Intensified inhibition of renin-angiotensin system: A way to improve renal protection?

Several large, randomized, multicenter studies in diabetic and nondiabetic patients with chronic proteinuric nephropathies have clearly demonstrated that angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARB) are able to reduce urinary protein excretion and retard renal disease progression. However, the number of patients who reach end-stage renal failure is still considerable and there is a great need to identify therapies that can arrest evolution of kidney damage. Maximizing renin-angiotensin system (RAS) blockade through combined ACE inhibitor and ARB therapy has been shown to further increase antiproteinuric and nephroprotective effects of each drug class. However, in order to slow to the greatest extent progression of renal disease, the ideal therapeutic approach for patients with proteinuric nephropathies should be a multimodal strategy including dual RAS blockade, antialdosterone therapy, lipid-lowering agents, smoking cessation, and tight glucose control for diabetes.     

Do not Deny Pancreatic Resection to Elderly Patients

Introduction  Radical resection is the only potential cure for pancreatic malignancies and a useful treatment for other benign diseases, such as pancreatitis. Over the last two decades, medical and surgical improvements have drastically changed the postoperative outcome of elderly patients undergoing pancreatic resection, and appropriate treatment for elderly potential candidates for pancreatic resection has become an important issue. Materials and Methods  Ninety-eight consecutive patients undergoing radical pancreatic resection between 2003 and 2006 at the Surgery Unit of the University of Modena, Italy, were considered and divided into two age groups, i.e., over 75-year-olds (group 1, 23 patients) and under 75-year-olds (group 2, 75 patients). The two groups were compared as regards demographic features, American Society of Anesthesiologists scores, comorbidities, previous major surgery, surgical procedure, postoperative mortality, and morbidity. Results  There were no significant differences between the two groups concerning postoperative mortality, and the duration of hospital stay and days in the postoperative intensive care unit were also similar. Complications such as pancreatic fistulas, wound infections, and pneumonia were more frequent in the older group, but the differences were not statistically significant. The overall median survival was 29.4 months and did not differ significantly between the two groups when calculated using the log-rank test (p = 0.961). Discussion  In the light of these findings and as reported for other series, old age is probably not directly related with any increase in the rate of postoperative complications, but comorbidities (which are naturally related to the patients’ previous life) may have a key role in the postoperative course.