Influence of Tyrosine Kinase Inhibitors on Hypertension and Nephrotoxicity in Metastatic Renal Cell Cancer Patients

Renal cell carcinoma (RCC) is one of the most common kidney malignancies. An upgraded comprehension of the molecular biology implicated in the development of cancer has stimulated an increase in research and development of innovative antitumor therapies. The aim of the study was to analyze the medical literature for hypertension and renal toxicities as the adverse events of the vascular endothelial growth factor (VEGF) signaling pathway inhibitor (anti-VEGF) therapy. Relevant studies were identified in PubMed and ClinicalTrials.gov databases. Eligible studies were phase III and IV prospective clinical trials, meta-analyses and retrospective studies that had described events of hypertension or nephrotoxicity for patients who received anti-VEGF therapy. A total of 48 studies were included in the systematic review. The incidence of any grade hypertension ranged from 17% to 49.6%. Proteinuria and increased creatinine levels were ascertained in 8% to 73% and 5% to 65.6% of patients, respectively. These adverse events are most often mild in severity but may sometimes lead to treatment discontinuation. Nephrotoxicity and hypertension are related to multiple mechanisms; however, one of the main disturbances in those patients is VEGF inhibition. There is a significant risk of developing hypertension and renal dysfunction among patients receiving anti-VEGF treatment; however, there is also some evidence that these side effects may be used as biomarkers of response to antiangiogenic agents.

Effectiveness of High Cut-Off Hemofilters in the Removal of Selected Cytokines in Patients During Septic Shock Accompanied by Acute Kidney Injury-Preliminary Study

Background

In recent years there have been attempts to treat sepsis using various methods of extracorporeal blood purification in order to eliminate selected mediators of inflammation.

Material/Methods

This retrospective study assessed 28 patients (17 males, 11 females, age 60.3 ± 14.5 years) in septic shock, treated with continuous venovenous hemodialysis (CVVHD). Oligoanuric patients with acute kidney injury were qualified for 24-hour CVVHD using high cut-off (HCO) hemofilter. Before the start of dialysis and after 24 hours of treatment, the concentration levels of selected cytokines (IFN-α, IFN-γ, TNF-α, IL-1β, IL-2, IL-6, IL-10, IL-12) in serum were assessed. After 12 hours and 24 hours of treatment, the concentration of the same cytokines in the dialysis fluid was assessed. The aim of our study was to evaluate the effectiveness of HCO-CVVHD in the removal of selected cytokines.

Results

After 24-hour HCO-CVVHD treatment, IL-10 and IL-12 levels in serum were significantly lower. Concentrations of INF-α, IL-1β and IL-2 in dialysis fluid significantly increased during HCO-CVVHD, which corresponded with the parallel rise of related clearances. Clearance of IL-6 was approximately four times higher than IL-10. The rise of IL-6 during HCO-CVVHD significantly correlated with mortality due to sepsis.

Conclusions

Continuous venovenous hemodialysis using high cut-off hemofilter proved to be effective in the removal of IFN-α, IL-1β, IL-2 and IL-6, IL-10 and IL-12 from serum in patients during septic shock. The rise of IL-6 during HCO-CVVHD seems to be a marker of bad prognosis in septic shock patients.

Renal vascular response to angiotensin II inhibition in intensive antihypertensive treatment of essential hypertension

INTRODUCTION

High blood pressure (BP) leads to target organ damage. It is suggested that regression of early organ lesions is possible on condition of BP normalization. The study objective was to assess whether permanent reduction of BP to the recommended values modifies renal vascular response to acute angiotensin II inhibition in the Doppler captopril test (DCT) in patients with essential hypertension (EH).

MATERIAL AND METHODS

Twenty-nine persons (58 kidneys) were found eligible for the study: 18 patients with EH and 11 healthy volunteers constituting the control group. Glomerular filtration rate estimation (eGFR), 24-h ambulatory BP monitoring (ABPM) and DCT with evaluation of renal resistive index change (ΔRI) were performed before and after a 6-month period of intensive antihypertensive therapy (IAT). Additional ABPM was performed at the end of IAT.

RESULTS

The mean IAT period was 8.5 ±2.4 months. The mean 24-h values of systolic and diastolic BP in the EH group were significantly lower in the IAT period than at the beginning and at the end of the study. Significantly lower systolic and diastolic BP (p < 0.05) and improvement of renal function (eGFR 121 ±38 vs. 139 ±40 ml/min, p < 0.001) were found after IAT as compared to initial values. Before IAT, ΔRI was significantly lower in the EH group as compared to the controls, but no such differences were found after IAT.

CONCLUSIONS

In EH patients, intensive BP lowering to the recommended values was associated with improvement of renal function and normalisation of renal vascular response to acute angiotensin II inhibition.

Renal perfusion index reflects cardiac systolic function in chronic cardio-renal syndrome

BACKGROUND

Cardiac dysfunction can modify renal perfusion, which is crucial to maintain sufficient kidney tissue oxygenation. Renal cortex perfusion assessed by dynamic ultrasound method is related both to renal function and cardiac hemodynamics. The aim of the study was to test the hypothesis that Renal Perfusion Index (RPI) can more closely reflect cardiac hemodynamics and differentiate etiology of chronic cardio-renal syndrome.

MATERIAL AND METHODS

Twenty-four patients with hypertension and chronic kidney disease (CKD) at 2-4 stage (12 with hypertensive nephropathy and 12 with CKD prior to hypertension) were enrolled in the study. Blood tests, 24-h ABPM, echocardiography, and ultrasonography with estimation of Total renal Cortical Perfusion intensity and Renal Perfusion Index (RPI) were performed.

RESULTS

In the group of all patients, RPI correlated with left ventricular stoke volume (LVSV), and cardiac index, but not with markers of renal function. In multiple stepwise regression analysis CKD-EPI(Cys-Cr) (b=-0.360), LVSV (b=0.924) and MAP (b=0.376) together independently influenced RPI (R2=0.74; p<0.0001). RPI<0.567 allowed for the identification of patients with chronic cardio-renal syndrome with sensitivity of 41.7% and specificity of 83.3%.

CONCLUSIONS

Renal perfusion index relates more strongly to cardiac output than to renal function, and could be helpful in recognizing chronic cardio-renal syndrome. Applicability of RPI in diagnosing early abnormalities in the cardio-renal axis requires further investigation.

Renal autoregulation in medical therapy of renovascular hypertension

INTRODUCTION

Renovascular hypertension (RVH) is caused by renal ischaemia associated with haemodynamically significant renal artery stenosis (RAS). The choice of optimal treatment of atherosclerotic RAS is still controversial. Increase in the renal resistive index (RI) value after captopril administration is considered to indicate preserved renal autoregulation. The objective of the study was to assess the effect of medical therapy of RVH on renal autoregulation efficiency in patients with atherosclerotic RAS.

MATERIAL AND METHODS

19 persons (38 kidneys) in 2 groups: 1) study: with RVH and stenosis of 1 renal artery - 8 patients; 2) control: - 11 healthy volunteers. Doppler captopril test with RI measurements and estimation of creatinine clearance (CCr) were performed in both groups at baseline, and after a period of controlled medical therapy (CMT) only in the study group. ABPM was evaluated in controls at baseline, and in the study group at the end of CMT.

RESULTS

In the study group the mean period of CMT was 8.3 ±2.7 months, the number of antihypertensive drugs was 4.1 ±1.0, and mean 24-hour blood pressure was 138/74 mmHg. Mean CCr was stable during the study. Significant increase of RI after captopril was found only in controls. At baseline, in the group of kidneys with a non-stenotic renal artery, significant lowering of RI was observed, and ΔRI differed significantly from controls. After CMT, ΔRI increased in non-stenotic kidneys in comparison to the baseline, and did not differ from controls.

CONCLUSIONS

Adequate medical therapy of RVH preserved renal function and improved renal autoregulation efficiency in non-stenotic kidneys.

Removal of Procalcitonin and Selected Cytokines during Continuous Veno-Venous Hemodialysis Using High Cutoff Hemofilters in Patients with Sepsis and Acute Kidney Injury

INTRODUCTION

The purpose of this study was to evaluate the impact of continuous veno-venous hemodialysis (CVVHD) using high cutoff (HCO) hemofilters on the removal of procalcitonin (PCT), and other inflammatory markers in the treatment of patients during septic shock with acute kidney injury (AKI).

MATERIALS AND METHODS

Thirty-six patients with septic shock and AKI were included in the study. Before and after the 24-h HCO-CVVHD, PCT, native C-reactive protein (CRP) and cytokines (interleukin-1β, interleukin-6, interleukin-12, interleukin-17, tumor necrosis factor-α) in serum and effluent were assessed.

RESULTS

After the HCO-CVVHD serum concentrations of PCT, CRP and selected cytokines were significantly lower. The decrease in PCT was bigger than in CRP (p = 0.007). The change in PCT concentration was significantly influenced by PCT and IL-17 clearances (R2 = 0.525; p < 0.001).

CONCLUSION

In contrast to the native CRP, monitoring of PCT during HCO-CVVHD is less useful because it reflects the clearance of this marker and anti-inflammatory effectiveness of the method.

Ultrasonic evaluation of renal cortex arterial area enables differentiation between hypertensive and glomerulonephritis-related chronic kidney disease

PURPOSE

Identifying the primary etiology of cardio-renal syndrome in a timely manner remains an ongoing challenge in nephrology. We hypothesized that hypertensive kidney damage can be distinguished from chronic glomerulonephritis at an early stage of chronic kidney disease (CKD) using ultrasound (US) Doppler sonography.

METHODS

Fifty-six males (age 54 ± 15, BMI 28.3 ± 3.5 kg/m2) with hypertension and stable CKD at stages 2-4 [38 with essential hypertension (HT-CKD); 18 with glomerulonephritis (GN-CKD)] were studied. Blood tests, UACR, echocardiography, ABPM, carotid IMT, and an ultrasound dynamic tissue perfusion measurement (DTPM) of the renal cortex were performed.

RESULTS

HT-CKD patients had reduced proximal renal cortex perfusion as well as reduced total and proximal renal cortex arterial area. Proximal renal cortex arterial area ≤0.149 cm2 identified hypertension-related CKD with a sensitivity of 71% and a specificity of 78% (AUC 0.753, p < 0.001).

CONCLUSIONS

Evidence of diminished arterial vascularity or perfusion of renal proximal cortex, both derived from US Doppler, could be helpful in differentiating hypertensive nephropathy from glomerulonephritis-related CKD.

Strain of experimental animals and modulation of nitric oxide pathway: their influence on development of renal failure in an experimental model of hepatorenal syndrome

INTRODUCTION

Pathomechanism of HRS is still poorly understood. The aim of our study was: (1) to test whether different strains of rats could develop typical HRS, and (2) to estimate the influence of activation and inhibition of nitric oxide for development of renal failure in course of HRS.

MATERIAL AND METHODS

First, we used 16 of Wistar and 16 of Sprague-Dawley rats in galactosamine model of HRS. Next, we used 48 of SDR rats, which received saline, N-nitro-L-arginine or L-arginine before and after liver damage. Twenty four hours urine and blood samples were collected 48 h after saline or Ga1N injection. Biochemical parameters were determined in serum or urine and then creatinine clearance and osmolality clearance were calculated. Liver and kidney tissues were collected for histopathological examination.

RESULTS

Liver failure developed in all tested groups with significant increase of bilirubin (p < 0.001), ALT (p < 0.001) and ammonia (p < 0.001). Nevertheless we did not achieve any evidence of renal failure in Wistar, but we found typical renal failure in Sprague-Dawley group with significant decrease in creatinine clearance (p < 0.0012) and increase in concentration of creatinine and urea (p < 0.001) and (p < 0.001) respectively. Inhibition of NOS prevented development of renal failure with significant improvement of GFR both before (p < 0.0017) and after (p < 0.003) Ga1N injection. Injection of L-arginine after Ga1N injection did not caused significant improvement of GFR.

CONCLUSIONS

Our study showed, that genetic factors might be responsible for development of renal failure in course of HRS and nitric oxide play important role in acute model of this syndrome.

Dynamic tissue perfusion assessment reflects associations between antihypertensive treatment and renal cortical perfusion in patients with chronic kidney disease and hypertension

PURPOSE

Renal cortical perfusion measured in noninvasive, dynamic ultrasonic method is connected with the hemodynamic cardiac properties and renal function. Antihypertensive drugs affect the functioning of the heart and kidneys. The aim of the study was to evaluate the effect of a chronic use of antihypertensive drugs on ultrasound parameters of renal cortical perfusion.

METHODS

The study included 56 consecutive patients (49 M + 7 F, age 54.0 ± 13.3) with stable chronic kidney disease and hypertension. Color Doppler dynamic tissue perfusion measurement was used to assess renal cortical perfusion.

RESULTS

Patients were treated with a mean of 2.7 ± 1.4 antihypertensive drugs, of which diuretics accounted for 25%, angiotensin-converting enzyme inhibitors (ACE-I) together with angiotensin receptor blockers (ARB) 24%, beta-blockers (BB) 23%, calcium channel blockers 16%, alpha-1 blockers (α1B) 9% and centrally acting drugs 3%. All investigated groups of drugs correlated significantly with parameters of renal perfusion. In multivariable regression analyses adjusted to age, diuretics were connected with the decrease (r = - 0.473) and ACE-I + ARB (r = 0.390) with the improvement of proximal and whole renal cortex perfusion (R² = 0.28; p < 0.001), whereas BB (r = - 0.372) and α1B (r = - 0.280) independently correlated with worsened perfusion of renal distal cortex (R² = 0.21, p < 0.01).

CONCLUSIONS

The type of antihypertensive therapy had a significant influence on the ultrasound parameters of renal cortical perfusion. Noninvasive, ultrasonic dynamic tissue perfusion measurement method appears to be an adequate tool to assess the impact of drugs on renal cortical perfusion.

Hemodynamic characteristics and the occurrence of renal biopsy-related arteriovenous fistulas in native kidneys

Purpose

Renal biopsy-related arteriovenous fistula (RB-AVF), although usually asymptomatic, may sometimes result in serious clinical implications. The aim of the study was to prospectively evaluate the incidence of RB-AVF in native kidneys, together with the assessment of hemodynamic characteristics and the impact of the histopathological results of biopsy.

Methods

The study included 138 patients (age 46.2 ± 15.2; 70 F, 68 M), who underwent percutaneous renal biopsy (PRB) of the native kidney. In all patients, 2D and color Doppler ultrasound was performed 24 h after PRB in order to exclude RB-AVF.

Results

Bleeding complications in the form of hematomas were found in 136 patients (98.55 %), and 23 cases of RB-AVF were observed (16.67 %). RB-AVF group had an increased maximal hematoma diameter and reduced number of glomeruli in PRB. The segmental arteries supplying the fistulas are characterized by higher maximum flow velocity (FV) and a lower resistance index (RI) compared to the normal segmental arteries (difference 45.9 ± 20.0 cm/s and 0.252 ± 0.104, respectively). In the ROC analysis, RI ≤ 0.524 allowed to detect RB-AVF with a sensitivity of 91 % and specificity of 100 % (AUC 0.998, p < 0.001). In approximately 39 % of RB-AVF cases, 2D ultrasound detected a hyperechogenic ischemic area between the fistula and the renal capsule.

Conclusions

Arteriovenous fistula is a quite frequent complication of native renal biopsy and can cause ischemia in the renal parenchyma detected by ultrasound. The arteries supplying the fistula are characterized by an increased flow velocity and reduced resistance index.

Doppler tissue perfusion parameters in recognizing pancreatic malignant tumors

BACKGROUND

Histopathology, radiological imaging methods with the administration of contrast agents are efficient to differentiate focal lesions of the pancreas. Invasiveness, contrast toxicity, and limited accessibility ameliorate their application. Noninvasive and contrast-agent-free method could improve diagnostics and accelerate treatment.

AIMS

The aim of the study is to evaluate the diagnostic properties of ultrasound parameters of organ perfusion in the detection of malignant tumors of the pancreas.

METHODS

Thirty-six patients with a focal lesion of the pancreas underwent endosonography with color flow imaging and biopsy for histological evaluation. Five patients were excluded because of the absence of the Doppler signal in pancreatic lesion. In the dynamic tissue perfusion measurement (DTPM) means of flow velocity (FV), resistive index, pulsatility index, and perfusion relief intensity (PR) were estimated.

RESULTS

In the group with malignant tumors FV was significantly lower compared with the group with inflammatory changes. In receiver operating characteristic (ROC) analysis FV below the optimal cut-off point of 2.382 cm/s identified patients with malignant lesions with a sensitivity of 92% and specificity of 90%. In the group with malignant tumors significantly lower values of PR in all considered percentiles were observed. Based on the ROC analysis in the group with solid tumors, it was found that PR25 ≤ 0.057 allowed to recognize malignancies with a sensitivity of 100% and specificity of 80%, and in the groups with solid and cystic tumors with a sensitivity of 100% and specificity of 79%.

CONCLUSIONS

FV and PR intensity derived from DTPM are reliable markers in recognition of pancreatic malignant masses.

Noninfectious, Severe Cryoglobulinemic Vasculitis with Renal Involvement - Safety and Efficacy of Long-Term Treatment with Rituximab

Background

The management of nonviral cryoglobulinemic vasculitis (CV) has not been established yet. Randomized control trials are challenging to perform because of the rarity of the disease. The most promising biological therapy is rituximab (RTX), an anti-CD 20 monoclonal antibody. The aim of the study was to assess rituximab treatment's safety and effectiveness in patients with severe noninfectious cryoglobulinemic vasculitis.

Materials and Methods

We retrospectively reviewed 8 courses of RTX treatment in three patients with severe noninfectious CV. In 2 patients, the indication for the start of RTX therapy was the relapse of the disease despite the maintenance treatment, for the third patient, it was the first-line therapy.

Results

Clinical, renal, and immunologic efficacy was observed in all evaluable RTX courses. We found a significant decrease of cryoglobulins in the 3-rd month from RTX treatment. However, 5 clinical relapses occurred and two patients experienced severe adverse events (SAEs) after RTX therapy. Patients with SAEs were relatively older and had a longer duration of disease. Lower levels of hemoglobin, C3 component of complement and eGFR as well as higher rheumatoid factor (RF) concentration were observed before RTX treatments complicated with SAEs.

Conclusion

Data from our observation show the efficacy of rituximab in the refractory, nonviral cryoglobulinemic vasculitis with a severe course of the disease. However, the therapy is associated with the risk of SAEs, especially in elderly patients with kidney failure and significant immunologic alterations.

Selected protein expression in a new prognostic model for patients with non-muscle-invasive bladder cancer

INTRODUCTION

After transurethral resection of a bladder tumor, patients frequently have a recurrence of the disease, thereby requiring adjuvant therapy.

PURPOSE

The study aimed to determine the prognostic value of expression levels of p53, Ki-67, and survivin, and to develop a new prognostic model for patients with non-muscle-invasive bladder cancer (NMIBC) after transurethral resection of a bladder tumor.

METHODS

The study group consisted of 101 patients with primary NMIBC. Univariate followed by multivariate Cox proportional hazard regression analysis was performed to obtain a model including the smallest possible number of descriptive variables with the highest statistical significance and impact on risk.

RESULTS

The RECINT model (RECurrence In Not Treated) including factors independently associated with cancer recurrence (tumor size [HR 1.148; p = 0.034], intensity of the color reaction for p53 [HR 1.716; p = 0.008], Ki-67 [HR 3.001; p = 0.022], and survivin [HR 1.461; p = 0.021]) adequately stratified recurrence free-survival (R2 = 0.341, p < 0.001) in patients with primary NMIBC. Patients with the lowest RECINT score (0-6) had the lowest probability of cancer recurrence (1- and 5-year recurrence of 16%) in comparison with other groups (p < 0.001).

CONCLUSIONS

The RECINT model may be useful for stratifying the risk of recurrence in patients with non-muscle-invasive bladder cancer and may allow for identification of those who may benefit the most from adjuvant BCG immunotherapy.

Recombinant Human Thyrotropin Worsens Renal Cortical Perfusion and Renal Function in Patients After Total Thyroidectomy Due to Differentiated Thyroid Cancer

Background: Although thyrotropin (TSH) receptors are found in many nonthyroid tissues, we know little about the direct action of TSH on these receptors. Patients after total thyroidectomy for differentiated thyroid cancer (DTC) provide an interesting model for studying this issue. The administration of exogenous TSH in patients with an established thyroid state on levothyroxine (LT4) treatment allows us to study the effect of elevated TSH concentrations independent of thyroid status on the function of various organs, including the kidneys. The aim of this study was to assess the effects of the administration of recombinant human TSH (rhTSH) on renal perfusion and glomerular filtration in this group of patients. Methods: The study included 24 patients after total thyroidectomy due to DTC, without concomitant diseases, receiving only LT4 who qualified for radioiodine treatment (RIT). For two consecutive days, the patients received rhTSH and subsequently the RIT. Clinical and biochemical evaluation of thyroid and renal function was carried out before and 24 hours after the second dose of rhTSH and before the RIT. On the sixth day of hospitalization, the patients' glomerular filtration rate was re-evaluated. Kidney perfusion was assessed using color Doppler ultrasound imaging before and 24 hours after the second dose of rhTSH and before the RIT. Results: The administration of rhTSH to patients after total thyroidectomy due to DTC caused significant deterioration of renal perfusion after the second dose of rhTSH before the RIT, which was followed by a significant reduction in glomerular filtration. Furthermore, rhTSH did not significantly affect the hemodynamic parameters that could worsen renal function. Conclusions: This study indicates that TSH alone, independent of thyroid hormone concentrations, can influence renal perfusion and renal function.

Increased Intestinal Permeability and Stool Zonulin, Calprotectin and Beta-Defensin-2 Concentrations in Allogenic Hematopoietic Cell Transplantation Recipients

Significant progress has been made in understanding the connection between intestinal barrier function and allogenic hematopoietic cell transplantation (allo-HCT) recipients' outcomes. The purpose of this study was to further evaluate gut barrier permeability and other potential intestinal barrier disruption markers in the allo-HCT setting. Fifty-one patients were enrolled in the study. Intestinal permeability was assessed with the sugar absorption test and faecal concentrations of the zonulin, calprotectin and beta-defensin-2 levels in the peri-transplantation period. Most patients undergoing allo-HCT in our department had a disrupted intestinal barrier at the baseline, which was associated with older age and higher Hematopoietic Cell Transplantation-specific Comorbidity Index (HCT-CI). Regardless of this, we observed a further increase in gut barrier permeability after allo-HCT in most patients. However, there was no association between permeability assay and other markers (zonulin, calprotectin and beta-defensin-2). Patients with acute GVHD had significantly higher median calprotectin concentrations after allo-HCT compared with the patients without this complication. Our findings indicate that gut barrier damage develops prior to allo-HCT with progression after the procedure and precedes further complications, but did not prove other markers to be useful surrogates of intestinal permeability.

Evaluation of the usefulness of positron emission tomography with [18F]fluorodeoxylglucose performed to detect non-radioiodine avid recurrence and/or metastasis of differentiated thyroid cancer - a preliminary study

BACKGROUND

About 30% of patients with disseminated differentiated thyroid cancer (DTC) may experience a loss of iodine uptake. It is associated with higher aggressiveness of the tumour and a reduced 10-year survival rate. The diagnosis of non-radioiodine avid DTC metastases remains a diagnostic challenge. A helpful technique for this diagnosis is positron emission tomography with 2-[¹⁸F]fluoro-2-deoxy-D-glucose (PET/CT with [¹⁸F]FDG). On the other hand, there are still discussions about the clinical value of using exogenous thyroid-stimulating hormone (TSH) stimulation before PET/CT with [¹⁸F]FDG. The aim of the study was the assessment of the usefulness of PET/CT with [¹⁸F]FDG under TSH suppression and stimulation of TSH performed in the detection of non-radioiodine avid DTC metastases, as well as determination of the thyroglobulin concentration under suppression and stimulation of TSH, which influences the result of PET/CT with [¹⁸F]FDG in patients with non-radioiodine avid DTC.

MATERIAL AND METHODS

Retrospective analysis of 37 PET/CT with [¹⁸F]FDG performed in patients with DTC diagnosed and treated at the Department of Endocrinology and Isotope Therapy of the Military Institute of Medicine from January 2018 to July 2020. Of these, PET/CT with [¹⁸F]FDG under exogenous rhTSH stimulation was performed in 22 patients and PET/CT with [¹⁸F]FDG under TSH suppression in 15 was performed. In all analyzed patients, the result of diagnostic whole-body scintigraphy (WBS) using 80 MBq ¹³¹I under rhTSH stimulation was negative, and the concentration of thyroglobulin after stimulation (sTg) was greater than 1.0 ng/mL.

RESULTS

In the group of patients examined under TSH suppression, non-radioiodine avid in PET/CT with [¹⁸F]FDG were found in 6 out of 15 patients (40%) and in the group of patients examined under rhTSH stimulation in 10 out of 22 patients (45%). The differences between the groups were not statistically significant. The analysis of the receiver operating characteristic (ROC) curves allowed to determine the cut-off point for the positive result of PET/CT performed under TSH suppression with sTg concentration of 11.03 ng/mL. In the group of studies performed under rhTSH stimulation, the cut-off point for sTg was 6.3 ng/mL. There was no statistically significant difference between the baseline thyroglobulin (natTg) and sTg levels and the positive PET/CT result. The administration of rhTSH before the PET/CT examination also had no statistically significant effect on the maximum standard uptake value (SUVmax) of the dominant lesion identified in the PET/CT.

CONCLUSIONS

1) PET/CT with [¹⁸F]FDG is a useful tool for detection of non-radioiodine avid recurrence and/or metastases of DTC. 2) The concentration of natTg and sTg is highly correlated with a positive result of PET/CT with [¹⁸F]FDG. 3) The concentration of natTg is comparable with sTg in predicting a positive result of PET/CT with [¹⁸F]FDG. 4) The cut-off point for a positive result of PET/CT for natTg was 1.36 ng/mL and for sTg was 7.05 ng/mL.

Multi-Method Complex Approach for Hydration Assessment Does Not Detect a Hydration Difference in Hemodialysis versus Peritoneal Dialysis Patient

Assessment of hydration status is essential in monitoring the effectiveness of renal replacement therapy and is usually based on physical examination. However, comparisons of hydration status achieved with different dialysis methods are not conclusive. We compared the hydration status of patients on chronic hemodialysis (HD, n = 60) and peritoneal dialysis (PD, n = 20) in a comprehensive assessment including physical examination and additional methods. The mean age of the 80 chronically dialyzed patients (53 males, 27 females) was 58.1 ± 13.9 years. The clinical evaluation took into account the presence of peripheral edema, dyspnea, and crackling over the lung fields. Additional tests included lung ultrasound, electrical bioimpedance (performed in 79 patients), impedance cardiography, ultrasound assessment of large abdominal vessels (performed in 79 patients), select echocardiographic parameters (obtained in 78 patients), and serum NT-proBNP concentration. Residual diuresis volume was significantly higher in the PD group. We found no significant differences between the two groups in any other baseline characteristics or in the results of the clinical examination or additional tests. The use of different methods for assessing hydration does not allow differentiation of patients treated with dialysis in terms of the dialysis technique used. Therefore, it seems reasonable to use common algorithms to objectify the hydration status of these patients.

Ultrasound Doppler Flow Parameters Are Independently Associated with Renal Cortex Contrast-Enhanced Multidetector Computed Tomography Perfusion and Kidney Function

BACKGROUND

The assessment of kidney perfusion has an emerging significance in many diagnostic applications. However, whether and which of the ultrasound Doppler parameters better express renal cortical perfusion (RCP) was not shown. The study aimed to prove the usefulness of Doppler ultrasound parameters in the assessment of RCP regarding low-dose contrast-enhanced multidetector computer tomography (CE-MDCT) blood flow.

METHODS

Thirty non-stenotic kidneys in twenty-five hypertensive patients (age 58.9 ± 19.0) with mild-to-severe renal dysfunction were included in the study. Resistive index (RI) and end-diastolic velocity (EDV) in segmental arteries, color Doppler dynamic RCP intensity (dRCP), RI (dRI), pulsatility index (dPI), and CE-MDCT blood flow (CBF) in the renal cortex were estimated.

RESULTS

CBF correlated significantly with age, estimated glomerular filtration rate (eGFR), RI, EDV, dRI, dPI, and dRCP. In separate multivariable backward regression analyses, RI (R² = 0.290, p = 0.003) and dRCP (R² = 0.320, p = 0.001) were independently associated with CBF. However, in the common ultrasound model, only dRCP was independently related to CBF (R² = 0.317, p = 0.001). Only CBF and EDV were independently associated with eGFR (R² = 0.510, p < 0.001).

CONCLUSIONS

Renal cortical perfusion intensity is the best ultrasound marker expressing renal cortical perfusion. In patients with hypertension and kidney dysfunction, renal resistive index and end-diastolic velocity express renal cortical perfusion and kidney function, respectively.

Application of the Molecular Adsorbent Recirculating System in Type 1 Hepatorenal Syndrome in the Course of Alcohol-Related Acute on Chronic Liver Failure

BACKGROUND This study aimed to evaluate the Molecular Adsorbent Recirculating System (MARS) effectiveness in patients with alcohol-related acute-on-chronic liver failure (AoCLF) complicated with type 1 hepatorenal syndrome (HRS). So far, MARS efficacy and safety has been demonstrated in various acute liver failure scenarios. MATERIAL AND METHODS Data from 41 MARS procedures (10 patients with type 1 HRS, in the course of alcohol-related AoCLF were considered for this study. Biochemical tests of blood serum were performed before and after each procedure. The condition of patients was determined before and after the treatment with the use of the model for end-stage liver disease - sodium (MELD-Na) and the stage of encephalopathy severity based on the West Haven criteria. RESULTS During the observation period (20.5±13.9 days), 5 patients died, and the remaining 5 surviving patients were discharged from the hospital. In the group of 10, the 14-day survival, starting from the first MARS treatment, was 90%. The MARS procedure was associated with a 19% reduction in bilirubin (27.5±6.1 versus 22.3±4.0 mg/dL, P<0.001), 37% reduction in ammonia (44.1±22.5 versus 27.6±20.9 P<0.001), 27% reduction in creatinine (1.5±1.0 versus 1.1±0.6 mg/dL, P<0.001) and 14% reduction urea (83.8±36.1 versus 72.1±33.3, P<0.001) in blood serum samples, with stable hemodynamic parameters. In the group of patients discharged from the clinic (n=5), the MARS treatments resulted in an improvement in hepatic encephalopathy (West Haven; P=0.043), as well as a reduction in the MELD-Na score (P=0.015). CONCLUSIONS MARS is a hemodynamically safe method for supporting the function of the liver and the kidneys. Application of the MARS reduces the symptoms of encephalopathy in patients with alcohol-related type 1 HRS.

CD4, CD20 and PD-L1 as Markers of Recurrence in Non-Muscle-Invasive Bladder Cancer

INTRODUCTION

A tumor microenvironment plays an important role in bladder cancer development and in treatment response.

PURPOSE

The aim of the study was to assess how the components of the microenvironment affect tumor recurrence and to find the potential biomarkers for immunotherapy in NMIBC.

METHODS

The study group consisted of 55 patients with primary NMIBC. Immunohistochemistry was performed on sections of primary papillary urothelial carcinoma of the bladder. Cox proportional hazard multiple regression analysis was performed to characterize tumors with the highest probability of an unfavorable outcome.

RESULTS

Multivariate analysis confirmed that the CD4 (p = 0.001), CD20 (p = 0.008) and PD-L1 expressed on tumor cells (p = 0.01) were independently associated with the risk of recurrence of bladder cancer. Patients with weak CD4+ cell infiltration (<4.6%) and severe CD20+ infiltration (>10%) belong to the group with a lower risk of recurrence. The cancer in this group also frequently recurs after 12 months (p = 0.0005).

CONCLUSIONS

The evaluation of CD4+ and CD20+ cells in the tumor microenvironment, in addition to PD-L1 on tumor cells, facilitates the determination of a group of patients with a low risk of recurrence.

[Treatment of renal anemia with intravenous erythropoietin in patients in the program of continuous ambulatory peritoneal dialysis]

AIM OF THE STUDY

In the face of non fully correctable renal anemia in patients on continuous ambulatory peritoneal dialysis (CAPD) injecting erythropoetin subcutaneously by themselves, we compared the effectiveness of renal anemia compensation as well as potentially positive influence on the clinical course of CAPD erythropoietin alpha (EPOalpha) given intravenously 1 or 2 times weekly, by PD-nurse at patients home with the same protocol of erythropoietin beta (EPObeta) given subcutaneously by patient himself or by family helper.

MATERIAL AND METHODS

There were 2 groups of CAPD patients qualified in years 2003-2005 to the 6 months study. Group 1 consisted of 12 patients who were receiving EPOalpha intravenously (7 women and 5 men; aged 57.8 +/- 14.0 years) and group 2 consisted of 12 patients who were given EPObeta subcutaneously by themselves (7 women and 5 men; age 58.0 +/- 12.5 years). In the course of home visits the nurses supervised the correctness of CAPD program performed by patient or family helper.

RESULTS

The results were as follows: we observed significant increase of the Hgb level in the group 1 between 3-rd and 6-th month of the study without significant increase of EPO dose. With respect to the course of CAPD program we found significantly higher frequency of peritonitis (1/11 vs 1/68 patient months; p < 0.05) and longer mean time of hospitalization (2.33 +/- 1.97 vs 1.17 +/- 1.03 days/pt; p < 0.05) in the group 2 in comparison with group 1. Mean peritonitis-free survival time was significantly longer in the group 1 in comparison with the group 2 (22.14 +/- 6.41 vs 16.51 +/- 9.70 weeks; p < 0.05).

CONCLUSIONS

We conclude that EPOalpha given intravenously by PD-nurse in patient home enabled maintenance of recommended Hgb level. The additional benefit from nurse assisted PD was reduction of peritonitis rate as well as duration of hospitalization from various reasons.