Clinical outcomes and mortality in elderly peritoneal dialysis patients

OBJECTIVES:

To evaluate the clinical outcomes and identify the predictors of mortality in elderly patients undergoing peritoneal dialysis.

METHODS:

We conducted a retrospective study including all incident peritoneal dialysis cases in patients ≥65 years of age treated from 2001 to 2014. Demographic and clinical data on the initiation of peritoneal dialysis and the clinical events during the study period were collected. Infectious complications were recorded. Overall and technique survival rates were analyzed.

RESULTS:

Fifty-eight patients who began peritoneal dialysis during the study period were considered for analysis, and 50 of these patients were included in the final analysis. Peritoneal dialysis exchanges were performed by another person for 65% of the patients, whereas 79.9% of patients preferred to perform the peritoneal dialysis themselves. Peritonitis and catheter exit site/tunnel infection incidences were 20.4±16.3 and 24.6±17.4 patient-months, respectively. During the follow-up period, 40 patients were withdrawn from peritoneal dialysis. Causes of death included peritonitis and/or sepsis (50%) and cardiovascular events (30%). The mean patient survival time was 38.9±4.3 months, and the survival rates were 78.8%, 66.8%, 50.9% and 19.5% at 1, 2, 3 and 4 years after peritoneal dialysis initiation, respectively. Advanced age, the presence of additional diseases, increased episodes of peritonitis, the use of continuous ambulatory peritoneal dialysis, and low albumin levels and daily urine volumes (<100 ml) at the initiation of peritoneal dialysis were predictors of mortality. The mean technique survival duration was 61.7±5.2 months. The technique survival rates were 97.9%, 90.6%, 81.5% and 71% at 1, 2, 3 and 4 years, respectively. None of the factors analyzed were predictors of technique survival.

CONCLUSIONS:

Mortality was higher in elderly patients. Factors affecting mortality in elderly patients included advanced age, the presence of comorbid diseases, increased episodes of peritonitis, use of continuous ambulatory peritoneal dialysis, and low albumin levels and daily urine volumes (<100 ml) at the initiation of peritoneal dialysis.     

Rare etiology of mechanical intestinal obstruction: Abdominal cocoon syndrome

Abdominal cocoon syndrome is a rare cause of intestinal obstruction with unknown etiology. Diagnosis of this syndrome, which can be summarized as the small intestine being surrounded by a fibrous capsule not containing the mesothelium, is difficult in the preoperative period. A 47-year-old male patient was referred to the emergency department with complaints of abdominal pain, nausea, and vomiting for two days. The abdominal computed tomography examination detected dilated small intestinal loops containing air-fluid levels clustered in the left upper quadrant of the abdomen and surrounded by a thick, saclike, contrast-enhanced membrane. During exploratory surgery, a capsular structure was identified in the upper left quadrant with a regular surface that was solid-fibrous in nature. Abdominal cocoon syndrome is a rarely seen condition, for which the preoperative diagnosis is difficult. The combination of physical examination and radiological signs, and the knowledge of “recurrent characteristics of the complaints” that can be learned by a careful history, may be helpful in diagnosis.     

High dose sequential chemotherapy and autologous stem cell transplantation in patients with relapsed/refractory lymphoma

Although high-dose chemotherapy followed by autologous stem cell transplantation (ASCT) has become the standard approach for patients with relapsed/refractory Hodgkin's disease (HD) or non-Hodgkin's lymphoma (NHL), more than 50% of patients will experience relapse following ASCT. High-dose sequential chemotherapy (HDSC) can intensify the conventional salvage treatment and improve the outcome of ASCT by maximal debulking of the tumor load with the use of non-cross resistant drugs, each at their maximal tolerated doses. We conducted a phase II study in 40 patients with relapsed/refractory HD (n = 18) and NHL (n = 22) using HDSC followed by ASCT. Only patients sensitive to salvage chemotherapy were eligible for the protocol, consisting of three phases. Phase I consisted of cyclophosphamide (4.5 g/m²) followed by G-CSF and peripheral blood stem cell (PBSC) collection. Phase II consisted of etoposide (2 g/m²). The transplant phase consisted of mitoxantrone (60 mg/m²) and melphalan (180 mg/m²) followed by PBSC infusion. Eleven out of nineteen patients with B-cell lymphoma received rituximab. Prior to HDSC, 45% of the patients were in complete remission (CR) and 55% were in partial remission (PR). After completion of all phases of the protocol, 35 out of 39 evaluable patients achieved CR (90%) and this was durable in 30 (75%) patients with a projected progression-free survival (PFS) rate at 4 years of 71.7%. Treatment-related mortality rate at day +100 was 2.5% (n = 1). At a median follow-up of 32 months (range, 3 - 61), nine patients relapsed/progressed and eleven patients died. The estimated 4-year PFS and overall survival (OS) were 72.2% and 47.6% in HD patients and 70.3% and 69.4% in NHL patients, respectively. Factors predicting OS were response to conventional salvage therapy and stage prior to salvage therapy. When compared to patients achieving PR, patients who attained CR prior to HDSC had a significantly higher probability of 4-year OS (78.4% vs 31.3%, p = 0.02). Three prognostic subgroups were defined according to the score determined by stage prior to initiation of salvage chemotherapy, remission duration prior to salvage (refractory/early relapse vs. late relapse) and response to salvage. Prognostic score was found to predict OS, PFS and event free survival (EFS). In conclusion, HDSC followed by ASCT is an effective salvage therapy with acceptable toxicity, allowing further consolidation of response attained by conventional salvage therapy.     

Serum tocopherols, selenium and lung cancer risk among tin miners in China

Objective: To evaluate the association of prediagnostic serum antioxidants and lung cancer risk we conducted a case–control study nested in an occupational cohort of tin miners. Methods: Male workers free of cancer enrolled in the cohort. During up to 6 years of follow-up, 339 lung cancer cases were diagnosed and, among these cases, those who donated blood prospectively (n = 108) were eligible for this study. For each case, two controls alive and free of cancer at the time of case diagnosis were matched on age and date of blood collection. Results: Overall, we observed no association between serum alpha-tocopherol, gamma-tocopherol or selenium levels and lung cancer risk. However, a significant gradient of decreasing lung cancer risk with increasing serum alpha-tocopherol was apparent for men less than 60years old (odds ratio by tertile: 1.0, 0.9, 0.2; trend p = 0.002). Alpha-tocopherol was also protective in men who reported no alcohol drinking (OR by tertile: 1.0, 0.6, 0.3; trend p = 0.008). Conclusion: Although there were no significant overall associations between prospectively collected serum alpha-tocopherol, gamma-tocopherol or selenium and incidence of lung cancer, results from this study suggest that higher alpha-tocopherol levels may be protective in men less than 60 years old and in those who do not drink alcohol.     

Increased micronucleus frequency in rat bone marrow after acrylamide treatment

This study was performed to investigate whether acrylamide (AA), occured during cooking carbohydrate-rich foods at high temperature, increased the frequency of micronucleated polychromatic erythrocytes (MNPCEs) in rat bone marrow. For this purpose AA, dissolved in distilled water, was administered to 8-week old male Sprague Dawley rats at single oral doses of 0, 125, 150 or 175 mg/kg b.w. After 48 h from AA treatment, the bone marrow samples were analysed for the frequency of MNPCEs. The cytotoxic effect of AA on bone marrow was also tested by assessing polychromatic erythrocyte/normochromatic erythrocyte (PCE/NCE) ratio. It was found that all three doses applied significantly increased the frequency of MNPCEs and this increase was 3.75-fold in rats given the highest administered dose of AA. In addition AA decreased the PCE/NCE ratio, which is indicative of bone marrow cytotoxicity when compared to the control group. This study displayed that AA increased the formation of micronuclei in polychromatic erythrocytes (PCEs) of rat bone marrow and this increase might have resulted from administrating the high dose level of AA to rats by gavage instead of by i.p. injection.     

Mild cognitive impairment in Parkinson’s disease is associated with decreased P300 amplitude and reduced putamen volume

ObjectiveFunctional and structural brain alterations of cognitively normal Parkinson’s disease (PD-CN) and Parkinson’s disease mild cognitive impairment (PD-MCI) patients were investigated using event-related potentials (ERP) P300 and volumetric magnetic resonance imaging (MRI) parameters.MethodsTwenty three patients with PD-CN, 21 with PD-MCI, and 23 demographically-matched healthy controls were included. EEGs were recorded using a visual oddball task and mean amplitude and peak latency values of P300 were measured. Gray matter volumes (GMV) of thalamus, caudate, putamen, globus pallidus, hippocampus, amygdala and nucleus accumbens were obtained using FMRIB Integrated Registration and Segmentation Tool. Correlations among P300, subcortical GMV and cognitive performances were assessed.ResultsPD-CN patients demonstrated reduced P300 amplitudes compared to healthy controls. PD-MCI patients had lower P300 amplitudes than both PD-CN patients and controls and reduced volumes of the putamen compared to controls. Both putamen volumes and P300 amplitudes showed moderate associations with executive functions.ConclusionsOur findings support that P300 amplitude may be a useful marker for the detection of preclinical changes before the appearance of cognitive and structural deterioration in PD, as shown by decreased frontal P300 amplitudes in PD-CN. The reduction further spread to centro-parietal areas in PD-MCI patients, which was accompanied by lower putamen volumes.SignificanceThis study is the first to report on changes in ERP P300 amplitude and subcortical volume in well-matched samples of PD-CN, PD-MCI and healthy controls.     

Incisional Complications and Cosmetic Evaluation After Hand-assisted Retroperitoneoscopic Donor Nephrectomy

PurposeHand-assisted retroperitoneoscopic (HARP) donor nephrectomy prevents major complications, but incision site complications may be more frequent in hand-assisted approach. We evaluated long-term incisional complication rates and cosmetic outcomes after HARP donor nephrectomy in our series.Materials and MethodsA total of 609 donors who underwent nephrectomy between February 2009 and June 2016 were invited for physical examination and face-to-face interview. A total of 209 donors (35.3%) participated to the study. Sex, age, body mass index (BMI), mean follow-up period, incision-related outcomes of cosmesis, and postoperative complications were evaluated. Body image scale (BIS) and cosmetic scale (CS) (scar test) questionnaires were applied. Higher cosmesis and body image scores indicated greater satisfaction.ResultsA total of 191 donors had paramedian (91.4%), and 18 donors had Pfannenstiel incision (8.6%); 121 donors were female (57.9%). The donor mean age and BMI were 49.1 (SD, 1.8) years and 29.7 (SD, 5.1), respectively. Body mass index was significantly lower in the Pfannenstiel group (P < .001). The mean BIS score was 18.9 (SD, 1.8), and the CS questionnaire score was 19.3 (SD, 4,7). The BIS score was significantly better in donors with Pfannenstiel incisions (P < .001), but there was no statistical significance in CS score. The total rate of wound infection was 4.8%, and rate of incisional hernia was 4.8%. The rate of incisional hernia was more frequent in donors with paramedian incision (5.2%), but there was no statistical significance. Six donors (2.9%) required rehospitalization because of incision site complications.ConclusionHand-assisted retroperitoneoscopic donor nephrectomy avoids intra-abdominal complications, but rate of incision site complications can be higher in hand-assisted procedure. The donors were convinced from the cosmetic outcome after HARP donor nephrectomy. The ones who had Pfannenstiel incision had better satisfaction according to BIS score.     

Intestinal obstruction due to phytobezoars: An update

The term bezoar refers to an intraluminal mass in the gastrointestinal system caused by the accumulation of indigestible ingested materials, such as vegetables, fruits, and hair. Bezoars are responsible for 0.4%-4% of cases of mechanical intestinal obstruction. The clinical findings of bezoar-induced ileus do not differ from those of mechanical intestinal obstruction due to other causes. The appearance and localization of bezoars can be established with various imaging methods. Treatment of choice depends on the localization of the bezoar which makes the clinical findings.     

Posterior epidural disc herniation at L3-L4 mimicking a spinal tumor: a case report

Posterior epidural disc migration is a rare event. Many differential diagnoses are possible in the posterior epidural space other than disc disease. This is a case report of L3-L4 posterior epidural disc herniation that was misdiagnosed as a tumor depending on the preoperative magnetic resonance imaging study with a peripheral ring enhancement around the mass lesion after IV gadolinium. Decompressive L4 laminectomy was performed and a free disc fragment was observed beneath the lamina. There wasneither dural tearnor attachment to it. The patient was free of pain postoperatively. After 3 months, the patient applied to the outpatient clinic for a regular control T he patient was neurologically intact and free of pain. Diagnosis of posterior migrated disc fragment with subtle clinical findings, even though the free fragment has to pass through many anatomical barriers including the nevre roots, is a clinical challenge. Many differential diagnoses should be kept in mind. MRI findings (especially with contrast material use) are useful which should be imprinted with clinical knowledge.