Efficacy and safety of tacrolimus versus corticosteroid as initial monotherapy in adult-onset minimal change disease: a meta-analysis

Objective

The objective of this meta-analysis was to compare the efficacy and safety of tacrolimus (TAC) monotherapy versus corticosteroid as initial monotherapy in adult-onset minimal change disease (MCD) patients.

Methods

Databases including PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure, and Wanfang database were searched from the inception to March 20, 2021. Eligible studies comparing TAC monotherapy and corticosteroid as initial monotherapy for adult-onset MCD patients were included. Data were analyzed using Review Manager Version 5.3.

Results

Four randomized controlled trials (RCTs) involving 196 patients were included in the meta-analysis. For initial monotherapy for adult-onset MCD, TAC and corticosteroid had similar complete remission (OR 1.06, 95% CI 0.47–2.41, P?=?0.89), total remission (OR 1.30, 95% CI 0.39–4.35, P?=?0.67), relapse rate (OR 0.63, 95% CI 0.28–1.42, P?=?0.26). Main drug-related adverse effects of two therapeutic regimens had no difference concerning infection (OR 0.54, 95% CI 0.23–1.27, P?=?0.15), glucose intolerance (OR 0.55, 95% CI 0.16–1.84, P?=?0.33) and acute renal failure (OR 1.37, 95% CI 0.36–7.31, P?=?0.71).

Conclusion

TAC monotherapy is comparable with corticosteroid monotherapy in initial therapy of MCD. To further confirm the conclusion, more large multicenter RCTs are necessary.

     

The relationship between survival rate and intradialytic blood pressure changes in maintenance hemodialysis patients

Objective: The objective of this study is to investigate the relationship between blood pressure changes and all-cause mortality, and between blood pressure changes and cardiovascular mortality, for maintenance hemodialysis (MHD) patients during dialysis.

Methods: Data regarding general condition, biochemical indices, and survival prognosis of MHD patients who were treated at the Shanghai Jiao Tong University School of Medicine-affiliated Renji Hospital from July 2007 to December 2012 were collected, in order to evaluate the relationship between patients’ blood pressure changes during hemodialysis and mortality.

Results: Among 364 patients, with an average age of 63.07?±?13.93?years, an average dialysis vintage of 76.00 (range, 42.25–134.00) months, and a follow-up time of 54.86?±?19.84?months, there were 85 cases (23.4%) of all-cause death and 46 cases (14.2%) of cardiovascular death. All-cause mortality and cardiovascular mortality were lowest (OR, 0.324 and 0.335; 95% CI, 0.152–0.692 and 0.123–0.911; p value, .004 and .032, respectively) in patients whose systolic blood pressure difference (ΔSBP) before and after dialysis was between 7.09 and 14.25?mmHg. Kaplan–Meier analysis indicated that both all-cause mortality and cardiovascular mortality were markedly increased for patients with ΔSBPless than ?0.25?mmHg (p value, .001 and .044, respectively). Cox regression analysis showed that ΔSBPKt/v and albumin were independent risk factors for all-cause mortality in MHD patients.

Conclusions: MHD patients whose blood pressure increased significantly after hemodialysis had a higher risk of dying; ΔSBP, hemoglobin concentration, Kt/v and albumin were independent risk factors for all-cause mortality in MHD patients.     

The efficacy and safety of immunosuppressive agents plus steroids compared with steroids alone in the treatment of Henoch–Schönlein purpura nephritis: A meta-analysis

Background

Henoch–Schönlein purpura nephritis (HSPN) is the most severe symptom of Henoch–Schönlein purpura. The role of immunosuppressive agents combined with steroids is controversial in treating HSPN. Our meta-analysis was performed to assess the efficacy and safety of the combined therapy in the treatment of HSPN compared with steroids alone.

Methods

Cochrane Library, Pubmed, Embase, and Web of Science were searched and Newcastle–Ottawa Scale was used to assess the quality of the literatures. Odds ratios (OR) and standard mean difference (SMD) with a 95% confidence interval (CI) were used for dichotomous and continuous variables. A random-effect model or fixed-effect analysis was applied according to heterogeneity.

Results

A total of 9 articles were selected in our study. HSPN patients treated with combined therapy demonstrated a significant increase in complete remission rates (OR?=?1.95; 95% CI 1.17–3.23, P?=?0.010) and total remission rates (OR?=?2.30 95% CI 1.33–3.98, P?=?0.003) when compared with steroids alone. Children seemed to benefit more from combined treatment (OR?=?2.45; CI 1.20–5.02, P?=?0.014) than adults (OR?=?1.56; CI 0.76–3.20, P?=?0.225). Additionally, immunosuppressants plus steroids had an advantage on decreasing proteinuria (SMD?=?0.28; CI 0.05–0.52, P?=?0.019) and increasing the level of serum albumin (SMD?=?0.98; CI 0.35–1.60, P?=?0.002). However, significant differences were not found in the estimated glomerular filtration rate (eGFR) and rates of side-effects.

Conclusion

Administration of immunosuppressive agents combined with steroids may be a superior alternative for HSPN. Nevertheless, long-term, high-quality, large-sample, and multicenter RCTs are required to make the results more convincing.

     

Correlation analysis of low-level serum uric acid and cardiovascular events in patients on peritoneal dialysis

Background

The impact of serum uric acid (SUA) on development of cardiovascular disease (CVD) in patients undergoing peritoneal dialysis (PD) remains controversial, especially the impact of hypouricemia (HUA) on CVD. The aim of our study was to investigate the influence of low-level SUA on cardiovascular (CV) events in PD patients.

Methods

A retrospective cohort study was conducted.728 PD patients from February 1, 2010 to May 31, 2019 were enrolled. All demographic and laboratory data were collected at baseline and 6 months after PD treatment. The study cohort was divided into four groups according to SUA level (μmol/L) after 6 months of PD: Group1 (<?360), Group2 (360–420), Group3 (420–480), Group4 (≥?480). The clinical characteristics of each group were analyzed. With Group2 as reference, logistic regression analysis was performed to investigate the correlation between SUA levels and risk of CV events in patients undergoing PD. Use Kaplan–Meier method to generate CV events risk graph.

Results

728 patients were enrolled in this study, including 403 (55.4%) males and 325 (44.6%) females, with an average age of 48.66?±?13.98 years; of which 158 (21.7%) patients developed CV events. Multivariate COX regression showed that after adjusting for multiple clinical factors, Group1 (HR?=?1.92, 95% CI 1.17–3.15, P?=?0.01), Group3 (HR?=?1.89, 95% CI 1.13–3.15, P?=?0.015), and Group4 (HR?=?2.38, 95% CI 1.35–4.19, P?=?0.003) are all independent risk factors for developing CV events. The Kaplan–Meier risk curve of CV events showed that the risk of CV events in the Group1, Group3 and Group4 were significantly higher (Log-Rank?=?12.67; P?=?0.005). Restricted cubic spline (RCS) showed that SUA level is non-linearly associated with the risk of CV events, showing an U-shaped curve (\(\chi_{4}^{2}\)=13.3 P?=?0.01).

Conclusions

Our study suggested that patients with SUA level less than 360 μmol/L also exhibited the higher risk for developing CV events, an U-shaped association between SUA level and risk of CV events in patients undergoing PD. Both SUA levels below 360 μmol/L and above 420 μmol/L were found to be significant risk factors for developing CV events in patients undergoing long-term PD.

     

Aortic pulse wave velocity is a strong predictor of all – cause and cardiovascular mortality in chronic dialysis patients

Background/Aims: The aim of this study was to investigate all-cause and cardiovascular mortality in chronic hemodialysis patients (CHP) and to identify the determinants of mortality predictors. Methods: In this study with 3 years of follow-up period, we studied a cohort of 80 CHPs. Mean age at entry was 59.3?±?11.8 years (duration of dialysis 5.47?±?5.16 years). At entry, together with standard clinical and biochemical analyses, pulse wave velocity (PWV) was determined from time diversity propagation of the common carotid artery and common femoral artery flow signals by Doppler ultrasound. Results: The mean PWV (m/s) was presented at entry: in survived (12.5?±?2.01) and deceased (13.13?±?1.70) patients. The PWV cutoff point (by ROC curves) was 11.8. The regression coefficients (b) and Exp (b) hazard ratio coefficients of covariates in Cox-regression survival analysis in all-cause and CV outcomes was: PWV (b?=?0.2617, Exp[b]?=?1.2992, p?=?0.0027; b?=?0.3569, Exp[b]?=?1.4289, p?=?0.0005), CRP (b?=?0.0776, Exp[b]?=?1.0807, p?=?0.0001; b?=?0.0832, Exp[b]?=?1.0868, p?=?0.0001) and albumin (b?=??0.1302, Exp[b]?=?0.8779, p?=?0.0089; b?=??0.1881, 0.8285, p?=?0.0030), respectively. Relative risk for exposed groups according to all-cause and CV events was 4.2976 (95% CI?=?1.6051–11.5071) and 14.3590 (95% CI?=?1.6051–11.5071), p?=?0.0037, respectively. Conclusions: We conclude that PWV, CRP and serum albumin are strong independent predictors of overall and CV mortality in patients undergoing dialysis.     

Recurrent acute kidney injury in elderly patients is common and associated with 1-year mortality

Background

Acute kidney injury (AKI) is common among elderly patients after a first hospitalized AKI. Patients who recover are at risk for recurrence, but recurrent geriatric AKI is not well-studied.

Methods

This was a retrospective, 12-month cohort study using data from the National Clinical Research Center for Geriatric Diseases. Recurrent AKI was defined as a new spontaneous rise of?≥?0.3 mg/dl (≥?26.5 µmol/L) within 48 h or a 50% increase in serum creatinine (Scr) from the baseline within 7 days after the previous AKI episode. The outcome measured was 12-month mortality.

Results

Among 1711 study patients, 652 developed AKI. Of the 429 AKI survivors in whom recovery could be assessed, 314 patients recovered to their baseline renal function, and 115 patients developed chronic kidney disease (CKD). Of the group that recovered renal function, 90 patients (28.7%) subsequently developed recurrent AKI, while 224 (71.3%) did not. Of the 429 survivors with AKI, 103 patients (24.0%) died within 12 months. Multivariate logistic regression analysis revealed that recurrent AKI was significantly associated with coronary disease (odds ratio [OR?=?2.008; 95% confidence interval [CI] 1.024–3.938; P?=?0.042), a need for mechanical ventilation (OR?=?2.265; 95% CI 1.267–4.051; P?=?0.006) and high blood urea nitrogen levels (OR?=?1.036; 95% CI 1.002–1.072; P?=?0.040) at the first AKI event. Kaplan–Meier curves showed the 12-month survival of patients with non-recurrent AKI was better than that of patients with CKD, and survival of patients with recurrent AKI was worse than that of patients with CKD (log rank P?<?0.001). In the multivariate Cox regression analysis, mortality at 12 month was higher in the patient with recurrent AKI as compared with those with a single episode (HR?=?3.375; 95% CI 2.241–5.083; P?<?0.001).

Conclusion

Recurrent AKI is common among elderly patients who recovered their renal function post-AKI and is associated with significantly higher 12-month mortality compared with CKD patients.

     

Potassium supplementation and long-term outcomes in chronic peritoneal dialysis patients with end-stage renal disease: a propensity score matching study

Objective: In this retrospective matched-cohort study, the association between potassium supplementation and long-term outcomes was determined.

Methods: Chronic peritoneal dialysis (PD) patients, aged ≥?16 years, being referred to four PD centers in China, with serum potassium levels ≤?3.5 mEq/L on three consecutive monthly in Q4 2008 and without receiving oral potassium supplementation in the prior three months were included in this study. Patients were divided into two groups, either to receive (test group) or not (control group) oral potassium supplementation in both Q4 2008 and the subsequent follow-up period, until 31 December 2014. The patients from the test group were matched to those from the control group using a propensity score. The clinical outcomes for all-cause and cardiovascular mortality were estimated by Matched Cox regression models during 61.5 months of median follow-up. All patients were also categorized according to serum potassium correction levels (<3.0, 3.0 to <4.0, 4.0 to <5.0 and ≥5.0 mEq/L) after the whole follow-up. The hazard ratios (HRs) were used to assess the relationship between corrected potassium levels and all-cause and cardiovascular mortality in PD patients. Subgroup analysis was used to determine the homogeneity of the associations between potassium supplementation and all-cause mortality.

Results: All-cause mortality occurred in 108 patients (605/10,000 person-years) in the test group and 114 patients (677/10,000 person-years) in the control group during 1786- and 1685-year follow-up, respectively [hazard ratio (HR), 0.89; 95% confidence interval (CI), 0.68–1.16; p?=?0.38]. Cardiovascular mortality occurred in 97 patients (542/10,000 person-years) in the test group and 101 patients (598/10,000 person-years) in the control group (HR, 0.89; 95% CI, 0.67–1.18; p?=?0.43). There were no significant interactions between potassium supplementation and any of the subgroups, except for diabetes mellitus and volume overload. During a median follow-up of 61.5 months, adjusted all-cause mortality hazard ratio (HR) and 95% confidence interval (CI) for corrected serum potassium of <3.0, 3.0 to Conclusion: The use of potassium supplementation in chronic PD patients is not associated with mortality. While it may be necessary for the correction of hypokalemia or the maintenance of normokalemia, and the consequent reduction of hypokalemia-associated mortality. Additionally, use of aldosterone antagonists may be preferable for the handling of hypokalemia in PD patients.     

Meta-analysis of statin therapy in maintenance dialysis patients

Abstract

The effects of statin therapy in patients on maintenance dialysis remained uncertain. We conducted a meta-analysis to investigate the effects of statin on major clinical outcomes. We systematically searched Pubmed, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure, Wanfang and Chinese Technological Journal of Database for randomized controlled trials (RCTs). Criteria for inclusion were RCTs on statins therapy versus placebo, >3 months of follow-up. The outcomes were serum level of low density lipoprotein-cholesterol (LDL-C), high-density lipoprotein-cholesterol (HDL-C), triglyceride (TG), high-sensitivity C-reactive protein (hs-CRP) and albumin (ALB), all cardiac events, cardiovascular deaths and all-cause mortality. Twenty-one trials were identified, providing data for 8186 patients on maintenance dialysis. Statin therapy reduced LDL-C (weighted mean difference [WMD]?=??0.74?mmol/L; 95%CI [?0.96,??0.52], p?<?0.00001), TG (WMD?=??0.36?mmol/L; 95%CI [?0.57,??0.14], p?=?0.001), and hs-CRP (WMD?=??3.98?mg/L; 95%CI [?5.24,??2.72], p?<?0.00001), elevated HDL-C (WMD?=?0.25?mmol/L; 95%CI [0.10,?0.39], p?=?0.0007) and ALB (WMD?=?1.70?g/L; 95%CI [0.19,?3.21], p?=?0.03) significantly comparing with placebo. Statin therapy also had benefit in reducing all cardiac events (relative risk [RR]?=?0.90; 95%CI [0.83,?0.97], p?=?0.006), but had no effect on cardiovascular deaths (RR?=?0.97; 95%CI [0.88,?1.07], p?=?0.54) or all-cause mortality (RR?=?0.98; 95%CI [0.93,?1.04], p?=?0.49). In conclusion, statins had no impact on all-cause or cardiovascular mortality, while there was an overall significant improvement for dyslipidemia, hs-CRP, hypoalbuminemia and cardiovascular events in dialysis patients.     

Intradialytic hypotension is associated with dialytic age in patients on chronic hemodialysis

Abstract

Objective: Intradialytic hypotension (IDH) is common in patients on chronic hemodialysis, but knowledge on determinants is still unclear. The present study aims at evaluating the association between IDH and dialytic age (DA) in patients on chronic hemodialysis. Methods: Between January 2012 and January 2013, 82 patients on chronic hemodialysis for at least 1?year were screened for inclusion in the present study. Of these, 14 were excluded because of advanced heart failure (n.9), history of alcohol/substance abuse (n.1), diagnosis of dementia (n.2), actual instability of clinical conditions requiring hospitalization (n.2). IDH was defined as a decrease in systolic blood pressure ≥20?mmHg or a decrease in mean arterial pressure (MAP) by 10?mmHg associated with clinical events and need for nursing interventions. The number of IDH episodes in 10 consecutive hemodialysis sessions was recorded for each patient. Linear and logistic regressions were adopted to assess the adjusted association between IDH and DA. Results: The mean DA was 92?±?81. Eleven patients (16%) experienced IDH. DA was associated with IDH (OR?=?1.01; 95% CI?=?1.01–1.02; p?=?0.048), after adjusting for potential confounders. DA was associated with the numbers of IDH events in the unadjusted model (B?=?0.02; 95% CI?=?0.01–0.03; p?=?0.042), after adjusting for age and sex (B?=?0.01; 95% CI?=?0.01–0.03; p?=?0.042) as well as in the multivariable model (B?=?0.02; 95% CI?=?0.01–0.05; p?=?0.045). Conclusion: DA is associated with an increased probability of IDH and with increased number of IHD events. Studies are needed to understand the underlying factors of such an association.     

Neutrophil–lymphocyte ratio predicts cardiovascular and all-cause mortality in hemodialysis patients

Neutrophil–lymphocyte ratio (NLR) is a marker of systemic inflammation that has been shown to predict mortality in patients with malignancies, ischemic heart disease and peripheral vascular disease. Its prognostic value in hemodialysis patients is unclear. The aims of this study were to: (i) explore the relationship between NLR and other biochemical parameters and (ii) to examine the value of NLR as a predictor of cardiovascular and all-cause mortality in hemodialysis patients. The study included all the incident hemodialysis patients from a single center between 2007 and 2012. NLR was calculated using samples obtained 3 months after commencing hemodialysis. One hundred seventy hemodialysis patients were included with a median follow-up of 37 months. There were 54 deaths (32%). NLR was positively correlated with C-reactive protein (r?=?0.24, p?=?0.0023) and negatively correlated with hemoglobin (r?=??0.27, p?=?0.00048), albumin (r?=??0.23, p?=?0.0034) and total cholesterol (r?=??0.17, p?=?0.049) levels. In multivariate Cox regression, NLR was independently associated with both all-cause mortality (adjusted hazard ratio [HR] 1.4; 95% confidence interval [CI], 1.2–1.6; p?≤?0.0001) and cardiovascular death (HR 1.3, 95% CI 1.1–1.6, p?=?0.0032). Other predictors of all-cause mortality were age (HR 1.6 per decade; 95% CI, 1.2–2.1; p?=?0.0017), body mass index (HR 0.93; 95% CI, 0.88–0.98; p?=?0.0047), albumin (HR 0.91; 95% CI, 0.86–0.97; p?=?0.0035) and peripheral vascular disease (HR 2.7; 95% CI, 1.4–5.1; p?=?0.0023). NLR is a practical, cost-efficient and easy to use predictor of cardiovascular and all-cause mortality in incident hemodialysis patients.     

Regression of left atrial diameter after kidney transplantation is associated with prolonged survival: an observational study

Renal transplantation reduces the dramatically elevated risk of cardiovascular death in dialysis patients. We previously showed that left atrial diameter before transplantation predicts cardiovascular and overall mortality. Now, we investigated the association of changes in cardiac morphology after transplantation and mortality. We retrospectively analyzed data from the Austrian transplant repository using multivariable Cox and competing risk models and multivariable logistic regression for the prediction of changes in cardiac morphology. We identified 414 patients with a median follow‐up of 8 years and observed a significant progression of mean diameter of left atrium (LA), right atrium and right ventricle and a significant regression of left ventricle. Complete case analysis of 243 patients with a regression of initially enlarged LA diameter had a significantly lower risk of adjusted overall and cardiovascular mortality; hazard ratio (HR 0.45, 95% CI 0.30–0.69, P < 0.001, 124 deaths), and HR of 0.43 [95% CI 0.21–0.92, P = 0.029, 48 cardiovascular (CV) deaths], respectively. Only age at transplantation was significantly associated with regression of LA (OR 0.75, 95% CI 0.60–0.93, P = 0.007). Patients with regression of LA after kidney transplantation exhibited a lower overall and CV mortality risk. Besides age, peritoneal dialysis and antihypertensive therapy were mediators of LA regression.     

Association of angiotensin-converting enzyme insertion/deletion polymorphism with type 1 diabetic nephropathy: a meta-analysis

Objective: This study aimed to systematically evaluate the effect of an angiotensin-converting enzyme (ACE) insertion/deletion (I/D) gene polymorphism on type 1 diabetic nephropathy (DN).

Methods: Cochrane Library, Embase, PubMed, Science Direct, Web of science, Wanfang data, VIP database, China Knowledge Resource Integrated Database, and SinoMed were searched. A total of 17 case–control studies analyzing ACE I/D polymorphism and type 1 DN risk were included in the present meta-analysis.

Results: Overall, a significant increased risk was found in allele comparison (OR?=?1.16, 95% CI?=?1.05–1.28, p?=?0.04), dominant comparison (OR?=?1.56, 95% CI?=?1.14–2.15, p?=?0.006) and homozygote comparison (OR?=?1.52, 95% CI?=?1.06–2.19, p?=?0.02). In subgroup analyses according to ethnicity, the risk of type 1 DN in Asian population was increased in allele comparison (OR?=?1.98, 95% CI?=?1.15–3.42, p?=?0.01), recessive comparison (OR?=?2.48, 95% CI?=?1.51–4.10, p?=?0.0004), dominant comparison (OR?=?3.15, 95% CI?=?1.90–5.23, p?p?=?0.05). However, there was no association between the ACE I/D genetic variants and type 1 DN in Caucasian populations.

Conclusions: Our meta-analysis results indicate that the ACE I/D polymorphism may contribute to type 1 DN development, especially in the Asian groups with type 1 diabetes. The current findings need to be confirmed by future well-designed and larger sample size primary studies in populations with different ethnicities.     

Effectiveness of renal-specific oral nutritional supplements compared with diet counseling in malnourished hemodialysis patients

Background

Malnutrition is highly prevalent and a consequence of inflammation and related comorbidities among patients on maintenance hemodialysis. Oral nutritional supplementation (ONS) is recommended for malnourished patients with kidney failure. The study aimed to evaluate renal-specific oral nutrition (ONCE dialyze) supplement on nutritional status in patients on hemodialysis.

Methods

Patients were randomized into 3 groups; treatment groups received 370 kcal/day of ONCE Dialyze (N?=?26) or 370 kcal/day of NEPRO (N?=?30) for 30 days. The control group (N?=?24) received no intervention. All patients were counseled by the same registered dietitian during the study. The nutritional status was evaluated using malnutrition inflammation score (MIS) assessment, body compositions, serum albumin and pre-albumin levels at baseline and 30 days.

Results

Eighty patients were analyzed with mean age of 57.2?±?15.9 years. The intervention group exhibited significant improvements in energy, protein, fat, fiber and magnesium intake by dietary interview compared with the control group. Percentage of changes in MIS was ? 29.0% (95% CI ? 40.5 to ? 17.4), ? 23.9% (95% CI ? 37.2 to ? 10.6) and 12.1% (95% CI ? 19.2 to 43.4) for the ONCE dialyze, NEPRO and control groups, respectively (overall P?=?0.006). Percentage of changes in serum albumin was 5.3% (95% CI 1.9–8.7), 3.3% (95% CI ? 0.1 to 6.7) and ? 0.8% (95% CI ? 4.3 to 2.7) for the ONCE dialyze, NEPRO, and control groups, respectively (overall P?=?0.039; P?=?0.043 for ONCE dialyze vs. control). No serious adverse effects were reported in any group.

Conclusion

Dietary advice combined with ONS especially ONCE dialyze was associated with improved MIS, serum albumin, dietary energy and macronutrient intake among patients with kidney failure on maintenance hemodialysis.

Clinical trial registration

TCTR20200801001.

     

The Association of Frailty with Outcomes after Cancer Surgery: A Systematic Review and Metaanalysis

Background

Cancer is common in older adults, who often have concurrent frailty. Frailty is a strong predictor of adverse outcomes in surgical patients. Our objective is to systematically review the association of frailty with postoperative mortality and other adverse outcomes in adult patients who have undergone nonemergency cancer surgery.

Methods

After registration (CRD42020171163), we systematically reviewed PubMed, MEDLINE, EMBASE, and CINAHL databases to identify all studies reporting an association between a preoperative frailty measurement and a relevant outcome (primary: all-cause mortality in-hospital or within 30 days of surgery; secondary outcomes: postoperative complications, length of stay, discharge disposition, mortality between 30 days and 1 year, postoperative function, and delirium). All stages of the review were completed in duplicate. Risk of bias was assessed using the Quality in Prognostic Studies (QUIPS) tool. Metaanalysis was used to pool effect estimates using random-effects models.

Results

A total of 2877 studies were identified, and 71 were included. Frailty was significantly associated with mortality within 30 days (adjusted odds ratio (OR) 3.02, 95% confidence interval (CI) 1.77–5.15), adverse discharge disposition (adjusted OR 2.14, 95% CI 1.52–3.02), postoperative complications (adjusted OR 2.39, 95% CI 1.64–3.49), longer-term mortality (unadjusted OR 4.32, 95% CI 2.15–8.67), and length of stay (mean difference 2.30, 95% CI 1.10–3.50). The number of studies presenting adequately adjusted estimates was small. Findings may be limited due to publication bias.

Conclusions

In adults having elective cancer surgery, frailty is strongly associated with adverse health outcomes. Preoperative frailty assessment should be considered in prognostication.

     

The influence of cardiac valvular calcification on all-cause and cardiovascular mortality in maintenance hemodialysis patients

Objective

To investigate the effect of cardiac valve calcification (CVC) on all-cause and cardiovascular mortality in maintenance hemodialysis (MHD) patients.

Methods

A retrospective cohort study was conducted in 183 long-term hemodialysis patients with complete follow-up data from January 1, 2012, to December 30, 2015. The baseline data between CVC and non-CVC groups were compared. Kaplan–Meier method was used to analyze all-cause and cardiovascular mortality. The effect of CVC on prognosis was analyzed using the Cox proportional hazard regression model and subgroup analysis.

Results

Among 183 patients under hemodialysis, 104 (56.8%) were males, with an average age of 56.1?±?17.0 years and 68 (37.2%) were complicated with valvular calcification. The median follow-up period was 30.8 months. All-cause and cardiovascular mortality were 50% vs. 14.8% and 25% vs. 7.0% in the CVC and non-CVC groups, respectively (P?<?0.05). Kaplan–Meier indicated that differences in all-cause and cardiovascular mortality were statistically significant between the two groups (P?<?0.001). Cox regression analysis showed that CVC significantly increased all-cause (hazards ratio [HR] 2.161 [1.083–4.315]) and cardiovascular mortality (3.435 [1.222–9.651]) after adjusting for multiple factors. Meanwhile, CVC also increases the incidence of new-onset cardiovascular events. Subgroup analysis revealed that all-cause and cardiovascular mortality were significantly higher in patients with aortic valve calcification (AVC) than in patients with mitral valve calcification (MVC). Multivariate calibration showed that AVC increased the risk of cardiovascular death (HR 5.486 [1.802–16.702]) (P?<?0.05), whereas MVC did not. By further comparing the echocardiographic data of the two groups, the incidence of LVH and pulmonary hypertension in the AVC group was significantly higher than that in the MVC group.

Conclusion

Valve calcification increases the risk of all-cause and cardiovascular mortality in MHD patients, also new-onset cardiovascular events, and aortic valve calcification contributes more to the risk of cardiovascular mortality.

     

Effect of calcium channels blockers and inhibitors of the renin-angiotensin system on renal outcomes and mortality in patients suffering from chronic kidney disease: systematic review and meta-analysis

Background: The renoprotective effect of inhibitors of renin-angiotensin system (RAS) has been identified through placebo-controlled trials. However, the effect of calcium-channel blockers (CCBs) on renal system is still controversial. Our current meta-analysis includes available evidences to compare the effect of dihydropyridine CCBs and ACEIs or ARBs on renal outcomes and mortality. We also further investigate whether CCBs can be used in combination with inhibitors of RAS to improve the prognosis of patients with chronic kidney disease (CKD). Methods and results: Electronic databases were searched up to July 2012, for clinical randomized controlled trials, assessing the effect of dihydropyridine CCBs on the incidence of end-stage renal disease (ESRD) and all-cause mortality in contrast to ACEIs or ARBs. Eight clinical trials were included containing 25,647 participants. ESRD showed significantly higher frequency with CCBs therapy compared with ACEIs or ARBs therapy, though blood pressure was decreased similarly in both groups in every trial (OR, 1.25; 95% CI, 1.05–1.48; p?=?0.01). In contrast, there was no significant difference in the incidence of all-cause mortality between these two groups, though ACEIs or ARBs exhibited better renoprotective effect compared to CCBs (OR, 0.96; 95% CI, 0.89–1.03; p?=?0.24). Conclusions: CCBs did not increase all-cause mortality incidence in patients with CKD though they displayed weaker renoprotective, compared to ACEIs or ARBs therapy. Our results suggest the combination of a CCB and an ACEI or ARB should be a preferable antihypertensive therapy in patients with CKD, considering their higher effect in decreasing blood pressure and fewer adverse metabolic problems caused.     

Feasibility of E-PASS score to predict postoperative complications in laparoscopic nephrectomy

Purpose

To evaluate the usefulness of E-PASS score to predict postoperative complications after laparoscopic nephrectomy.

Methods

Between 2008 and 2020, 424 patients (179 patients: simple nephrectomy, 158 patients: radical nephrectomy, 87 patients: donor nephrectomy) who underwent laparoscopic nephrectomy in our clinic, were included in the study. Patient groups separated according to the presence of postoperative complications were compared retrospectively regarding demographic, clinical, intraoperative, and postoperative data, comorbidities, and E-PASS scores (PRS, SSS, and CRS). The relationship between postoperative complications and E-PASS scores was examined.

Results

Postoperative complications occurred in 43 (10.1%) of the patients. Age, previous abdominal/retroperitoneal surgery, radical nephrectomy rate of surgeries, operation time, amount of bleeding, need for blood transfusion, rate of conversion from laparoscopic surgery to open surgery, hospitalization time, E-PASS PRS, SSS, and CRS were statistically significantly higher in the group with postoperative complications. The cutoff value of the E-PASS CRS was ? 0.2996 to predict the development of postoperative complications (AUC?=?0.706; 95% CI 0.629–0.783; p?<?0.001). According to multivariate analysis, presence of previous abdominal/retroperitoneal surgery (OR?2.977; 95% CI?1.502–5.899; p?=?0.002), laparoscopic radical nephrectomy (OR?2.518; 95% CI?1.224–5.179; p?=?0.012), conversion from laparoscopic surgery to open surgery (OR?4.869; 95% CI?1.046–22.669; p?=?0.044) and E-PASS CRS?>?? 0.2996 (OR?2.816; 95% CI?1.321–6.004; p?=?0.007) were found to be independent risk factors predicting postoperative complications.

Conclusion

The E-PASS scoring system is an effective and convenient system for predicting postoperative complications after laparoscopic nephrectomy.

     

Video-assisted thoracoscopic surgery thymectomy versus open thymectomy in patients with myasthenia gravis: a meta-analysis

Background: Video-assisted thoracoscopic surgery (VATS) thymectomy has become a feasible treatment for myasthenia gravis (MG) in recent years. The objective of the present meta-analysis was to evaluate the perioperative characteristics, safety, and completely stable remission rate in patients with MG who received VATS or open thymectomy (OT).

Methods: We searched PubMed, Embase, ScienceDirect, Web of Science, and CNKI for related articles using combinations of the search terms video-assisted thoracoscopic thymectomy, transsternal thymectomy, and MG. The inter-study heterogeneity was assessed by χ²-based Q statistics, and the extent of inconsistency was generated by I² statistics.

Results: A total of 12 studies with 1173 patients were included, and there was no difference in the operation time (p?=?0.08) and ICU time (p?=?0.14) between the two groups, but VATS thymectomy was associated with less intra-operation blood loss and hospital time (p?p?=?0.03) and myasthenic crisis (OR = 0.51; 95% CI, 0.28–0.92; p?=?0.03), but the rates of pneumonia (OR = 0.59; 95% CI, 0.29–1.32; p?=?0.21) and complete remission rate (CSR) (OR = 0.64; 95% CI, 0.38–1.09; p?=?0.10) had no obvious differences between the VATS and OT groups.

Conclusion: Patients with MG undergoing VATS thymectomy achieved better surgical outcomes and fewer complications than those who received OT.     

The Obesity Paradox in the Trauma Patient: Normal May not Be Better

Objective

The obesity paradox is the association of increased survival for overweight and obese patients compared to normal and underweight patients, despite an increased risk of morbidity. The obesity paradox has been demonstrated in many disease states but has yet to be studied in trauma. The objective of this study is to elucidate the presence of the obesity paradox in trauma patients by evaluating the association between BMI and outcomes.

Methods

Using the 2014–2015 National Trauma Database (NTDB), adults were categorized by WHO BMI category. Logistic regression was used to assess the odds of mortality associated with each category, adjusting for statistically significant covariables. Length of stay (LOS), ICU LOS and ventilator days were also analyzed, adjusting for statistically significant covariables.

Results

A total of 415,807 patients were identified. Underweight patients had increased odds of mortality (OR 1.378, p < 0.001 95% CI 1.252–1.514), while being overweight had a protective effect (OR 0.916, p = 0.002 95% CI 0.867–0.968). Class I obesity was not associated with increased mortality compared to normal weight (OR 1.013, p = 0.707 95% CI 0.946–1.085). Class II and Class III obesity were associated with increased mortality risk (Class II OR 1.178, p = 0.001 95% CI 1.069–1.299; Class III OR 1.515, p < 0.001 95% CI 1.368–1.677). Hospital and ICU LOS increased with each successive increase in BMI category above normal weight. Obesity was associated with increased ventilator days; Class I obese patients had a 22% increase in ventilator days (IRR 1.217 95% CI 1.171–1.263), and Class III obese patients had a 54% increase (IRR 1.536 95% CI 1.450–1.627).

Conclusion

The obesity paradox exists in trauma patients. Further investigation is needed to elucidate what specific phenotypic aspects confer this benefit and how these can enhance patient care.

Level of evidence

Level III, prognostic study

     

The Frequency and Outcome of Acute Kidney Injury in a Tertiary Hospital: Which Factors Affect Mortality?

Acute kidney injury (AKI) is a major cause of mortality and morbidity in hospitalized patients. Incidence and mortality rates vary from country to country, and according to different in‐hospital monitoring units and definitions of AKI. The aim of this study was to determine factors affecting frequency of AKI and mortality in our hospital. We retrospectively evaluated data for 1550 patients diagnosed with AKI and 788 patients meeting the Kidney Disease: Improving Global Outcomes (KDIGO) guideline AKI criteria out of a total of 174 852 patients hospitalized in our institution between January 1, 2007 and December 31, 2012. Staging was performed based on KDIGO Clinical Practice for Acute Kidney Injury and RIFLE (Risk, Injury, Failure, Loss of kidney function and End‐stage renal failure). Demographic and biochemical data were recorded and correlations with mortality were assessed. The frequency of AKI in our hospital was 0.9%, with an in‐hospital mortality rate of 34.6%. At multivariate analysis, diastolic blood pressure (OR 0.89, 95% CI 0.87–0.92; P < 0.001), monitoring in the intensive care unit (OR 0.18, 95% CI 0.09–0.38; P < 0.001), urine output (OR 4.00, 95% CI 2.03–7.89; P < 0.001), duration of oliguria (OR 1.51, 95% CI 1.34–1.69; P < 0.001), length of hospitalization (OR 0.83, 95% CI 0.79–0.88; P < 0.001), dialysis requirement (OR 2.30, 95% CI 1.12–4.71; P < 0.05), APACHE II score (OR 1.16, 95% CI 1.09–1.24; P < 0.001), and albumin level (OR 0.32, 95% CI 0.21–0.50; P < 0.001) were identified as independent determinants affecting mortality. Frequency of AKI and associated mortality rates in our regional reference hospital were compatible with those in the literature. This study shows that KDIGO criteria are more sensitive in determining AKI. Mortality was not correlated with staging based on RIFLE or KDIGO. Nonetheless, our identification of urine output as one of the independent determinants of mortality suggests that this parameter should be used in assessing the correlation between staging and mortality.