Diagnosis and management of prolactin-secreting pituitary adenomas: a Pituitary Society international Consensus Statement

This Consensus Statement from an international, multidisciplinary workshop sponsored by the Pituitary Society offers evidence-based graded consensus recommendations and key summary points for clinical practice on the diagnosis and management of prolactinomas. Epidemiology and pathogenesis, clinical presentation of disordered pituitary hormone secretion, assessment of hyperprolactinaemia and biochemical evaluation, optimal use of imaging strategies and disease-related complications are addressed. In-depth discussions present the latest evidence on treatment of prolactinoma, including efficacy, adverse effects and options for withdrawal of dopamine agonist therapy, as well as indications for surgery, preoperative medical therapy and radiation therapy. Management of prolactinoma in special situations is discussed, including cystic lesions, mixed growth hormone-secreting and prolactin-secreting adenomas and giant and aggressive prolactinomas. Furthermore, considerations for pregnancy and fertility are outlined, as well as management of prolactinomas in children and adolescents, patients with an underlying psychiatric disorder, postmenopausal women, transgender individuals and patients with chronic kidney disease. The workshop concluded that, although treatment resistance is rare, there is a need for additional therapeutic options to address clinical challenges in treating these patients and a need to facilitate international registries to enable risk stratification and optimization of therapeutic strategies.

Fabrication and dialysis performance of functionalized multiwall carbon nanotubes integrated cellulose acetate/poly(vinylpyrrolidone) membranes

Mixed matrix membranes (MMMs) of cellulose acetate/poly(vinylpyrrolidone) (CA/PVP) infused with acid functionalized multiwall carbon nanotubes (f-MWCNTs) were fabricated by an immersion phase separation technique for hemodialysis application. Membranes were characterized using FTIR, water uptake, contact angle, TGA, DMA and SEM analysis. The FTIR was used to confirm the bonding interaction between CA/PVP membrane matrix and f-MWCNTs. Upon addition of f-MWCNTs, TGA thermograms and glass transition temperature indicated improved thermal stability of MMMs. The surface morphological analysis demonstrated revealed uniform distribution of f-MWCNTs and asymmetric membrane structure. The water uptake and contact angle confirmed that hydrophilicity was increased after incorporation of f-MWCNTs. The membranes demonstrated enhancement in water permeate flux, bovine serum albumin (BSA) rejection with the infusion of f-MWCNTs; whereas BSA based anti-fouling analysis using flux recovery ratio test shown up to 8.4% improvement. The urea and creatinine clearance performance of MMMs were evaluated by dialysis experiment. It has been found that f-MWCNTs integrated membranes demonstrated the higher urea and creatinine clearance with increase of 12.6% and 10.5% in comparison to the neat CA/PVP membrane. Thus, the prepared CA/PVP membranes embedded with f-MWCNTs can be employed for wide range of dialysis applications.

Renal Function Replacement by Hemodialysis: Forty-Year Anniversary and a Glimpse into the Future at Hand

From its introduction in 1943 and until the late 1970s, hemodialysis (HD) has been a lengthy and cumbersome treatment administered by a few skilled physicians and technicians to a very limited number of terminal kidney patients. The technological innovations introduced over the years made HD a treatment administered and supervised by nursing personnel to a very large numbers of kidney patients, hopefully until recovery of kidney functions or kidney transplantation. In 2013, it is estimated that 2.250.00 kidney patients were treated worldwide, and their number is steadily increasing. Shortage of transplant kidneys and quality of current treatments has contributed to increasing the survival of HD patients. Today, it is not unusual to find patients who have been on HD for longer than twenty years. All this generated the feeling that performance of membranes and dialysis technology has reached its limit. Recently, the increasing economic burden of healthcare caused by people ageing and the increasing incidence of degenerative diseases (e.g. diabetes and cardiovascular diseases), and the economic crisis has pushed many governments and health insurances to cut resources for healthcare. The main consequence is that investments in research and development in HD have been significantly reduced. The question is whether there is indeed no need for innovation in HD.

In this paper, it is discussed how the paradigm of HD has changed and what possibly are now the drivers for innovation in HD. A few ideas are proposed that could be developed by adapting existing technologies to the future needs of HD.

Quality of life and sexuality in chronic dialysis female patients

Patients in end-stage renal disease (ESRD) present reduced quality of life (QOL) and impaired sexual function. Previous studies have mostly addressed male sexual dysfunction. This was a cross-sectional controlled study that applied a general and the World Health Organization Quality of Life-bref questionnaires to assess demographic, marital, and sexual conditions, and QOL in 86 healthy women aged 18 or more years (Group 1), and 38 female ESRD patients on dialysis for at least 2 months (Group 2). The effect of several explanatory variables upon QOL components was estimated. Quality of life was lower in Group 2 -- overall, and on physical and environment domains. To undergo dialysis and to be poorly educated negatively affected the QOL. Yet age, a stable marital relationship or being sexually active had no effect. Female patients undergoing chronic dialysis had lower QOL and were significantly more sexually dysfunctional than comparable healthy women. Decline in sexual function had no effect on the QOL.

Clinical study of high-flux cuprammonium rayon hemodialysis membranes

The aim of this crossover clinical study was to gain basic information on the hemocompatibility and effectiveness of recently developed high-flux membranes made of cuprammonium rayon with ultrafiltration coefficients of 10, 17, and 19 ml/mm Hg/h (S12W, SU12W, and SS12W dialyzers, respectively), and to identify any possible differences from a conventional membrane made of the same material with an ultrafiltration coefficient of 6 ml/mm Hg/h (C12W dialyzer). All the tested membranes led to an abrupt drop in leukocyte count in the initial phase of hemodialysis. In high-flux membranes, C5a anaphylatoxin would pass into the dialysate, but mean C5a anaphylatoxin concentrations in the dialysate were lower by orders of magnitude than its plasma concentrations, which behaved, in high- and low-flux membranes alike, typically of those made of nonsubstituted cellulose with no intermembrane differences. As judged by the concentrations of the thrombin-antithrombin III complex, the coagulation system was activated--again, without differences between membranes. The reduction rates for urea, creatinine, and phosphates were comparable for all the tested membranes. Compared with baseline, the post-dialysis serum concentrations of beta 2-microglobulin in high-flux membranes, unlike the low-flux membrane, were significantly lower. We conclude that there are no significant differences between the tested high- and low-flux membranes made of cuprammonium rayon in the monitored hemocompatibility parameters, and that high-flux membranes are capable of reducing serum beta 2-microglobulin concentrations.

Clinical evaluation of a new dialyzer, FLX-12 GW, with a polyester-polymer alloy membrane

The performance of a membrane in renal failure therapy is determined by its structure, its overall mass transfer properties, and its blood compatibility. In this regard, removal of beta 2-microglobulin (beta 2M) has become a major objective of dialysis therapy. In the present study, a newly developed high-flux membrane composed of a polyester-polymer alloy (PEPA) with the components of polyarylate and polyethersulfone (dialyzer FLX-12 GW; Nikkiso Co., Japan) has been evaluated with regard to both biocompatibility and elimination capacity for beta 2M during hemodialysis of 8 stable chronic uremic patients. The clearance values of low molecular weight solutes were in the same range as those reported for high-flux dialyzers of comparable surface area. There was no drop in leukocyte counts and only a minimal fall in platelet counts nearly in the same range as has been observed by other investigators using polyamide membrane. C3a Des Arg generation was low, and C5a Des Arg formation was not significantly influenced. There was a sharp drop in the serum beta 2M level (-35%) during dialysis with a clearance between 59.7 +/- 5.6 ml/min (QB 200 ml/min) and 70.1 +/- 9.7 ml/min (QB 300 ml/min), respectively. Accordingly, the sieving coefficient was calculated to be 0.2 at 30 min after start of dialysis and 0.6 1 h later. The membrane was able to remove 184.0 +/- 22.3 mg/4 h due to an apparent rate of adsorption during the first hour of treatment in combination with high transmembrane transfer in the following time.