2.9 and 23.2?months, respectively. Of several factors examined, univariate analysis identified performance status (PS), significant clinical pain, bone metastasis, schedule of treatment, treatment cycle, and PSA response as significant predictors of OS, of which only PS, treatment cycle, and PSA response appeared to be independently associated with OS on multivariate analysis. The major grade 3?C4 toxicities were myelosuppression, including neutropenia, anemia, and thrombocytopenia in 78 (49.1?%), 22 (13.8?%), and 14 (8.8?%), respectively.

Conclusions

These findings suggest that docetaxel-based chemotherapy is clinically feasible in Japanese men aged ??75?years with mCRPC considering the cancer control as well as safety associated with this therapy.     

Predictors for Microinvasion of Small Hepatocellular Carcinoma ≤2?cm

Background

Hepatocellular carcinoma (HCC) ??2?cm in diameter is considered to have a low potential for malignancy.

Methods

A retrospective review was undertaken of 149 patients with primary solitary HCC ??2?cm who underwent initial hepatic resection between 1994 and 2010. The independent predictors of the microinvasion (MI) such as portal venous, hepatic vein, or bile duct infiltration and/or intrahepatic metastasis were identified by multivariate analysis. Prognosis of patients with HCC ??2?cm accompanied by MI was compared to that of patients with HCC ??2?cm without MI.

Results

Forty-three patients with HCC ??2?cm had MI in patients (28.9%). Three independent predictors of the MI were revealed: invasive gross type (simple nodular type with extranodular growth or confluent multinodular type), des-??-carboxy prothrombin (DCP) >100?mAU/ml, and poorly differentiated. Disease-free survival rates of patients with HCC ??2?cm with MI (3?year 44%) were significantly worse than those for HCC ??2?cm without MI (3?year 72%). This disadvantage of disease-free survival rate of patients with HCC ??2?cm with MI could be dissolved by hepatic resection with a wide tumor margin of ??5?mm (P?=?0.04).

Conclusions

Even in cases of HCC ??2?cm, patients who are suspected of having invasive gross type tumors in preoperative imaging diagnosis or who have a high DCP level (>100?mAU/ml) are at risk for MI. Therefore, in such patients, hepatic resection with a wide tumor margin should be recommended.     

Safe Criteria for Less Radical Trachelectomy in Patients with Early-Stage Cervical Cancer: A Multicenter Clinicopathologic Study

Background

To determine the safe criteria for less radical trachelectomy to treat patients with early-stage cervical cancer.

Methods

We reviewed medical records and pathologic slides of 65 patients with International Federation of Gynecology and Obstetrics (FIGO) stage IA?CIB1 cervical cancer. The safe criteria for less radical trachelectomy were determined by using three factors such as tumor size ??1?cm, stromal invasion ??5?mm, and no lymphovascular space invasion (LVSI) for minimizing parametrial involvement, lymph node metastasis (LNM), and the need of adjuvant radiotherapy. The diagnostic values were investigated by calculating specificity, negative predictive value for no parametrial involvement, no LNM, and no need of adjuvant radiotherapy.

Results

The median age was 32?years (range 22?C44?years), and the median duration of follow-up was 26?months (range 2?C103?months). Among seven single or combined factors for the safe criteria, (1) tumor size ??1?cm, (2) tumor size ??1?cm and stromal invasion ??5?mm, (3) tumor size ??1?cm and no LVSI, (4) tumor size ??1?cm, stromal invasion ??5?mm, and no LVSI did not show parametrial involvement, LNM, and the need of adjuvant radiotherapy. In particular, tumor size ??1?cm showed the highest specificity (28.1?C29.5%) and negative predictive value (100%). In spite of no difference in progression-free survival (PFS) between tumor size ??1?cm and >1?cm (P?=?0.22), tumor size ??1?cm showed better PFS without disease recurrence than tumor size >1?cm (2-year PFS, 100% vs. 90%).

Conclusions

Less radical trachelectomy may be safe in patients with early-stage cervical cancer who have tumor size ??1?cm.     

Severity of nephrotic IgA nephropathy according to the Oxford classification

Background

IgA nephropathy with nephrotic syndrome (nephrotic IgAN) is a rare form of IgAN. Its prognosis and response to steroid therapy are still controversial because the differential diagnosis between nephrotic IgAN and minimal change nephrotic syndrome with IgA depositions is sometimes confused.

Methods

In this retrospective cohort analysis, we accurately diagnosed 42 cases of nephrotic IgAN (4.4%) from 954 IgAN patients, according to the Oxford classification. We analyzed the clinical and histological data, prognosis, and response to steroid therapy.

Results

In nephrotic IgAN, mean estimated glomerular filtration rate (eGFR) was 51.1?±?24.6?ml/min, proteinuria was 5.71?±?2.56?g/day, and urinary red blood cells were 51.0?±?37.8 high power field. Both active and chronic histological lesions were observed. Cumulative renal survival rate was significantly lower in nephrotic IgAN than in non-nephrotic IgAN (the control group consisted of 47 non-nephrotic IgAN patients diagnosed between 1995 and 1996) (log-rank test: P?Conclusion Nephrotic IgAN is a very severe form of IgAN, with renal dysfunction, massive hematuria, and active and chronic histopathological lesions. Renal outcome is severe; however, steroid therapy can improve prognosis in cases with higher eGFR and lower T-grade, according to the Oxford classification.     

Comparison between steroid pulse therapy alone and in combination with tonsillectomy for IgA nephropathy

Purpose

To the best of our knowledge, no study has compared intermittent steroid pulse therapy, according to Pozzi’s regimen, with versus without tonsillectomy.

Methods

In this retrospective cohort analysis, we compared clinical findings, histological findings according to the Oxford classification, and complete remission rates (RR), defined in terms of urinary protein excretion (U-Prot <0.3 g/g creatinine) and urinary red blood cell count (U-RBC <5/high-power field), after 1 year of treatment in patients with IgA nephropathy (IgAN), who received tonsillectomy with steroid pulse therapy (TSP group, n = 26) or steroid pulse therapy alone (SP group, n = 15).

Results

The baseline clinical and histological characteristics did not differ between the two groups. The RR for U-Prot analyzed by the Kaplan–Meier method did not differ between the groups (76.9 vs. 53.3 %). However, the RR for U-RBC was significantly higher in the TSP than in the SP group (88.4 vs. 33.3 %, log-rank test; P = 0.0008). The RRs for U-Prot and U-RBC were significantly higher in the TSP group than in the SP group (69.2 vs. 13.3 %, log-rank test; P = 0.0019). Cox’s regression analysis showed that combination therapy was associated with higher RR (odds ratio, 12.5; 95 % confidence interval, 2.91–86.7; P = 0.0002).

Conclusions

Tonsillectomy combined with steroid pulse therapy achieved higher RR after 1 year of treatment, compared with steroid pulse monotherapy in patients with IgAN. The long-term effects on renal survival should be analyzed in further studies.     

Histologically advanced IgA nephropathy treated successfully with prednisolone and cyclophosphamide

Background

No definitive therapeutic consensus has been established for progressive immunoglobulin A nephropathy (IgAN).

Methods

We retrospectively investigated 35 patients with histologically advanced IgAN. The patients were divided into two groups: 27 received prednisolone and cyclophosphamide (PSL+CPA group) and 8 received supportive treatment (control group). The initial doses of PSL and CPA were 30?mg/day and 50?mg/day, respectively. PSL was tapered to 2.5?mg/day over 2 years and CPA was discontinued at 6 months.

Results

In the control group, mean follow-up duration was 22.9 months, renal progression rate was ?20.9 × 10<συπ>?3?dl/mg per month, and all patients developed endstage renal disease within 5 years. In the PSL+CPA group, mean follow-up duration was 64.3 months, renal progression rate was ?1.5 × 10<συπ>?3?dl/mg per month, and renal survival at 5 years was 89.8%. Renal prognosis was markedly improved in the PSL+CPA group compared with the control group. The patients in the PSL+CPA group were divided into two subgroups according to baseline serum creatinine (<2?mg/dl or ≥2?mg/dl); renal survival in the two subgroups was similar (84.4% versus 100% at 5 years). Adverse effects of PSL+CPA were minimal and mild.

Conclusions

It is possible that PSL+CPA therapy safely improved the renal prognosis of patients with severe IgAN who would otherwise have required dialysis therapy within 5 years. However, a prospective, multicenter clinical trial is required to prove the effects and safety of this treatment.

     

Supplemented surgical management of resistant pulmonary mycobacterium tuberculosis, 6?years’ experience

Introduction

In patients with resistant pulmonary tuberculosis, proper anti-mycobacterial drugs, lung resection and manipulation of their living environment should result in sputum negativity. In published literature, 10?C15?% of patients continued to be sputum- smear or culture positive or developed a relapse after proper lung resection.

Objectives

The aim of current study was to review results of our surgically treated patients to definerate and possible causes of persistent or relapsing tuberculosis and also to evaluate the efficacy of a program of medical, surgical, physical and nutritional support that was offered to all patients.

Patients and methods

In spite of regular four-drug anti-tuberculosis regimen including rifampin and isonecotenic acid hydrazide for 90?days or more, the examined bronchial lavage was positive for tuberculosis in 167 patients. Consequently, they had lung resection surgery, continued proper medical treatment and a staff supervised manipulation of life style by physiotherapy, nutritional support and education on hygienic measures. Follow up examination and results of sputum smear were analyzed.

Results

After lung resection, four patients (2?%) had prolonged air leak and two(1?%) developed post-pneumonectomyempyema, One patient had a relapse of pulmonary tuberculosis and six(4?%) hadpersistently positive sputum smears. One of them developed broncho-pleural fistula and subsequently died.

Conclusions

Pulmonary resection combined with continuation of proper anti-tuberculous drugs and manipulation of the patient??s life style with nutritional support, education and physio-therapy improved results of lung resection in this group of patients.     

The complex of immunoglobulin A and uromodulin as a diagnostic marker for immunoglobulin A nephropathy

Background

The only tool to diagnose immunoglobulinn A nephropathy (IgAN) is renal biopsy which requires hospitalization; moreover, renal biopsy has a risk of critical bleeding. Therefore, a non-invasive method for accurate diagnosis of IgAN is desirable and a must-to-have tool for the clinics. For this purpose, we evaluated the diagnostic value of the IgA–uromodulin complex in the urine of patients with IgAN for its feasibility and adequacy.

Method

We determined the IgA–uromodulin complex as a candidate for a diagnostic marker of IgAN by immunoprecipitation, liquid chromatography?mass spectrometry (LC–MS) and Western blot analysis. The enzyme-linked immunosorbent assay (ELISA) for the IgA–uromodulin complex was developed and applied to urine samples obtained from various kidney disease patients.

Result

One hundred and three of 126 urine samples (81.7%) from IgAN patients were positive for the IgA–uromodulin complex, while only 25 out of 94 urine samples (26.6%) in other kidney disease patients were positive. Sensitivity was 81.7%, specificity was 73.4%, and diagnosis efficiency was 78.2%. The complex was negative in eight urine samples obtained from patients with Alport syndrome which is almost impossible to discriminate from IgAN by routine urinalysis.

Conclusion

Detection of the urinary IgA–uromodulin complex by ELISA is a useful non-invasive method to diagnose IgAN.     

Weight Loss Surgery for Mild to Moderate Obesity: A Systematic Review and Economic Evaluation

Background

A systematic review and economic evaluation was commissioned to determine the effectiveness and cost-effectiveness of bariatric surgery for mild [class I, body mass index (BMI) 30 to 34.99] or moderate (class II, BMI 35 to 39.99) obesity.

Methods

We searched 17 electronic resources (to February 2010) and other sources. Studies meeting predefined criteria were identified, data-extracted and assessed for risk of bias using standard methodology. A model was developed to estimate cost-effectiveness.

Results

Two RCTs were included. Evidence from both indicated a statistically significant benefit from laparoscopic adjustable banding (LAGB) compared to a non-surgical comparator for weight loss and in obesity-related comorbidity. Both interventions were associated with adverse events. LAGB costs more than non-surgical management. For people with class I or II obesity and type 2 diabetes (T2D), the incremental cost-effectiveness ratio (ICER) at 2?years is ??20,159, reducing to ??4,969 at 5?years and ??1,634 at 20?years. Resolution of T2D makes the greatest contribution to this reduction. In people with class I obesity, the ICER is ??63,156 at 2?years, ??17,158 at 5?years, and ??13,701 at 20?years. Cost-effectiveness results are particularly sensitive to utility gain from reduction in BMI, factors associated with poorer surgical performance and diabetes health state costs.

Conclusions

Bariatric surgery appears to be a clinically effective and cost-effective intervention for people with class I or II obesity who also have T2D but is less likely to be cost-effective for people with class I obesity.     

Fear of Recurrence and Perceived Survival Benefit are Primary Motivators for Choosing Mastectomy over Breast-Conservation Therapy Regardless of Age

Introduction

Recent studies have reported increases in the rate of mastectomy and contralateral prophylactic mastectomy (CPM). We hypothesized that there would be different reasons for choosing mastectomy for women aged <50 compared with those aged ??50?years.

Methods

A questionnaire was administered to 332 patients who underwent unilateral or bilateral mastectomy for breast cancer from 2006 to 2010. The survey queried on demographics, surgical choices, and rationale for those choices. A retrospective chart review was performed to determine tumor characteristics. Responses and clinical characteristics were described by contingency tables and compared using Fisher exact test or ??² test, as appropriate.

Results

Of 332 patients surveyed, 310 were evaluable. Median age was 55?years, including 88 patients <50 (28?%) and 222 patients ??50 (72?%) at time of diagnosis. Forty-four percent of women <50 and 41?% of women ??50 were given the option of breast conservation and chose mastectomy (p?>?0.63). The two groups did not differ in their reason for choosing mastectomy, with lower recurrence risk and improved survival cited as the two most common reasons. Younger patients were more likely to undergo reconstruction and CPM (p?p?Conclusions Choosing mastectomy and the reasons for doing so were the same for women aged <50 and ??50?years. Prospective studies are needed to determine whether patient education regarding perceived versus actual recurrence risk and survival would alter this decision-making process.     

Growth hormone improves growth in pediatric renal transplant recipients��a systemic review and meta-analysis of randomized controlled trials

Background

Growth hormone had been applied to treat pediatric renal allograft recipients with growth retardation. In this systemic review and meta-analysis, we assess the efficiency and safety of growth hormone use in post-renal transplant children.

Methods

A literature search revealed five prospective randomized controlled trials assessing this therapy, with a total of 401 patients. The outcomes, including the baseline height standard deviation score (HSDS), HSDS after a 1-year therapy, delta height standard deviation score (??HSDS), allograft rejection rates and changes in the glomerular filtration rates (GFR) were analyzed.

Results

Pooled data of the five studies showed that 1 year after the randomized controlled trials, the experimental group receiving growth hormone had a significantly higher growth velocity than the control group, with a mean HSDS difference of 0.68 [95?% confidence interval (CI) 0.25?C1.11, P?=?0.002] between the two groups. The mean difference in the ??HSDS between the treated and control group was 0.52 (95?% CI 0.37?C0.68, P?<?0.00001). The rejection episode rates were 35/205 and 19/185, respectively (number of patients with rejection/ total number of patients) (risk ratio 1.56, 95 % CI 0.97?C2.53, P?=?0.07), and the mean difference in the ??GFR was 3.27?ml/min per 1.73?m² (95 % CI ?3.54?C10.09, P?=?0.35), which was not statistically significant.

Conclusions

Based on these studies, we suggest that the application of growth hormone is an effective treatment to promote the growth velocity of children after kidney transplantation. However, the safety of this treatment needs further evaluation.