Comparing mortality in renal patients on hemodialysis versus peritoneal dialysis using a marginal structural model

When comparing the causal effect of peritoneal dialysis (PD) and hemodialysis (HD) treatment on lowering mortality in renal patients, using observational data, it is necessary to adjust for different forms of confounding and informative censoring. Both the type of dialysis treatment that is started with and mortality are affected by baseline covariates. Longitudinal and baseline variables can affect both the probability of switching from one type of dialysis to the other, and mortality. Longitudinal and baseline variables can also affect the probability of receiving a kidney transplant, possibly causing informative censoring. Adjusting for longitudinal variables by including them as covariates in a regression model potentially causes bias, for instance by losing a possible indirect effect of dialysis on mortality via these longitudinal variables. Instead, we fitted a marginal structural model (MSM) to estimate the causal effect of dialysis type, adjusted for confounding and informative censoring. We used the MSM to compare the hazard of death as well as cumulative survival between the potential treatment trajectories "always PD" and "always HD" over time, conditional on age and diabetes mellitus status. We used inverse probability weighting (IPW) to fit the MSM.     

Continuous ambulatory peritoneal dialysis: experience with 22 unselected patients with renal failure.

The present study describes our experience with CAPD in an unselected group of patients presenting with endstage renal failure. Twenty-three consecutive patients were offered CAPD, in-center, and home hemodialysis. Twenty-two patients selected CAPD, including 14 patients more than 60 years of age, four patients with diabetes, and one with multiple myeloma. CAPD training was performed in an out-of-hospital office facility. One patient returned to hemodialysis following the development of resistant Pseudomonas peritonitis, two patients died of a myocardial infarction, and one patient died with a GI bleed. The other 18 patients are doing well. Assessment of 17 patients maintained on therapy for four months or more revealed that the patients are less depressed, less organic, and have fewer physical symptoms than previously reported for a comparable group of patients maintained on hemodialysis for a similar period of time. In conclusion, CAPD can be successfully employed, at least for the initial months of therapy, to treat the vast majority of patients with endstage renal disease. CAPD training and follow-up care can be provided in an out-of-hospital office facility.     

Genotoxicity evaluation in chronic renal patients undergoing hemodialysis and peritoneal dialysis, using the micronucleus test

Patients with chronic renal disease have an increased incidence of cancer. It is well known that long periods of hemodialysis treatment are linked to DNA damage due to oxidative stress. This genotoxic effect may cause the loss of chromosome fragments, or even entire chromosomes, which form micronuclei after cell division, and can be detected by the micronucleus test. In the present case-control study, we evaluated the genotoxic effect of hemodialysis treatment in 20 patients undergoing hemodialysis, and 20 subjected to peritoneal dialysis, matched for gender and age with 40 controls. Genetic damage was assessed by examining the frequency of micronuclei in 2000 exfoliated buccal cells per individual. Our results revealed that patients undergoing hemodialysis treatment have a significantly higher frequency of micronucleated cells (MNC; 5.60 +/- 5.31) compared to control subjects (1.50 +/- 2.01, p < 0.01). Interestingly, the same was not observed for the peritoneal dialysis patients who showed no significant differences in MNC (2.85 +/- 2.96) frequency compared to control individuals (3.25 +/- 3.85). In addition, we evaluated the possible association between creatine levels, smoking, alcohol intake, age, duration of treatment, and incomes of the individuals (separately analyzed according to their gender) and the frequency of micronuclei. The results reported here indicate that the duration of treatment is the only factor associated with increased MNC frequency among hemodialysis patients (Spearman coefficient of 0.414, p = 0.01). The number of MNC found in individuals with six years or less of treatment was significantly lower (2.91 +/- 2.74) compared to patients with seven or more years of treatment (8.89 +/- 5.96, p < 0.05). Overall, peritoneal dialysis may be a safer choice of treatment, but further studies need to be performed to investigate the risks and benefits of both treatments.     

Activity of some lysosomal enzymes in peritoneal macrophages of patients with end-stage renal failure treated by intermittent peritoneal dialysis.

Acid phosphatase, beta-D-Glucuronidase and N-acetyl-beta-D-glucosaminidase were assessed cytochemically in peritoneal macrophages obtained from 50 patients with end-stage renal failure treated by intermittent peritoneal dialysis and from 30 control subjects with normal renal function. A statistically significant increase in beta-D-glucuronidase activity accompanied by a decrease in acid phosphatase activity were observed in peritoneal macrophages of dialysed patients, as compared with the control group. In patients with dialysis-associated peritonitis, the activity of N-acetyl-beta-D-glucosaminidase was significantly higher than that observed in the same patients during the complication-free period of the treatment.     

Phagocytic activity of neutrophils from the peritoneal dialysate of patients with chronic renal failure treated by intermittent peritoneal dialysis.

The phagocytic activity of peritoneal neutrophils was assessed using Bacto-Latex in 50 patients with chronic renal failure treated with intermittent peritoneal dialysis, and in 30 control patients with normal renal function. In the group of patients treated with peritoneal dialysis 20 were additionally investigated while developing peritonitis. A significant decrease in the phagocytic activity of neutrophils was observed in the both dialysed groups, as compared with control subjects. Moreover, the phagocytic activity was significantly lower in patients with peritonitis as compared with dialysed patients without this complication.     

Effect of long term dialysis therapy on blood prolactin patients with chronic renal failure

An effect of dialysis therapy on baseline prolactinemia and prolactinemia following suppression test with alpha-bromocriptine was determined in 34 patients with chronic renal failure. Gradual decrease in hyperprolactinemia with the duration of dialysis therapy has been observed. Prolactinemia baseline values in patients dialysed for 100 months did not differ from those determined in healthy individuals.     

Speciation of chromium in plasma and liver tissue of endstage renal failure patients on continuous ambulatory peritoneal dialysis

This work is a first attempt to determine the speciation of Cr in human plasma. With the aid of in vitro and in vivo⁵¹Cr-labeled experiments, it was possible to develop the necessary biochemical techniques for the separation of the plasma proteins. Further work will use real samples, taking care to avoid contamination of the various fractions and to preserve the original binding of the Cr to the specific plasma compounds. In a first attempt on the distribution of Cr over the different organelles of liver tissue, work will be restricted to in vivo labeled experiments with rats. The procedure to do the speciation work seems so elaborate that it may be impossible ever to achieve the contemplated speciation of Cr in human liver tissue by subcellular fractionation.     

Impact of continuous ambulatory peritoneal dialysis on treatment of renal failure in patients aged over 60.

Thirty eight patients aged over 60 with end stage renal disease were treated by continuous ambulatory peritoneal dialysis for up to three years. Most of these patients, because of their age or coexisting diseases, had been considered to be unsuitable for haemodialysis by the criteria used before the advent of continuous ambulatory peritoneal dialysis in 1980. Actuarial patient survival at one and two years was 72% and 61% respectively, and only two patients were permanently transferred to haemodialysis. Twenty one of the 23 survivors were fully rehabilitated, the remaining two being partially disabled but living at home. Continuous ambulatory peritoneal dialysis permits more liberal selection of patients with end stage renal disease for renal replacement treatment with excellent survival and rehabilitation and without overburdening scarce hospital haemodialysis facilities.     

Zoledronic Acid as an adjuvant therapy in patients with breast cancer: a systematic review and meta-analysis

Background

Zoledronic acid is widely used as adjuvant chemotherapy for the treatment of breast cancer. However, previous trials reported inconsistent findings regarding their clinical efficacy and safety. We carried out a comprehensive systematic review and meta-analysis to evaluate the effects of zoledronic acid on disease-free survival (DFS), overall survival (OS), and drug-related toxicities.

Methodology and Principal Findings

We systematically searched Medline, EmBase, the Cochrane Central Register of Controlled Trials, reference lists of articles and proceedings of major meetings for relevant literatures with a time limit of Dec. 1, 2011. Randomized controlled trials evaluated the effects of zoledronic acid on OS, DFS, and RFS compared with control were eligible for inclusion in our research. Of 175 identified studies, we collected data from 7 randomized controlled trials of zoledronic acid that had OS, DFS, and RFS reported as one of the endpoint. Overall, we noted that patients receiving zoledronic acid therapy had significant longer OS than the group with non-zoledronic acid therapy (HR, 0.85, 95%CI, 0.73 to 1.00, P = 0.047). Furthermore, zoledronic acid therapy also had a clear effect on frature events (RR, 0.66, 95%CI, 0.52 to 0.84, P<0.001). Subgroup analysis indicated that zoledronic acid therapy showed a great beneficial effect on disease recurrence in patients with early-stage breast cancer, however, it also significantly increased the harm of disease recurrence in patients with advanced breast cancer. Bone pain, neutropenic fever, pyrexia, rash were more frequent in the zoledronic acid therapy group.

Conclusion/Significance

Treatment with zoledronic acid had a clear effect on fracture events, and it might contribute an important role for overall survival.     

Arteriovenous haemofiltration: a recent advance in the management of renal failure.

Twenty five patients with oliguric renal failure were treated by a combination of continuous arteriovenous haemofiltration and intermittent haemodialysis over 18 months. Haemofiltration was given for a mean of 6.6 days and the mean filtration volume was 6.0 1/day. Fourteen of the 25 patients survived beyond two months after the period of oliguria. Haemofiltration proved to be a simple and effective method of fluid removal; it allowed maintenance of stable fluid balance and permitted optimum nutrition during prolonged oliguria.