Dialysis‐linked complaints and burdens of illness on patient and spouse as predictors of survival in end‐stage renal disease patients with home hemodialysis: a 10‐year follow‐up study

Participants were 40 persons from a group of 44 end‐stage renal disease patients in southern Sweden who in 1985 received home hemodialysis under the auspices of a hospital renal unit, together with their spouses (n = 35). At a 10‐year follow‐up, 15 of the patients had died and 25 had survived. Univariate log rank tests of the influence of physical and demographic factors, the patient's dialysis‐linked complaints and the burdens of the illness indicated the most important predictors of 10‐year survival to be the patient's age, severity of the illness, the patient's dialysis‐linked complaints (notably that of itching), and the burdens of the patient's disease on the spouse (particularly burdens of a sexual character). Copyright © 2004 John Wiley & Sons, Ltd.     

Vietnam, 1968-1969: a place and a year like no other

THE VIETNAM WAR touched a generation of Americans with its human tragedy, sacrifice, and strife. In terms of casualties, it was the fourth most costly war in American history. However, despite a monumental military effort and modern technology, the war was lost as support from the American public and its elected officials waned. Now, in the aftermath of September 11, 2001, as we embark on what might well be another protracted war, lessons from the Vietnam experience become relevant. On a positive note, a refined system for the triage, management, and evacuation of wounded military personnel evolved in Vietnam. A wounded soldier could actually be at a well-equipped base hospital within minutes after injury. At those facilities, casualties had a more than 90% chance of survival, despite some of the most horrific wounds in the history of warfare.     

Peritoneal albumin leakage: 2 year prospective cardiovascular event occurrence and patient survival analysis

Aim: High peritoneal transport status is a determinant of morbidity and mortality in peritoneal dialysis (PD) patients. It was hypothesized that 24 h peritoneal albumin leakage predicted 2 year prospective cardiovascular outcome and survival in patients receiving PD. Methods: Sixty‐six patients were included. A simplified peritoneal equilibration test was performed and 24 h peritoneal albumin leakage was calculated. Patients were followed up for 2 years. Patient outcome (alive or dead) and occurrence of a cardiovascular event were recorded. Results: During a 2 year follow‐up period, 10 (15.2%) patients had suffered from a cardiovascular event and seven (10.6%) patients had died. Patients who had suffered from a cardiovascular event during the follow up period were older (54.0 ± 9.4 years vs 44.3 ± 14.5 years, P = 0.025), had lower serum pre‐albumin concentrations (29.3 ± 10.0 g/dL vs 36.0 ± 9.2 g/dL, P = 0.034) and had higher 24 h peritoneal albumin leakage (median, 3.4 g/day (1.66–15.4 g/day) vs 2.4 g/day (0.76–7.31 g/day), P = 0.011) than patients who did not suffer from a cardiovascular event. In the Cox proportional hazards multivariate analysis of factors which differed significantly between patients with and without a cardiovascular event (age, serum pre‐albumin and 24 h peritoneal albumin leakage), only advanced age (hazards ratio, 1.083; 95% confidence interval, 1.023–1.147, P = 0.006) was an independent predictor of a cardiovascular event. Conclusion: In contrast to the hypothesis, 24 h peritoneal albumin leakage is not a predictor of 2 year prospective cardiovascular outcome and patient survival. Only advanced age independently predicts the occurrence of a cardiovascular event in patients receiving PD.     

A natural recombinant PRRSV between HP‐PRRSV JXA1‐like and NADC30‐like strains

Porcine reproductive and respiratory syndrome virus (PRRSV ) is a major economically significant pathogen that has adversely affected China's swine industry. Currently, a novel type 2 PRRSV , called the NADC 30‐like strain, is epidemic in numerous provinces of China, and commercial vaccines provide limited protection for infected animals. The extensive recombination phenomenon among NADC 30‐like PRRSV s is identified as a unique molecular characteristic of the virus. However, our understanding of how recombination influences NADC 30‐like PRRSV s is largely inadequate. In this study, we analysed the genetic characteristics of a recombinant NADC 30‐like PRRSV (SC ‐d) and examined its pathogenicity compared with a non‐recombinant NADC 30‐like PRRSV (SD ‐A19) and a highly pathogenic PRRSV (HuN4). SC ‐d has three discontinuous deletions in nsp2, consistent with NADC 30 isolated from the United States in 2008. Furthermore, we identified four recombination breakpoints in the SC ‐d genome, which separated the SC ‐d genome into four regions (regions A, B, C and D). Regions A and C are closely related to the JXA 1‐like strain, one of the earliest Chinese HP ‐PRRSV strains, and regions B and D are closely related to the NADC 30 strain. Moreover, SC ‐d inoculated piglets exhibited a persistent fever, moderate weight loss, mild thymus atrophy and obvious microscopic lung lesions. In summary, the recombinant NADC 30‐like PRRSV SC ‐d strain displayed a higher pathogenicity than the non‐recombinant NADC 30‐like PRRSV SD ‐A19 strain; however, the pathogenicity of the NADC 30‐like PRRSV SC ‐d was lower compared with the HP ‐PRRSV HuN4 strain in piglets. Our findings demonstrate that recombination is responsible for the enormous genetic diversity and pathogenicity variance of the NADC 30‐like PRRSV in China. This study provides a theoretical basis for developing a more reasonable PRRSV control and prevention strategy.     

Early steroid withdrawal results in improved patient and graft survival and lower risk of post‐transplant cardiovascular risk profiles: A single‐center 10‐year experience

Long‐term use of steroids results in predictable secondary effects that can lead to increased morbidity and mortality. In this study, we present 10 years worth of data of early steroid withdrawal (ESW) immunosuppression consisting of mycophenolate, sirolimus, and tacrolimus. From 2003 to 2013, 563 kidney transplant recipients were weaned off steroids prior to discharge. We compared outcomes with that of our 65 historical controls maintained on steroids. We analyzed graft and patient survival and determined the incidence of steroid‐related comorbidities such as hypertension, hypercholesterolemia, diabetes, coronary artery disease, and weight gain. Patients on ESW maintenance immunosuppression had improved patient and graft survival compared to controls. (HR: 0.23; P≤.011, 0.57; P=.026). Rates of biopsy‐proven acute rejection were not different among both groups (HR: 1.24; P=.610). Incidence of post‐transplant diabetes were reduced but not statistically significant (OR: 0.67; P=.138). Additionally, the development of hypertension (OR: 0.86, P≤.01), hypercholesterolemia (RR: 0.82; P=.027), CAD (RR: 0.43; P=.002), and >20 lbs. weight gain (RR: 0.29; P≤.01) was significantly improved over 10 years following initiation of ESW protocols. Early steroid withdrawal in renal transplant recipients results in improved patient and graft survival as well as better rates of post‐transplant comorbid conditions.     

The impact of cytomegalovirus serology for 7‐year graft survival in cadaveric kidney transplantation ‐ the Newcastle experience

Abstract To analyse the contribution of cytomegalovirus (CMV) serology to long‐term graft survival in cadaveric kidney transplantation, 404 transplants from a single centre were divided into four subgroups with respect to the combination of donor and recipient CMV antibody status. Graft survival was estimated according to Kaplan‐Meier for 1, 3, 5 and 7 years post‐transplantation. The single‐centre results confirm a negative impact of CMV‐positive donor organs for initial graft survival in CMV‐negative recipients within the first 3 years after transplantation. However, when 5‐ and 7‐year long‐term graft survival was studied, Donor +/Recipient ‐ pairs showed a favourable long‐term result, whilst D +/R ‐ pairs had surprisingly a poorer outcome. Therefore, the concept of avoiding transplantation in the D +/R + CMV serology group should be ignored whereas attempts could be made to improve the poor long‐term outcome of D +/R + pairs or to reduce its size by organ allocation.     

Implementing a pre‐operative checklist to increase patient safety: a 1‐year follow‐up of personnel attitudes

Background: The operating room is a complex work environment with a high potential for adverse events. Protocols for perioperative verification processes have increasingly been recommended by professional organizations during the last few years. We assessed personnel attitudes to a pre‐operative checklist (‘time out’) immediately before start of the operative procedure. Methods: ‘Time out’ was implemented in December 2007 as an additional safety barrier in two Swedish hospitals. One year later, in order to assess how the checklist was perceived, a questionnaire was sent by e‐mail to 704 persons in the operating departments, including surgeons, anesthesiologists, operation and anesthetic nurses and nurse assistants. In order to identify differences in response between professions, each alternative in the questionnaire was assigned a numerical value. Results: The questionnaire was answered by 331 (47%) persons and 93% responded that ‘time out’ contributes to increased patient safety. Eighty‐six percent thought that ‘time out’ gave an opportunity to identify and solve problems. Confirmation of patient identity, correct procedure, correct side and checking of allergies or contagious diseases were considered ‘very important’ by 78–84% of the responders. Attitudes to checking of patient positioning, allergies and review of potential critical moments were positive but differed significantly between the professions. Attitudes to a similar checklist at the end of surgery were positive and 72–99% agreed to the different elements. Conclusion: Staff attitudes toward a surgical checklist were mostly positive 1 year after their introduction in two large hospitals in central Sweden.     

Inferior graft survival of hepatitis B core positive grafts is not influenced by post‐transplant hepatitis B infection in liver recipients—A 35‐year single‐center experience

Nonoptimal liver grafts, and among them organs from anti‐HBc+ donors, are increasingly used for liver transplantation. In this retrospective study including 1065 adult liver transplantations performed between 1977 and 2012, we analyzed long‐term patient and graft survival and occurrence of HBV infection. A total of 52 (5.1%) patients received an anti‐HBc+ graft. The 10‐year graft and patient survival of these recipients were 50.9% and 59.0% compared to 72.0% and 76.5% (P = 0.001; P = 0.004) of patients receiving anti‐HBc‐ grafts, respectively. Cox regression model showed that high urgency allocation (P = 0.003), recipient age (P = 0.027), anti‐HCV+ recipients (P = 0.005), and anti‐HBc+ organs (P = 0.048) are associated with decreased graft survival. Thirteen of 52 (25.0%) patients receiving anti‐HBc+ grafts developed post‐transplant HBV infection within a mean of 2.8 years. In this study, antiviral prophylaxis did not have significant impact on HBV infection, but long‐term survival (P = 0.008). Development of post‐transplant HBV infection did not affect adjusted 10‐year graft survival (100% vs. 100%; P = 1). Anti‐HBc+ liver grafts can be transplanted with reasonable but inferior long‐term patient and graft survival. The inferior graft survival is not, however, related with post‐transplant HBV infection as long as early diagnosis and treatment take place.     

Self‐cannulation of the vascular access in home hemodialysis: Overcoming patient‐level barriers

Patients with end‐stage kidney disease who are considering home hemodialysis (HHD ) face the challenge of learning to self‐cannulate their arteriovenous access. Current practice discourages the use of tunneled central venous catheters, with recent indications that self‐cannulating patients have superior outcomes. Patient‐level barriers do not appear to preclude a successful HHD program and should not be viewed as insurmountable by healthcare staff or patients. The healthcare team must address patient fears while instructing the patient to perform self‐cannulation safely. Identification and understanding of the barriers perceived by the patient will allow the patient and healthcare team work collaboratively, toward the goal of independence with self‐cannulation both during initial training and follow‐up care. The aim of this review was to provide a practical resource to aid in the identification and resolution of these patient‐level barriers, with the overall goal of improving the patient experience and medical outcomes in home hemodialysis programs.     

Concerted actions of insulin‐like growth factor 1, testosterone,and estradiol on peripubertal bone growth: A 7‐year longitudinal study

A better understanding of how bone growth is regulated during peripuberty is important for optimizing the attainment of peak bone mass and for the prevention of osteoporosis in later life. In this report we used hierarchical models to evaluate the associations of insulin‐like growth factor 1 (IGF‐1), estradiol (E₂), and testosterone (T) with peripubertal bone growth in a 7‐year longitudinal study. Two‐hundred and fifty‐eight healthy girls were assessed at baseline (mean age 11.2 years) and at 1, 2, 3.5, and 7 years. Serum concentrations of IGF‐1, E₂, and T were determined. Musculoskeletal properties in the left lower leg were measured using peripheral quantitative computed tomography (pQCT). Serum levels of IGF‐1, E₂, and T increased dramatically before menarche, whereas they decreased, plateaued, or increased at a lower rate, respectively, after menarche. IGF‐1 level was positively associated with periosteal circumference (PC) and total bone mineral content (tBMC) throughout peripuberty but not after adjustment for muscle cross‐sectional area (mCSA). On the other hand, IGF‐1 was associated with tibial length (TL) independently of mCSA before menarche. T was positively associated with TL, PC, tBMC, and cortical volumetric bone mineral density, independent of mCSA, before menarche but not after. E₂ was associated with TL positively before menarche but negatively after menarche. These findings suggest that during puberty, circulating IGF‐1 promotes bone periosteal apposition and mass accrual indirectly, probably through stimulating muscle growth, whereas the effects of sex steroids on bone growth differ before and after menarche, presenting a biphasic pattern. Hence the concerted actions of these hormones are essential for optimal bone development in peripuberty. © 2011 American Society for Bone and Mineral Research     

Robotic kidney transplantation in the obese patient: 10‐year experience from a single center

Despite increasing obesity rates in the dialysis population, obese kidney transplant candidates are still denied transplantation by many centers. We performed a single‐center retrospective analysis of a robotic‐assisted kidney transplant (RAKT) cohort from January 2009 to December 2018. A total of 239 patients were included in this analysis. The median BMI was 41.4 kg/m², with the majority (53.1%) of patients being African American and 69.4% of organs sourced from living donors. The median surgery duration and warm ischemia times were 4.8 hours and 45 minutes respectively. Wound complications (mostly seromas and hematomas) occurred in 3.8% of patients, with 1 patient developing a surgical site infection (SSI). Seventeen (7.1%) graft failures, mostly due to acute rejection, were reported during follow‐up. Patient survival was 98% and 95%, whereas graft survival was 98% and 93%, at 1 and 3 years respectively. Similar survival statistics were obtained from patients undergoing open transplant over the same time period from the UNOS database. In conclusion, RAKT can be safely performed in obese patients with minimal SSI risk, excellent graft function, and patient outcomes comparable to national data. RAKT could improve access to kidney transplantation in obese patients due to the low surgical complication rate.     

The 1‐year Renal Biopsy Index: a scoring system to drive biopsy indication at 1‐year post‐kidney transplantation

Surveillance biopsies after renal transplantation remain debatable. To drive the decision of such intervention, we propose a predictive score of abnormal histology at 1‐year post‐transplantation, named 1‐year Renal Biopsy Index (1‐RBI). We studied 466 kidney recipients from the DIVAT cohort alive with a functioning graft and a surveillance biopsy at 1‐year post‐transplantation. Patients displaying abnormal histology (49%) (borderline, acute rejection, interstitial fibrosis and tubular atrophy [IFTA] grade 2 or 3, glomerulonephritis) were compared to the normal or subnormal (IFTA grade 1) histology group. Obtained from a lasso penalized logistic regression, the 1‐RBI was composed of recipient gender, serum creatinine at 3, 6, and 12 month post‐transplantation and anticlass II immunization at transplantation (internal validation: AUC = 0.71, 95% CI [0.53–0.83]; external validation: AUC = 0.62, 95% CI [0.58–0.66]). While we could not determinate a threshold able to identify patients at high chance of normal or subnormal histology, we estimated and validated a discriminating threshold capable of identifying a subgroup of 15% of the patients with a risk of abnormal histology higher than 80%. The 1‐RBI is computable online at www.divat.fr . The 1‐RBI could be a useful tool to standardize 1‐year biopsy proposal and may for instance help to indicate one in case of high risk of abnormal histology.