The Impact of Membrane Permeability and Dialysate Purity on Cardiovascular Outcomes

The effects of high-flux dialysis and ultrapure dialysate on survival of hemodialysis patients are incompletely understood. We conducted a randomized controlled trial to investigate the effects of both membrane permeability and dialysate purity on cardiovascular outcomes. We randomly assigned 704 patients on three times per week hemodialysis to either high- or low-flux dialyzers and either ultrapure or standard dialysate using a two-by-two factorial design. The primary outcome was a composite of fatal and nonfatal cardiovascular events during a minimum 3 years follow-up. We did not detect statistically significant differences in the primary outcome between high- and low-flux (HR=0.73, 95% CI=0.49 to 1.08, P=0.12) and between ultrapure and standard dialysate (HR=0.90, 95% CI=0.61 to 1.32, P=0.60). Posthoc analyses suggested that cardiovascular event-free survival was significantly better in the high-flux group compared with the low-flux group for the subgroup with arteriovenous fistulas, which constituted 82% of the study population (adjusted HR=0.61, 95% CI=0.38 to 0.97, P=0.03). Furthermore, high-flux dialysis associated with a lower risk for cardiovascular events among diabetic subjects (adjusted HR=0.49, 95% CI=0.25 to 0.94, P=0.03), and ultrapure dialysate associated with a lower risk for cardiovascular events among subjects with more than 3 years of dialysis (adjusted HR=0.55, 95% CI=0.31 to 0.97, P=0.04). In conclusion, this trial did not detect a difference in cardiovascular event-free survival between flux and dialysate groups. Posthoc analyses suggest that high-flux hemodialysis may benefit patients with an arteriovenous fistula and patients with diabetes and that ultrapure dialysate may benefit patients with longer dialysis vintage.Cardiovascular mortality is substantially higher in patients undergoing maintenance hemodialysis (HD) compared with the nonuremic population.¹ Several risk factors unique to uremia are implicated in the high rates of cardiovascular disease (CVD) and mortality in these patients (for example, accumulation of medium-sized or large middle molecules and predominance of a chronic inflammatory state).² Consequently, use of high-flux synthetic membranes, providing enhanced removal of higher-molecular weight uremic toxins coupled with better biocompatibility, together with ultrapure dialysis fluid might be expected to improve patient outcomes.Because of proven clinical benefits and a possible survival advantage reported by several observational studies,^3–5 high-flux HD is increasingly the most common dialysis treatment modality.⁶ Although the Hemodialysis (HEMO) Study was not able to confirm superiority of high- over low-flux HD,⁷ a survival benefit was reported in long-term HD patients in a posthoc analysis of the study, where high-flux dialyzers showed reduced cardiovascular mortality.^8–11 In the multicenter European Membrane Permeability Outcome (MPO) Study, subgroup analyses showed better survival rates with high-flux HD in patients with hypoalbuminemia and patients with diabetes.¹²Ultrapure dialysis fluid has also been associated with less inflammation, resulting in clinically relevant improvements, including amelioration of erythropoietin response,¹³ better nutritional status,^14,15 and reduction in the incidence of β₂-microglobulin amyloidosis.¹⁶ Although preliminary reports suggested lower cardiovascular morbidity with the use of ultrapure dialysis fluid,¹⁷ no randomized and controlled trial has been performed addressing hard clinical outcomes.This randomized controlled trial was designed to determine whether membrane permeability and dialysate purity affect the incidence of fatal and nonfatal cardiovascular events and overall survival in prevalent maintenance HD patients.     

Cross-sectional area of the labrum: role in the diagnosis of anterior acetabular labral tears

European Radiology - To investigate the utility of ultrasound cross-sectional area (CSA) measurements for diagnosing acetabular labral (AL) tears. The study included qualitative/quantitative...     

Effects of dexpanthenol and N-acetylcysteine pretreatment in rats before renal ischemia/reperfusion injury

Background: We investigated the anti-inflammatory and protective effects of concomitant use of dexpanthenol (DXP) and N-acetylcysteine (NAC) induced ischemia/reperfusion (I/R) injury of kidney. Methods: Forty rats were randomly divided into 5 groups. In all groups except for Group 1(Sham), renal arteries bilaterally occluded with vascular clamp for IR injury. Group 1(Sham), received a single dose of 10?mL/kg isotonic saline daily by intraperitoneal (IP) injection for three days. Group 2(IR), received a single dose of 10?mL/kg isotonic saline daily by IP injection for three days. Group 3(IR?+?NAC), received 300?mg/kg NAC daily by IP injection for three days. Group 4(IR?+?DXP), received 500?mg/kg DXP daily by IP injection for three days. Group 5(IR?+?NAC?+?DXP), received 500?mg/kg DXP and 300?mg/kg NAC daily by IP injection for three days. Serum urea (BUN), creatinine (Cr) and neutrophil gelatinase-associated lipocalin (NGAL, lipocalin 2, siderocalin) levels were measured as kidney function tests. TNF-α levels were measured as inflammatory marker. Tissue sections were evaluated histopathologically under light microscopy. Results: IR?+?NAC?+?DXP group received both NAC and DXP before induction of renal I/R and as the biochemical and histopathological data revealed the results of the IR?+?NAC?+?DXP group and sham group were similar. Biochemically and histopathologically, combined use of NAC and DXP has better results when each of them used alone. Conclusion: We concluded that concomitant use of DXP and NAC plays a major role against I/R injury and may be useful in acute treatment of I/R induced renal failure.     

Impact of metabolic syndrome on stress urinary incontinence in pre- and postmenopausal women

Aim

In the present study, we prospectively collected data from pre- to postmenopausal women with or without metabolic syndrome (MetS) and evaluated the impact of MetS on stress urinary incontinence (SUI) in women.

Material and methods

The women divided into four equal groups: premenopausal with and without MetS; postmenopausal with and without MetS. There were 100 women in each group. We assessed the women for SUI at gynecologic position and we determined cough stress test. MetS was defined according to the criteria established in 2005 by the NCEP/ATP III.

Results

Mean age was 48.52 ± 8.16 in women with MetS and 48.81 ± 8.31 in women without MetS. SUI was found more often in both pre- and postmenopausal women with MetS (p = 0.001 and p < 0.001). It seems that postmenopausal women have more SUI than premenopausal women with MetS. We also evaluated the association between five components of MetS and SUI. Just, higher fasting glucose levels and waist circumference were significantly associated with SUI (p < 0.05).

Conclusion

Our study shows that SUI is more prevalent in pre- and postmenopausal women with the MetS. SUI can be prevented with lifestyle changes for MetS. Multicenter studies with larger series and molecular studies are needed to determine the impact of the MetS on SUI.     

Outcomes of Surgical Treatment of Primary Signet Ring Cell Carcinoma of the Colon and Rectum: 22 Cases Reviewed With Literature

Colorectal primary signet ring cell carcinoma (PSRCCR) is a rare entity with a dismal prognosis, mainly because of delayed diagnosis. The objective of this study was to investigate the clinicopathologic features and prognostic factors for PSRCCR. This is a retrospective study including the data of 22 patients with PSRCCR who underwent surgery. Patients were categorized by age, sex, tumor site, and stage. Fifteen patients were male. Median age was 40 years. Sites for metastases were lymph nodes (86.4%), peritoneum (40.9%), and liver (9.1%). Most of the patients (91%) had stage III or IV tumors. The rates of curative and palliative resections performed were equal. Mean overall survival and mean progression-free survival times were found to be 33.3 ± 7.1 months (95% confidence interval, 19.4–47.2 months) and 11.8 ± 3.5 months (95% confidence interval, 4.9–18.7 months), respectively. It was concluded that site of the tumor, presence of bowel obstruction, peritoneum and lung metastases, adjacent organ infiltration, TNM stage, and efficiency of surgery have significant effects on survival. All in all, these aggressive tumors are generally diagnosed at advanced stages. Depending on the situation, survival is shorter. A high degree of vigilance is required for these patients to avoid the negative impact of late diagnosis on survival.Key words: Signet ring cell, Colorectal cancer, Histopathology, SurvivalPrimary signet ring cell carcinoma is a tumor most commonly located in the stomach, and less frequently in the breast, gallbladder, bladder, and pancreas.¹ Primary signet ring cell carcinoma of the colon and rectum (PSRCCR) is a rare entity, with a reported incidence of less than 1%.² It has a markedly poor prognosis.³ Because symptoms often develop late, it is usually diagnosed at an advanced stage.⁴ Furthermore, it typically appears in young adults.⁵Macroscopically, PSRCCR shows the characteristic appearance of linitis plastica, as a shrunken, rigid structure.^1–5 Histologically, the neoplastic cells resemble signet rings because they contain abundant intracytoplasmic mucin, which pushes the nuclei to the periphery.^1–5 The presence of mucus secretion in microscopic examinations of the tumor is one of the most important parameters determining the biologic behavior of colorectal carcinomas; other factors are age, sex, tumor location, tumor diameter, grade, stage, lymphatic and vascular invasion, periserosal overgrowth, and distant metastasis.^6,7So far, only a limited number of case reports have been published on this subject. Most publications have reported on a small number of patients and have presented controversial results. The objective of this study was to investigate the characteristic clinicopathologic features of colorectal signet ring cell carcinomas and the parameters affecting prognosis within our patient group.     

Single-Incision Laparoscopic Cholecystectomy and Overweight Patients

Background

Modifications of minimally invasive laparoscopic cholecystectomy have been achieved, including single-incision laparoscopic cholecystectomy (SILC). In the current literature, the effects of high body mass index (BMI) on the results of the surgical therapy have not been sufficiently investigated after SILC. We evaluated perioperative outcomes and postoperative complications of overweight patients who underwent SILC.

Methods

Two hundred two patients who underwent SILC were retrospectively evaluated. The data included demographics and outcomes such as postoperative complications and postoperative hospitalization were obtained. For the outcome analyses, patients were divided into two group according to their BMI (<30 vs ≥30 kg/m²).

Results

Of the 202 patients, 157 patients were in normal weight group and 45 patients were in overweight group. Mean operative time was 31.67?±?6.4 min in overweight group and 26.6?±?5.3 min in normal weight group. The wound infection rate for overweight and normal weight patients was 13.3 and 7.6 %, respectively. Eleven of the 202 patients (5.4 %) experienced port-site hernia (PSH).

Conclusions

This retrospective study comparing overweight and normal weight patient in SILC demonstrates that SILC is associated with the prolonged operative time, high additional port requirement, and increased wound complication rate. PSH occurrence rate was high after SILC irrespective of the body weight.