Short daily hemodialysis rapidly improves nutritional status in hemodialysis patients

BACKGROUND

Malnutrition is a common problem in maintenance hemodialysis patients and is associated with increased mortality and morbidity. Interventions such as oral or intravenous nutritional supplements have often failed to improve nutritional status. We studied the effect of a daily dialysis program on nutritional parameters.

METHODS

Eight patients treated with standard hemodialysis (SHD) 4 to 5 hours three times per week were converted to daily hemodialysis (DHD) 2 to 2.5 hours six times per week. Serum albumin, prealbumin, and total cholesterol were evaluated every three months. Anthropometry and dietary evaluation were performed every six months.

RESULTS

Serum albumin rose from 39.0 +/- 2.6 to 42.0 +/- 3.1 and 43.0 +/- 2.6 g/L, prealbumin from 0.36 +/- 0.04 to 0.41 +/- 0.05 and 0.42 +/- 0.1 g/L, total cholesterol from 1.7 +/- 0.4 to 1.9 +/- 0.4 and 1.8 +/-0.3 g/L at baseline and at 6 and 12 months, respectively, after switching patients to DHD. Daily protein intake increased from 1.29 +/- 0.20 g/kg/day to 1.48 +/- 0.60 and 1.90 +/- 0.70 (P < 0.05). These changes were accompanied by a dry body weight increase of 2.4 +/- 1.6 kg (P < 0.005) at month 6 and 4.2 +/- 2.8 kg at one year (P < 0.05). Lean body mass increased from 47.7 +/- 4.9 kg to 49.1 +/- 5.9 (P < 0.05) and 50.5 +/- 6.2 (P < 0.05).

CONCLUSIONS

Daily hemodialysis appears to be a suitable method to improve nutritional status in maintenance dialysis patients.

A meta-analysis of 21 178 patients undergoing open or endovascular repair of abdominal aortic aneurysm

Background

Several studies have compared outcomes after elective open and endovascular approaches to abdominal aortic aneurysm (AAA) surgery, with varying results.

Methods

A random-effects meta-analysis was undertaken to compare operative outcomes, postoperative complications, 30-day mortality and long-term patient survival after surgery. Endpoints were compared using odds ratios (ORs), weighted mean differences (WMDs) or log hazard ratios (HRs) as appropriate.

Results

Forty-two studies comprising 21 178 patients (10 855 open; 10 323 endovascular) were included. In the elective setting (20 715 patients), the endovascular method was associated with a shorter stay in intensive care (WMD − 36 h; P &lt; 0·001) and a shorter total postoperative stay (WMD − 5·4 days; P &lt; 0·001). Cardiac (OR 1·76; P = 0·002) and respiratory (OR 4·01; P &lt; 0·001) complications were more common after open surgery. In the endovascular group, 30-day mortality was lower (OR 0·46; P &lt; 0·001). Endovascular surgery was also associated with an improved long-term aneurysm-related mortality (HR 0·39; P &lt; 0·001). For ruptured AAA (463 patients), the less invasive operation was associated with a reduced stay in intensive care (WMD − 100·4 h; P = 0·005) and a significantly lower 30-day mortality (OR 0·45; P = 0·005).

Conclusions

The endovascular repair of AAA offers a clear benefit in terms of reduction in postoperative adverse events and 30-day mortality. In the longer term, it is also associated with a reduction in aneurysm-related mortality, but not in all-cause mortality.

Phlegmasia caerulea dolens and venous gangrene

Phlegmasia caerulea dolens and venous gangrene are rare conditions that tend to occur in association with malignancy. They are characterized by total or near-total occlusion of the venous drainage of the limb, including the microvascular collaterals. Associated mortality and morbidity rates are high, especially when progression to venous gangrene has occurred. Treatment options are limited; elevation and anticoagulation are recommended as first-line management. Experience with thrombolysis has been disappointing although intra-arterial administration of thrombolytic agents may improve results. Thrombectomy cannot be advocated routinely. Little advance in management, or in life and limb salvage, has been made in the past 30 years.

Management of asymptomatic popliteal aneurysms: the use of a Markov decision tree to determine the criteria for a conservative approach

With recent improvements in the results of treatment of popliteal aneurysms, it has been suggested that it may be preferable to treat asymptomatic aneurysms conservatively and to operate only if symptoms develop. This hypothesis has been tested using decision analysis, with sensitivity and threshold analysis to establish the conditions under which such a policy would be appropriate. A Markov decision tree has been used to model the problem and the relevant probabilities have been obtained from a review of the current literature. A computer spreadsheet was used to calculate the results of policies of immediate operation or operation only if symptoms occur. Sensitivity and threshold analysis have been carried out to assess the effect of inaccuracy or alteration in the key variables and to determine the optimum policy under different conditions. The results suggest that early elective operation produces better results than conservative management at 1-2 years after presentation. Sensitivity analysis reveals that the most crucial data are the rate of development of symptoms in patients with asymptomatic aneurysms and the expected limb loss and mortality of treatment for symptomatic aneurysms. Threshold analysis has been used to define the values of these parameters that would be necessary for conservative management to be preferred. It is concluded that, based upon the currently available data, the optimum policy is elective treatment of asymptomatic aneurysms.(ABSTRACT TRUNCATED AT 250 WORDS)

The natural history of clinically established radiation enteritis

70 patients presenting to a surgical unit with radiation enteritis were followed up. 11 of the 61 who underwent operations died of operation-related causes. The 51 patients who survived for more than 3 months were followed up for up to 12 years (median 12 months). 24 had no further symptoms related to their radiation enteritis. The other 27 patients had persistence of symptoms, post-operative complications, new radiation-related problems, or a combination of these. The twenty new radiation-related problems were stricture (8 patients), malabsorption (5), fistula (1), and miscellaneous (6). These developed in 12 of 36 patients presenting initially with stricture, compared with 8 of 9 patients presenting with a perforation or fistula (p = 0.007 Fisher's exact test) and none whose first symptom was bleeding (p = 0.001 vs perforation and fistula combined). 10 of the 27 patients with further problems required operations and 5 of them died. Radiation enteritis is thus a progressive disease, with further complications becoming apparent in about half of those surviving the initial lesion. Perforation or fistula formation indicates a poorer prognosis than does stricture or haemorrhage.

Natural history and surgical management of radiation enteritis

Radiation enteritis is an increasing problem. The effect of ionizing radiation is due to a direct effect on proliferating cells and due to a progressive obliterative vasculitis. Predisposing factors include the dose of radiation, combination with chemotherapy, previous operations and vascular disease. Management is related to the stage of disease at presentation, and tailored to the clinical problem. Surgical management must take into account the poor healing associated with irradiated intestine.

Intra-operative peritoneal lavage--who does it and why?

INTRODUCTION

Intra-operative peritoneal lavage (IOPL) is widely practised but its benefits are unclear. The frequency and pattern of its use amongst general surgeons is investigated.

METHODS

A postal questionnaire was sent to 153 general surgical consultants and registrars enquiring about their use of IOPL. The surgeon was asked the volume and type of lavage fluid used, under various circumstances.

RESULTS

118 (77%) questionnaires were returned. 115 (97%) surgeons used IOPL. The majority of surgeons (61%) lavaged until the fluid was clear, 20% used more than 1 l and 17% used between 500-1000 ml. In the case of the dirty abdomen (i.e. gross pus or faecal peritonitis), 47% used saline as the lavage fluid, 38% aqueous betadine, 9% water and 3% antibiotic lavage. Similar results were found in the case of a contaminated abdomen (i.e. a breached hollow viscus). 34% of surgeons used IOPL during clean cases. 36% used water lavage during intra-abdominal cancer surgery; 21% lavaged with saline and 17% with betadine. More registrars (47%) than consultants (29%) lavaged with water during cancer surgery. Consultants, however, used more aqueous betadine.

CONCLUSIONS

The frequency of use and choice of lavage fluid varies widely. The successful management of the septic abdomen rests on at least 3 tenants - systemic antibiotics, control of the source of infection and aspiration of gross contaminants. There is little good evidence in the literature to support IOPL in the management of the septic abdomen. The use of IOPL during cancer surgery is supported by in vitro evidence. The current use of IOPL, as shown by this study, appears not to be evidence based.

Short daily hemodialysis and nutritional status

Daily hemodialysis improves clinical outcomes in dialysis patients. This study shows the results of 10 patients who underwent short daily hemodialysis (SDHD) from 23.2 +/- 13 months and focuses on nutritional status under this strategy. With SDHD, patients had an increase in energy and protein intake confirmed by an increase in dry weight and lean body mass. Additional clinical improvement was obtained for blood pressure control, regression of left ventricular hypertrophy, correction of anemia, and better quality of life. These biological and clinical improvements are mainly the results of a higher frequency of dialysis sessions. The nutritional improvements with disappearance of anorexia are the consequence of general well being, less dietetic constraints, and less drugs prescribed. Short daily hemodialysis offers an adequate and more physiological strategy and may be considered for improving nutritional status in selected patients.

Management of popliteal aneurysm

BACKGROUND

The best management of patients with a popliteal aneurysm has yet to be established. This paper describes an experience of managing both patent and acutely thrombosed popliteal aneurysms.

METHODS

A prospective study was carried out of all patients who presented with a popliteal aneurysm from January 1988 to December 2001. Since 1993 asymptomatic popliteal aneurysms less than 3 cm in diameter without distortion have been managed conservatively. Ultrasonography was repeated at 6-month intervals. These results were compared with conservative management of popliteal aneurysms greater than 3 cm in diameter in patients who declined or were unfit for operation, and with the outcome of patients who underwent elective bypass of a popliteal aneurysm.

RESULTS

Fifty-eight patients (two women) presented with 92 popliteal aneurysms. Some 39 had a thrombosed aneurysm and these patients were significantly more likely to have bilateral aneurysms (P < 0.001). Of patent popliteal aneurysms managed conservatively, none below 3 cm in diameter thrombosed. The risk of postoperative complications was greater after repair of a thrombosed than a patent aneurysm (P < 0.005). Preoperative lysis for a thrombosed popliteal aneurysm was associated with more complications than operation and on-table lysis (P < 0.05).

CONCLUSION

Careful monitoring of asymptomatic popliteal aneurysms less than 3 cm in diameter is safe. Preoperative lysis is associated with increased risks compared with operation alone in patients with a thrombosed popliteal aneurysm.

A 1 year prospective study of management and outcome of patients presenting with critical lower limb ischaemia

OBJECTIVES

to determine management of patients with critical lower limb ischaemia (CLI) from first presentation to investigation and treatment.

DESIGN

prospective study of critical ischaemia patients.

METHODS

one-year prospective survey (May 2000-May 2001). Follow-up 3-15 months.

RESULTS

some 873 arterial cases presented, 134 patients had CLI. Of the latter 49% were men, 30% diabetic, the median age was 81 years. Only 15 (24%) of 62 cases were referred to outpatients as urgent. Patients waited a median of 25 days (range 1-100) to be seen in outpatients, and had symptoms for a median of 8 weeks. Treatment was conservative for 70 patients, and 11 primary amputations, six secondary amputations, and 62 revascularisation procedures (34 operative, 28 percutaneous transluminal angioplasty) were performed. At follow-up (3-15 months, median 9 months), rates of major amputation and death were 12 and 27% respectively. Significantly more diabetics underwent major amputation (p < 0.02) than non diabetics. Patients presenting with ulceration or gangrene were at greater risk of death than those with rest pain alone (p < 0.01).

CONCLUSION

patients with CLI often have symptoms for many weeks before being seen by a specialist, and 76% are referred as non-urgent cases. This compares with patients with suspected malignant disease in the U.K. who are required to be seen within 2 weeks.

Popliteal aneurysm: morphology and management

Since January 1988, 32 patients have presented with 44 popliteal aneurysms (22 thrombosed, 22 non-thrombosed). Patients with thrombosed aneurysms were older (median age 72 versus 66 years), and more likely to have bilateral lesions (P < 0.02) and serious associated cardiovascular disease (P < 0.02). Nineteen aneurysms thrombosed acutely; 12 were treated with intra-arterial thrombolysis, which was at least partially successful in seven. All 12 were subsequently bypassed, as were the other seven which were associated with such severe ischaemia that they required urgent operation. One patient died and two others required major amputation. Other complications included foot-drop (two patients), renal failure (one) and wound infection (two). Two grafts thrombosed and required re-exploration. Elective bypass was carried out in 11 patients without acutely thrombosed aneurysms; there were no significant postoperative problems. Distortion within the aneurysm (P < 0.01), large size (P < 0.01) and distortion of the popliteal artery above or below the lesion (P < 0.02) were all associated with thrombosis. Stenosis within the aneurysm was more likely in patients with multiple lesions (P < 0.01) and distortion with larger aneurysms (P < 0.01). After correcting for distortion, none of the other variables was independently significant. The combination of distortion and diameter > 3 cm was present in 13 of 15 thrombosed aneurysms. Morbidity is high following acute thrombosis of popliteal aneurysm. Distortion of the aneurysm appears to be a more sensitive predictor of thrombosis than size alone. The combination of distortion with a diameter > 3 cm may help to define popliteal aneurysms that should be bypassed electively.

History of the management of popliteal artery aneurysms

Management of popliteal aneurysms remains controversial. Debate continues as to when an asymptomatic popliteal aneurysm should be treated and, with concerns regarding the fate of a bypassed popliteal aneurysm and the advent of intravascular stents, what procedure is best. This paper reviews the history of popliteal artery aneurysm management with particular emphasis on treatment and results before the modern era of arterial reconstruction. The aim of treatment then was to induce thrombosis. Now it is to prevent thrombosis.

Mortality following elective infrarenal aortic reconstruction: a Joint Vascular Research Group study

BACKGROUND

This study aimed to define the cause of death in patients undergoing elective infrarenal aortic reconstruction.

METHODS

Members of the Joint Vascular Research Group who had collected details prospectively of patients undergoing elective aortic reconstruction provided information on those who died.

RESULTS

Details of 3786 patients were obtained. Some 171 patients died (133 following abdominal aortic aneurysm (AAA) and 38 after aortofemoral bifurcation graft (AFBG) for occlusive disease). The mortality rate following AAA repair was 4.8 per cent, rising to 16 per cent if repair was combined with either renal or distal reconstruction (P < 0.001). Similar results were obtained with AFBG (3.4 and 11 per cent respectively, P < 0.001). The first major complication encountered was cardiac (39.8 per cent), followed by bleeding (20.5 per cent), respiratory (13.5), and gut (5.3 per cent), or limb ischaemia (6.4 per cent). Bleeding was commoner following reconstruction for aneurysm compared with that for occlusive disease (P < 0.05). Eighty-six patients (50.3 per cent) died from the first major complication. Of the remainder, 45 (53 per cent) developed multisystem organ failure (MSOF). The most commonly involved systems were cardiac, respiratory and renal.

CONCLUSION

Cardiac problems were the major cause of death following infrarenal aortic reconstruction. MSOF is the 'final common pathway' in about half of the patients who survive the initial complication.

Prevention of wound infection in abdominal operations by peroperative antibiotics or povidone-iodine. A controlled trial

The wound-infection rate after abdominal operations was compared in 113 patients randomly allocated to an untreated control group, a group receiving preoperative lincomycin and tobramycin, or a group receiving local instillation of povidone-iodine. The wound-infection rate was 8.1% in 37 patients receiving antibiotics, 42.1% in 38 untreated controls, and 39.5% in 38 patients in the povidone-iodine group.

Acute limb deterioration during intra-arterial thrombolysis

Approximately 12 per cent of limbs undergoing intra-arterial thrombolysis (IAT) develop distal embolism or extension of thrombus during the procedure. These are usually of little clinical consequence and can be treated by increasing the rate of administration of the lytic agent. However, in some patients the clinical condition of the limb deteriorates rapidly. In an attempt to define the incidence of acute limb deterioration during IAT, information was collected from five centres in the UK with experience of the technique. A total of 866 treatments were recorded, with 20 limbs (2.3 per cent) undergoing acute deterioration. This complication was more common during the treatment of thrombosed popliteal aneurysm than during that of emboli or thrombosed atheromatous arteries or grafts (P < 0.001). The amputation rate associated with the complication was high, and operative intervention provided better results than continuation of lysis.

Popliteal Aneurysms: Distortion and Size Related to Symptoms

OBJECTIVES

To examine size and distortion of popliteal aneurysms (PA) in relation to symptoms produced at presentation.

METHODS

A prospective study of all PA presenting to a single unit 1988-1994. Wherever possible patients underwent angiography, duplex scanning and measurement of both PA diameter and the most proximal angle of distortion. Symptoms and measurements were noted at the time of first presentation.

RESULTS

Seventy-three patients presented with 116 PA. At initial diagnosis 44 PA (38%) were asymptomatic and 39 (34%) produced acute ischaemia. As the PA increased in diameter so did the degree of distortion (p < 0.0001). Size and distortion were greater in PA producing acute ischaemia or acute thrombosis than in asymptomatic PA (p < 0.01). Degree of distortion differentiated symptomatic from asymptomatic PA (p = 0.0066). Size was not significantly different between these two groups. For PA 3 cm or larger in diameter with greater than 45 degrees distortion sensitivity, specificity and positive and negative predictive values for thrombosis were 90, 89, 83 and 94%, respectively.

CONCLUSION

Distortion and size can differentiate between PA producing different symptoms. Combining the two provides a reliable method of differentiating PA which should be managed by early elective repair.

Prospective evaluation of quality of life after conventional abdominal aortic aneurysm surgery

OBJECTIVES

To evaluate the changes in quality of life following conventional abdominal aortic aneurysm repair.

DESIGN

Prospective study.

MATERIALS AND METHODS

Fifty-nine consecutive patients (50 men; nine women) in two surgical centres were investigated preoperatively, and at 6 weeks, 3 months and 6 months postoperatively. Quality of life was measured using the Short Form 36 (SF 36) questionnaire and the York Quality of Life questionnaire, from which the Rosser index was calculated.

RESULTS

Rosser index assessment showed restoration of quality of life to preoperative levels by 3 months, and significant improvement at 6 months. Changes in the SF 36 revealed significant improvement in mental health, and physical role limitation at all times postoperatively. Social function worsened at 6 weeks but improved to preoperative levels by 3 and 6 months after surgery.

CONCLUSIONS

Quality of life was improved after open aortic aneurysm repair. The time course of recovery shows a predominant improvement between 6 weeks and 3 months postoperatively.

Prevalence of abdominal aortic aneurysm in patients with occlusive peripheral vascular disease

Over a 1-year period, 242 patients with peripheral vascular disease underwent abdominal ultrasonography to detect the presence of an abdominal aortic aneurysm. In 34 (14 per cent) an abdominal aortic aneurysm was found; half of these aneurysms were greater than 4 cm in diameter. In addition, 16 patients had ectatic aortas. Abdominal aortic aneurysms were more common in men than in women (17 versus 8 per cent). Patients with claudication were as likely to have an abdominal aortic aneurysm as those with rest pain or gangrene. The presence of aortoiliac occlusive disease increased the chance of an aneurysm being present (P less than 0.02). Patients with occlusive peripheral vascular disease are a high-risk group with regard to the development of an abdominal aortic aneurysm. Patients with proximal occlusive disease represent a subgroup at even higher risk.

Twenty-five years of experience with out-center hemodialysis

Twenty-five years of experience with out-center hemodialysis.

BACKGROUND

Out-center hemodialysis (HD) offers patients a better quality of life, a greater independence, and a better rehabilitation opportunity. A lower mortality than with other modalities of dialysis has been reported. In addition, in France the charges paid depend on the modality of dialysis, out-center HD being the less expensive, and savings are also accomplished through fewer patient transports, which are additionally reimbursed. We present a 25-year experience of out-center HD.

METHODS

We retrospectively studied the clinical records of 471 patients treated between 1974 and 1997 in a single nonprofit organization operating regional home HD (H-HD) and facilities for self-care HD (SC-HD). Survival results were analyzed according to: (a) causes of end-stage renal disease, (b) age at the start of HD, (c) period of start of HD, (d) modality of HD (H-HD, SC-HD), and (e) a subgroup of 174 patients defined at risk because they were contraindicated for transplantation.

RESULTS

The mean age at the start of HD increased from 31.2 +/- 9.7 (mean +/- SD) years in 1974 to 52.6 +/- 13.5 years in 1997. Causes of the end of treatment were: (a) transplantation (63%), (b) transfer (20%), and (c) death (17%). The overall survival was 90% at 5 years, 77% at 10 years, 62% at 15 years, and 45% at 20 years, and, for the group at risk, 78%, 62%, 46%, and 31%, respectively. Cox proportional hazard analyses showed that risk factors were older age, diabetes, and renal vascular diseases.

CONCLUSION

If adequate choice is given, out-center HD offers a reliable and safe modality of dialysis with better survival results than survival in full-care in-center HD. In addition, out-center HD ensures a striking financial benefit as compared with the higher costs if the same patients were treated with full-care in-center HD. These modalities should be encouraged for all HD patients who are able to be treated by out-center modalities.

Major Groin Complications Following the Use of Synthetic Grafts

BACKGROUND

The ideal results of vascular reconstructive surgery include an uncomplicated operation, symptomatic relief, prompt wound healing, rapid return to pre-operative functional status without long term functional consequences. Long term complications are often not emphasized. This study describes false femoral aneurysms (FFA) and infection following use of synthetic graft in the groin.

METHODS

All patients under the care of one surgeon, undergoing synthetic graft insertion involving the groin between January 1988 and December 2005 were included.

RESULTS

Some 489 patients were included (745 at risk groins). A total of 34 patients developed either FFA or infection, involving 39 groins (5.2%). There were 18 FFA, presenting a median of four years after the original operation. FFA was more common following aortofemoral bypass grafts than femorofemoral or femorodistal bypasses (P=0.0084). Repair with interposition grafting was carried out in 17 cases. There was one death postoperatively. The remainder remained satisfactory at a median follow up of 60 months. Median time from original operation to 21 groin infections presenting was 12 months. Infection was commonest after femorofemoral cross over grafts P=0.023. Four major amputations were carried out. Debridement and sartorius transposition was useful in about half of the cases treated.

CONCLUSION

Serious groin complications occur in about 5% of cases following use of a synthetic graft. This can result in significant morbidity long after the original operation has been carried out. Patients need to be made aware of this when obtaining informed consent.

Quality of life following percutaneous transluminal angioplasty for claudication

OBJECTIVE

To determine quality of life in claudicants before and after percutaneous transluminal angioplasty (PTA).

DESIGN

Prospective study using EuroQuol questionnaire and visual analogue scales.

SETTING

District general hospital.

MATERIAL

Twenty-nine patients undergoing successful PTA.

RESULTS

Before PTA patients showed a significantly lower EuroQuol score compared with the normal population. There was also marked impairment of patients usual activities, mobility and perceived health state. Following successful PTA the EuroQuol score, perceived health state, mobility, usual activities, pain and discomfort and mental state were all significantly improved.

CONCLUSIONS

Intermittent claudication impairs quality of life. Following successful PTA there is significant improvement in symptoms and in general health.

Surgical aspects of radiation injury to the intestine

The clinical features are described of 37 patients requiring surgical management for radiation injury to the intestine sustained as a result of treatment of abdominal or pelvic malignancy. Twenty-nine of the patients underwent operation and only 4 remained symptom-free after the procedure. Thirteen patients died in the postoperative period, and of these, 5 were free of the original disease. Possible predisposing factors in the production of intestinal injury are discussed, as are various means of dealing with the established condition.

A glutathione S-transferase cDNA identified by mRNA differential display is upregulated during somatic embryogenesis in Cichorium

CHI-GST1, a cDNA encoding a glutathione S-transferase, was isolated by differential display in leaf tissues of chicory, during the early stages of somatic embryogenesis. Expression analysis of the gene by Northern blot indicated that the transcript accumulation is specific of the leaf developing somatic embryogenesis and is not observed in leaf tissue of the non-embryogenic cultivar.