Removal of kidney stones by extracorporeal shock wave lithotripsy is associated with delayed progression of chronic kidney disease

Purpose

This study aimed to elucidate whether stone removal by extracorporeal shock wave lithotripsy (ESWL) is associated with delayed chronic kidney disease (CKD) progression.

Materials and Methods

We conducted a retrospective analysis of 131 nephrolithiasis patients with stage 3 and 4 CKD. We collected baseline clinical and laboratory data, kidney stone characteristics, and history of receiving ESWL. We classified study patients into two groups according to whether they underwent ESWL or not (Non-ESWL group vs. ESWL group). We initially compared annual estimated glomerular filtration rate (eGFR) changes of Non-ESWL group with those of ESWL group before undergoing ESWL. In the next step, we sought to compare annual eGFR changes in the same patients before and after ESWL. Finally, we compared annual eGFR changes between success and failure groups among patients undergoing ESWL.

Results

The mean age of the patients was 62 years and 72.5% were male. The mean observation period was 3.2 years. Non-ESWL group and ESWL group before undergoing ESWL showed similar annual eGFR changes (-1.75±6.5 vs. -1.63±7.2 mL/min/1.73 m²/year, p=0.425). However, eGFR declined slower after undergoing ESWL than before ESWL (annual eGFR changes, -0.29±6.1 vs. -1.63±7.2 mL/min/1.73 m²/year, p<0.05). In addition, among patients in ESWL group, eGFR declined faster in the failure group than in the success group (annual eGFR change, -1.01±4.7 vs. -0.05±5.2 mL/min/1.73 m²/year, p<0.05).

Conclusion

Our results suggest that stone removal by ESWL is associated with delayed deterioration of renal function in CKD patients with nephrolithiasis.     

Assessment of deceased donor kidneys using a donor scoring system

Purpose

Marginal grafts should be used more actively in Asian countries where deceased donor transplantation is unpopular. We modified a quantitative donor scoring system proposed by Nyberg and his colleagues and developed a donor scoring system in order to assess the quality of deceased donor grafts and their prognostic value as an initial effort to promote usage of marginal donors.

Materials and Methods

We retrospectively evaluated 337 patients.

Results

A scoring system was derived from six donor variables [age, 0-25; renal function, 0-4; history of hypertension, 0-4; Human Leukocyte Antigen (HLA) mismatch, 0-3; body weight, 0-1; cause of death, 0-3 points]. Donor grafts were stratified by scores: grade A, 0-10; grade B, 11-20; grade C, 21-30; and grade D, 31-40 points. Donor grades significantly correlated with estimated glomerular filtration rate (eGFR) at 6 months (A, 64.0 mL/min/1.73 m²; B, 57.0 mL/min/1.73 m²; C, 46.8 mL/min/1.73 m²; p < 0.001). The five-year graft survival rate was also lower in grade C than grade A (74% vs. 93%, p = 0.002). Donors in grade C and D were regarded as marginal donors. The proportion of marginal donors was much lower in Korea, compared with data from the United Network for Organ Sharing (15.2% vs. 29%).

Conclusion

Considering the scarcity of deceased donor kidneys and the relatively better graft outcome with lower grade-donors in Korea, it is worth increasing the usage of marginal grafts.     

Impact of Renal Dysfunction on Clinical Outcomes of Acute Coronary Syndrome

Purpose

The present study aimed to compare the clinical outcomes and to investigate prognostic factors of acute coronary syndrome (ACS) in patients with renal dysfunction (RD).

Materials and Methods

The study was a retrospective cohort of 648 adult patients admitted with ACS between October 2005 and December 2006. The estimated glomerular filtration rate (GFR) was classified into 4 levels: 1) normal, GFR greater than 90 mL/min/1.73 m²; 2) mild RD, GFR of 60 to 90 mL/min/1.73 m²; 3) moderate RD, GFR of 30 to 60 mL/min/1.73 m²; and 4) severe RD, GFR less than 30 mL/min/1.73 m². Primary end points were death and complication in hospital courses. Secondary end points were major adverse cardiac event (MACE) during follow-up.

Results

The median follow-up was 505 ± 183 days, the mean age was 63 ± 12 years, and 71.8 percent of the group were men. A graded association was observed between severity of RD and clinical outcomes. Severe RD independently predicted MACE [hazard ratio, 2.731; 95% confidence interval (CI), 1.058 to 7.047, p = 0.038]. Low hemoglobin level was also an independent risk factor for MACE (hazard ratio, 1.155; 95% CI, 1.020 to 1.307, p = 0.022). Use of lipid-lowering therapy (hazard ratio, 0.456; 95% CI, 0.242 to 0.857, p = 0.015) was associated with reduced risk for MACE.

Conclusion

Severe RD and low hemoglobin level were an independent risk factors for the mortality and complications of ACS, while lipid-lowering therapy was associated with reduced risk.     

Renal function in children with congenital neurogenic bladder

AIMS:

Preservation of renal function in children with congenital neurogenic bladder is an important goal of treatment for the disease. This study analyzed the evolution of renal function in patients with congenital neurogenic bladder.

METHODS:

We reviewed the records of 58 pediatric patients with respect to the following attributes: gender, age, etiology of neurogenic bladder, reason for referral, medical/surgical management, episodes of treated urinary tract infections, urodynamics, DMSA scintigraphy, weight, height, blood pressure, glomerular filtration rate, microalbuminuria and metabolic acidosis. Statistical analysis was performed, adopting the 5% significance level.

RESULTS:

The mean age at presentation was 4.2 ± 3.5 years. Myelomeningocele was the most frequent etiology (71.4%). Recurrent urinary tract infection was the reason for referral in 82.8% of the patients. Recurrent urinary tract infections were diagnosed in 84.5% of the patients initially; 83.7% of those patients experienced improvement during follow‐up. The initial mean glomerular filtration rate was 146.7 ± 70.1 mL/1.73 m²/min, and the final mean was 193.6 ± 93.6 mL/1.73 m²/min, p  =  0.0004. Microalbuminuria was diagnosed in 54.1% of the patients initially and in 69% in the final evaluation. Metabolic acidosis was present in 19% of the patients initially and in 32.8% in the final assessment.

CONCLUSIONS:

Patient referral to a pediatric nephrologist was late. A reduction in the number of urinary tract infections was observed with adequate treatment, but microalbuminuria and metabolic acidosis occurred frequently despite adequate management.     

Concomitant Impact of High-Sensitivity C-Reactive Protein and Renal Dysfunction in Patients with Acute Myocardial Infarction

Purpose

The present study aimed to investigate the impact of high-sensitivity C-reactive protein (hs-CRP) and renal dysfunction on clinical outcomes in acute myocardial infarction (AMI) patients.

Materials and Methods

The study involved a retrospective cohort of 8332 patients admitted with AMI. The participants were divided into 4 groups according to the levels of estimated glomerular filtration rate (eGFR) and hs-CRP: group I, no renal dysfunction (eGFR ≥60 mL·min^-1·1.73 m^-2) with low hs-CRP (≤2.0 mg/dL); group II, no renal dysfunction with high hs-CRP; group III, renal dysfunction with low hs-CRP; and group IV, renal dysfunction with high hs-CRP. We compared major adverse cardiac events (MACE) over a 1-year follow-up period.

Results

The 4 groups demonstrated a graded association with increased MACE rates (group I, 8.8%; group II, 13.8%; group III, 18.6%; group IV, 30.1%; p<0.001). In a Cox proportional hazards model, mortality at 12 months increased in groups II, III, and IV compared with group I [hazard ratio (HR) 2.038, 95% confidence interval (CI) 1.450-2.863, p<0.001; HR 3.003, 95% CI 2.269-3.974, p<0.001; HR 5.087, 95% CI 3.755-6.891, p<0.001].

Conclusion

High hs-CRP, especially in association with renal dysfunction, is related to the occurrence of composite MACE, and indicates poor prognosis in AMI patients.     

The relationship between coronary artery calcification and renal function in nondialyzed patients

Purpose

Coronary artery calcification (CAC) has been described in individuals with chronic kidney disease (CKD), and its presence is associated with an increased risk of cardiovascular death. However, it is unclear whether there is an independent relationship between renal function and CAC. Therefore, we evaluated the association between renal function and CAC.

Materials and Methods

We retrospectively reviewed 870 Korean patients who had undergone computed tomographic coronary angiography. The glomerular filtration rate (GFR) was estimated using the Modification of Diet in Renal Disease study formula with an ethnic factor for the Korean population. The CKD stages were classified using estimated GFR (eGFR) and proteinuria.

Results

The mean age of the participants was 56.8±11.8 years, and the mean eGFR was 89.4±16.5 mL/min/1.73 m². Hypertension and diabetes were noted in 41.5 and 17.0% of patients, respectively. There were 584 and 286 patients with no CAC and with CAC, respectively. After adjusting for confounding variables, late stage CKD was associated with CAC [odds ratio (OR) 2.80, 95% confidence interval (CI) 1.05-7.46]. However, early stage CKD was not associated with CAC (OR 1.61, 95% CI 0.92-2.82). Diabetes was an independent risk factor of CAC (OR 2.06, 95% CI 1.36-3.13). There was no significant association between proteinuria and CAC (OR 1.65, 95% CI 0.96-2.85).

Conclusion

CAC is related to late stage CKD in nondialyzed patients. These findings emphasize that individuals with CAC should be considered a high-risk population for decreased renal function.     

Effect of shared care on blood pressure in patients with chronic kidney disease: a cluster randomised controlled trial

Background

Chronic kidney disease (CKD) is highly prevalent in patients with diabetes or hypertension in primary care. A shared care model could improve quality of care in these patients

Aim

To assess the effect of a shared care model in managing patients with CKD who also have diabetes or hypertension.

Design and setting

A cluster randomised controlled trial in nine general practices in The Netherlands.

Method

Five practices were allocated to the shared care model and four practices to usual care for 1 year. Primary outcome was the achievement of blood pressure targets (130/80 mmHg) and lowering of blood pressure in patients with diabetes mellitus or hypertension and an estimated glomerular filtration rate (eGFR)<60ml/min/1.73m².

Results

Data of 90 intervention and 74 control patients could be analysed. Blood pressure in the intervention group decreased with 8.1 (95% CI = 4.8 to 11.3)/1.1 (95% CI = −1.0 to 3.2) compared to −0.2 (95% CI = −3.8 to 3.3)/−0.5 (95% CI = −2.9 to 1.8) in the control group. Use of lipid-lowering drugs, angiotensin-system inhibitors and vitamin D was higher in the intervention group than in the control group (73% versus 51%, 81% versus 64%, and 15% versus 1%, respectively, [P = 0.004, P = 0.01, and P = 0.002]).

Conclusion

A shared care model between GP, nurse practitioner and nephrologist is beneficial in reducing systolic blood pressure in patients with CKD in primary care.     

Proteinuria as a Risk Factor for Mortality in Patients with Colorectal Cancer

Purpose

We investigated the effects of proteinuria and renal insufficiency on all-cause mortality in patients with colorectal cancer, with special emphasis on cancer staging and cancer-related deaths.

Materials and Methods

We retrospectively studied a cohort of patients with colorectal cancer. In protocol 1, patients were classified into four groups based on the operability of cancer and proteinuria: group 1, early-stage cancer patients (colorectal cancer stage ≤3) without proteinuria; group 2, early-stage cancer patients with proteinuria; group 3, advanced-stage cancer patients without proteinuria (colorectal cancer stage=4); and group 4, advanced-stage cancer patients with proteinuria. In protocol 2, patients were classified into four similar groups based on cancer staging and renal insufficiency (eGFR <60 mL/min/1.73 m²). Between January 1, 1998 and December 31, 2009, 3379 patients were enrolled in this cohort and followed until May 1, 2012 or until death.

Results

The number of patients with proteinuria was 495 (14.6%). The prevalence of proteinuria was higher in advanced-stage cancer (n=151, 22.3%) than in early-stage cancer patients (n=344, 12.7%). After adjusting for age, gender and other clinical variables, the proteinuric, early-stage cancer group was shown to be associated with an adjusted hazard ratio of 1.67 and a 95% confidence interval of 1.38-2.01, compared with non-proteinuric early-stage cancer patients. However, renal insufficiency was not associated with colorectal cancer mortality.

Conclusion

Proteinuria is an important risk factor for cancer mortality, especially in relatively early colorectal cancer.     

Treatment needs and diagnosis awareness in primary care patients with chronic kidney disease

Background

GPs in England are required to keep a register of patients with chronic kidney disease (CKD). National Institute for Health and Clinical Excellence (NICE) guidelines recommend regular follow-up, but patients are perceived to be low risk and not requiring active management.

Aim

To assess treatment needs of CKD stage 3 patients in primary care, as well as their awareness of CKD.

Design and setting

A cross-sectional analysis from a longitudinal prospective study in 32 general practices.

Method

A total of 1741 participants underwent clinical assessment including urine and blood tests. Participants were asked about awareness of their CKD. Results were reviewed and a letter recommending treatment in line with NICE guidelines was sent to their GP.

Results

The mean age of participants was 73 ± 9 years; 60% (n = 1052) were female and diabetes was present in 17%; 67% of participants required further intervention. Most required improved control of hypertension (n = 1576; 33.1% of cohort). Other recommendations included advice to investigate anaemia (n = 1142; 8.2%) or stop nephrotoxic drugs (n = 1120; 7.5%). Less than 6% of participants met NICE criteria for referral to nephrology services and 41% were unaware of their CKD diagnosis. Multivariable analysis identified subjects with formal educational qualifications, age <75 years, estimated glomerular filtration rate (eGFR) 30–44 ml/min/1.73 m², and significant albuminuria as more likely to be aware of their diagnosis.

Conclusion

The study data show that the majority of patients required at least one intervention to improve the management of their CKD. Most interventions could be delivered in primary care and only a minority required nephrology referral. Many patients were unaware of their CKD diagnosis, and efforts should be made to improve this to facilitate involvement in their care.     

Glomerular Filtration Rate Measured by 51Cr-EDTA Clearance: Evaluation of Captopril-Induced Changes in Hypertensive Patients with and without Renal Artery Stenosis

INTRODUCTION:

Renal artery stenosis can lead to renovascular hypertension; however, the detection of stenosis alone does not guarantee the presence of renovascular hypertension. Renovascular hypertension depends on activation of the renin-angiotensin system, which can be detected by functional tests such as captopril renal scintigraphy. A method that allows direct measurement of the baseline and post-captopril glomerular filtration rate using chromium-51 labeled ethylenediamine tetraacetic acid (⁵¹Cr-EDTA) could add valuable information to the investigation of hypertensive patients with renal artery stenosis. The purposes of this study were to create a protocol to measure the baseline and post-captopril glomerular filtration rate using ⁵¹Cr-EDTA, and to verify whether changes in the glomerular filtration rate permit differentiation between hypertensive patients with and without renal artery stenosis.

METHODS:

This prospective study included 41 consecutive patients with poorly controlled severe hypertension. All patients had undergone a radiological investigation of renal artery stenosis within the month prior to their inclusion. The patients were divided into two groups: patients with (n=21) and without renal artery stenosis, (n=20). In vitro glomerular filtration rate analysis (⁵¹Cr-EDTA) and ^99mTc-DMSA scintigraphy were performed before and after captopril administration in all patients.

RESULTS:

The mean baseline glomerular filtration rate was 48.6±21.8 ml/kg/1.73 m² in the group wuth renal artery stenosis, which was significantly lower than the GFR of 65.1±28.7 ml/kg/1.73m² in the group without renal artery stenosis (p=0.04). Captopril induced a significant reduction of the glomerular filtration rate in the group with renal artery stenosis (to 32.6±14.8 ml/ kg/1.73m², p=0.001) and an insignificant change in the group without RAS (to 62.2±23.6 ml/kg/1.73m², p=0.68). Scintigraphy with technetium-99m dimercapto-succinic acid (DMSA) did not show significant differences in differential renal function from baseline to post-captopril images in either group.

CONCLUSIONS:

Captopril induced a decrease in the GFR that could be quantitatively measured with ⁵¹Cr-EDTA. The reduction is more pronounced in hypertensive patients with RAS.     

Effect of Peritoneal Dialysis Modality on the 1-Year Rate of Decline of Residual Renal Function

Purpose

The effect of different peritoneal dialysis (PD) modalities on the decline in residual renal function (RRF) is unclear due to inconsistencies among studies. In particular, the effect of automated peritoneal dialysis (APD) modalities [continuous cyclic peritoneal dialysis (CCPD) and nightly intermittent peritoneal dialysis (NIPD)] on RRF has not been examined in a large cohort.

Materials and Methods

We conducted a single-center retrospective study to investigate the association between PD modalities and decline in RRF in 142 incident PD patients [34 on CCPD, 36 on NIPD, and 72 on continuous ambulatory peritoneal dialysis (CAPD)]. RRF was measured within 2 months from PD start and at 1 year after PD initiation.

Results

The RRF at 1 year after PD initiation was 1.98±2.20 mL/min/1.73 m² in CCPD patients and 3.63±3.67 mL/min/1.73 m² in NIPD patients, which were moderately lower than 4.23±3.51 mL/min/1.73 m² in CAPD patients (p=0.064). Moreover, there was no significant difference in the 1-year rate of decline of RRF between CCPD and NIPD patients, although APD patients had a faster 1-year RRF decline rate than CAPD patients (CCPD and NIPD vs. CAPD: -45.68 and -36.69 vs. 1.17%/year, p=0.045). APD was associated with a more rapid decline in RRF in patients with end-stage renal disease undergoing PD, although multivariate analysis attenuated the significance of this finding (β=-31.50; 95% CI, -63.61 to 0.62; p=0.052).

Conclusion

Our results suggest that CAPD might be more helpful than APD for preserving RRF during the first year of dialysis therapy, although there was no significant difference in the 1-year rate of decline of RRF between the two APD modalities.     

IMproving the imPlemEntation of cuRrent guidelines for the mAnagement of major coronary hearT disease rIsk factors by multifactorial interVEntion. The IMPERATIVE renal analysis

Introduction

The short-term effects of multifactorial intervention for cardiovascular disease (CVD) prevention on renal function and serum uric acid (SUA) levels in patients with stage 3 chronic kidney disease (CKD) and multiple CVD risk factors are unclear. The aim of the study was to prospectively assess these effects.

Material and methods

This post hoc analysis of 5 "best practice" studies involved patients with multiple CVD risk factors. Estimated glomerular filtration rate (eGFR) was assessed using the Modification of Diet in Renal Disease (MDRD) formula. Among the 4,153 patients, 1,235 (29.7%) had stage 3 CKD (eGFR between 30 and 59 ml/min/1.73 m²). A baseline visit was followed by a concerted effort from previously trained physicians to improve adherence to lifestyle advice and optimize drug treatment, including a statin, for all vascular risk factors. After 6 months eGFR and SUA levels were re-evaluated.

Results

The intervention improved compliance to lifestyle measures and increased the use of evidence-based medication, including a statin. There was also a 5.6% increase in eGFR (p < 0.001) in patients with stage 3 CKD and a 6.1% reduction in SUA levels (p < 0.001). Among patients with stage 3 CKD, 127 (10.3%) improved to stage 2 CKD and 9 (0.7%) advanced to stage 4 CKD by the end of the 6-month study period. There were no major side-effects.

Conclusions

Multitargeted intervention, including a statin, may improve renal function and reduce SUA levels within 6 months, thus offsetting 2 potential CVD risk factors in high-risk patients.     

Body weight reduction to avoid the excess risk of type 2 diabetes

Background

It is recognised that people who are overweight have an increased risk of diabetes but the quantitative relationship is less well recognised and the extent of weight reduction needed to avoid the excess risk of diabetes through being overweight, is not well appreciated

Aim

To derive a simple clinical algorithm to calculate the weight change needed to achieve a specified goal for reduction of body mass index (BMI, weight/height squared [kg/m²]) that would avoid the excess risk of diabetes and quantify the preventive effect.

Design and setting

Analysis of the results from two large published cohort studies of the incidence of diabetes in relation to BMI.

Method

Epidemiological data show that the risk of diabetes doubles for every 2.5 unit increase in BMI above a BMI of 22 kg/m² and halves for every 2.5 unit decrease in BMI down to 22 kg/m². The risk of diabetes also approximately doubles for every 10 years of age. From these relationships, a simple algorithm was derived to specify a person''s weight-reduction goal to avoid the excess risk of diabetes.

Results

Converting a BMI-reduction goal (for example, 27 kg/m² to 22 kg/m²) into a percentage reduction (in this example, 19%) specifies the same percentage weight reduction (19%) because, as a percentage, the reduction is independent of height. This percentage can then easily be converted into an absolute risk reduction (in this example, a 75% reduction in risk).

Conclusion

The algorithm achieves two objectives: (i) it specifies the weight-reduction goal to reverse a person''s excess risk of diabetes due to being overweight, and (ii) it quantifies the risk reduction.     

The Effect of Bortezomib on Expression of Inflammatory Cytokines and Survival in a Murine Sepsis Model Induced by Cecal Ligation and Puncture

Purpose

Although the proteasome inhibitor known as bortezomib can modulate the inflammatory process through the nuclear factor-kappa B signaling pathway, the immunomodulatory effect of pre-incubated bortezomib has not been fully evaluated for inflammation by infectious agents. Therefore, we evaluated the effect of bortezomib on the expression of inflammatory cytokines and mediators in macrophage cell lines and on survival in a murine peritonitis sepsis model.

Materials and Methods

Bortezomib was applied 1 hr before lipopolysaccharide (LPS) stimulation in RAW 264.7 cells. The cecal ligation and puncture (CLP) experiments were performed in C57BL/6J mice.

Results

Pre-incubation with bortezomib (25 nM or 50 nM) prior to LPS (50 ng/mL or 100 ng/mL) stimulation significantly recovered the number of viable RAW 264.7 cells compared to those samples without pre-incubation. Bortezomib decreased various inflammatory cytokines as well as nitric oxide production in LPS-stimulated cells. The 7-day survival rate in mice that had received bortezomib at 0.01 mg/kg concentration 1 hr prior to CLP was significantly higher than in the mice that had only received a normal saline solution of 1 mL 1 hr prior to CLP. In addition, the administration of bortezomib at 0.01 mg/kg concentration 1 hr before CLP resulted in a significant decrease in inflammation of the lung parenchyma. Collectively, pretreatment with bortezomib showed an increase in the survival rate and changes in the levels of inflammatory mediators.

Conclusion

These results support the possibility of pretreatment with bortezomib as a new therapeutic target for the treatment of overwhelming inflammation, which is a characteristic of severe sepsis.     

A Higher Meal Frequency May be Associated with Diminished Weight Loss after Bariatric Surgery

OBJECTIVE

This study aimed to investigate the relationship between meal frequency, the occurrence of vomiting and weight loss among patients submitted to Roux-en-Y gastric bypass up to 9 months after surgery.

METHODS

Female patients (n = 80) were followed at 3-month intervals for 9 months. Weight, BMI, 24-hour dietary recall, drug consumption and vomiting episodes were recorded and compared with nutritional outcome.

RESULTS

The BMI values at 3, 6 and 9 months were 45.1 ± 9.7, 39.9 ± 7.6 and 35.4 ± 8.2 kg/m², respectively. The corresponding choleric intakes were 535.6 ± 295.7, 677.1 ± 314.7 and 828.6 ± 398.2 kcal/day, and the numbers of daily meals were 5.0 ± 2.5, 4.7 ± 1.8 and 4.9 ± 1.0, respectively. The peak of vomiting episodes occurred within 6 months; however, patients tolerated this complication despite its high prevalence. A significant negative correlation between weight loss and diet fractioning, but not vomiting, was observed throughout the entire postoperative period (P = 0.001).

CONCLUSIONS

1) Frequent small meals were associated with a reduction in weight loss after gastric bypass and a decrease in vomiting episodes at 6 months, and 2) vomiting did not interfere with nutritional outcome. Unless required because of vomiting or other reasons, multiple small meals may not be advantageous after such intervention.     

Safety and Efficacy of Conversion from Twice-Daily Tacrolimus to Once-Daily Tacrolimus One Month after Transplantation: Randomized Controlled Trial in Adult Renal Transplantation

Purpose

The purpose of this study was to compare once-daily tacrolimus with twice-daily tacrolimus in terms of safety, efficacy, and patient satisfaction.

Materials and Methods

This prospective, randomized, open-label, multicenter study was conducted at three institutes. Patients in the investigational group were converted from tacrolimus twice daily to the same dose of extended-release tacrolimus once daily at 1 month post-transplantation, while patients in the control group were maintained on tacrolimus twice daily. The efficacies, safeties, and patient satisfaction for the two drugs at 6 months post-transplantation were compared.

Results

Sixty patients were enrolled and randomized to the investigational group (28 of 29 patients completed the study) or the control group (26 of 31 patients completed the study). At 6 months post-transplantation, composite efficacy failure rates including the incidences of biopsy-confirmed acute rejection in the investigational and control groups were 0% and 10.7%, respectively; patient survival was 100% in each group. No difference in estimated glomerular filtration rate values were observed at 6 months post-transplantation (p=0.97). The safety and satisfaction profile (immunosuppressant therapy barrier scale) of once-daily tacrolimus was comparable with that of twice-daily tacrolimus (p=0.35).

Conclusion

Conversion from twice-daily tacrolimus to once-daily tacrolimus one month after transplantation is safe and effective.     

⁹⁹mTc-RBC Scintigraphy for diagnosis of intestinal stromal tumor hemorrhage: a case report

Background

Gastrointestinal stromal tumors (GISTs) are rare and our understanding of the natural history and optimal treatment of GISTs are continually evolving. They are characterized by a remarkable cellular variability and their malignant potential is sometimes difficult to predict.

Case presentation

We report the case of intestinal stromal tumor in a 44 years old patient with a long history of anemia and recurrent hemafecia. By using ^99mTc-labeled red blood cell (^99mTc-RBC) scintigraphy, extensive tracer accumulation in the jejunum was detected. Immunohistochemically, the tumor strongly expresses the KIT (CD117) protein. The intestinal tumor was successfully resected with a postoperative favorable outcome.

Conclusion

^99mTc-RBC scintigraphy is an established technique for the identification and localization of gastrointestinal bleeding. Abdominal scintigraphy appears to be a valuable supplement to conventional diagnostic methods for the diagnosis of gastrointestinal stromal tumor hemorrhage.     

Motor-Behavioral Episodes in REM Sleep Behavior Disorder and Phasic Events During REM Sleep

Study Objectives:

To investigate if sudden-onset motor-behavioral episodes in REM sleep behavior disorder (RBD) are associated with phasic events of REM sleep, and to explore the potential meaning of such an association.

Design:

Observational review analysis.

Setting:

Tertiary sleep center.

Patients:

Twelve individuals (11 males; mean age 67.6 ± 7.4 years) affected by idiopathic RBD, displaying a total of 978 motor-behavioral episodes during nocturnal in-laboratory video-PSG.

Interventions:

N/A

Measurements and Results:

The motor activity displayed was primitive in 69.1% and purposeful/semi-purposeful in 30.9% of the motor-behavioral episodes recorded. Sleeptalking was significantly more associated with purposeful/semi-purposeful motor activity than crying and/or incomprehensible muttering (71.0% versus 21.4%, P < 0.005). In 58.2% of the motor-behavioral episodes, phasic EEG-EOG events (rapid eye movements [REMs], α bursts, or sawtooth waves [STWs]) occurred simultaneously. Each variable (REMs, STWs, α bursts) was associated more with purposeful/semi-purposeful than with primitive movements (P < 0.05).

Conclusions:

Motor-behavioral episodes in RBD were significantly more likely to occur in association with phasic than with tonic periods of REM sleep. The presence of REMs, α bursts and STWs was found to be more frequent in more complex episodes. We hypothesize that motor-behavioral episodes in RBD are likely to occur when the brain, during REM sleep, is in a state of increased instability (presence of α bursts) and experiencing stronger stimulation of visual areas (REMs).

Citation:

Manni R; Terzaghi M; Glorioso M. Motor-behavioral episodes in REM sleep behavior disorder and phasic events during REM sleep. SLEEP 2009;32(2):241–245.     

Serum neutrophil gelatinase-associated lipocalin as a marker of kidney function in pregnancy – useful or doubtful?

Introduction

The aim of the study was to assess whether neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C could reflect kidney function in pregnant healthy women.

Material and methods

The studies were performed on 130 healthy pregnant women (n = 63, 3^rd trimester; n = 21, 2^nd trimester; n = 46, 1^st trimester) and 30 healthy female volunteers. Serum NGAL, cystatin C, IL-6, and hs-CRP were assayed using commercially available kits.

Results

Serum cystatin C rose steadily during the pregnancy, whereas NGAL rose in the 2^nd trimester, then decreased in the 3^rd trimester. In univariate analysis, NGAL correlated with serum cystatin C, number of pregnancies, white blood cell count, total iron-binding capacity (TIBC), ferritin, and IL-6, and tended to correlate with eGFR. In multiple regression analysis the only predictor of serum NGAL was cystatin C.

Conclusions

Serum NGAL in pregnancy might reflect subclinical inflammation rather than kidney function. It seems that NGAL, similarly to cystatin C, is not useful to monitor renal function in pregnancy.     

Do unexplained symptoms predict anxiety or depression? Ten-year data from a practice-based research network

Background

Unexplained symptoms are associated with depression and anxiety. This association is largely based on cross-sectional research of symptoms experienced by patients but not of symptoms presented to the GP.

Aim

To investigate whether unexplained symptoms as presented to the GP predict mental disorders.

Design and setting

Cross-sectional and longitudinal analysis of data from a practice-based research network of GPs, the Transition Project, in the Netherlands.

Method

All data about contacts between patients (n = 16 000) and GPs (n = 10) from 1997 to 2008 were used. The relation between unexplained symptoms episodes and depression and anxiety was calculated and compared with the relation between somatic symptoms episodes and depression and anxiety. The predictive value of unexplained symptoms episodes for depression and anxiety was determined.

Results

All somatoform symptom episodes and most somatic symptom episodes are significantly associated with depression and anxiety. Presenting two or more symptoms episodes gives a five-fold increase of the risk of anxiety or depression. The positive predictive value of all symptom episodes for anxiety and depression was very limited. There was little difference between somatoform and somatic symptom episodes with respect to the prediction of anxiety or depression.

Conclusion

Somatoform symptom episodes have a statistically significant relation with anxiety and depression. The same was true for somatic symptom episodes. Despite the significant odds ratios, the predictive value of symptom episodes for anxiety and depression is low. Consequently, screening for these mental health problems in patients presenting unexplained symptom episodes is not justified in primary care.