End-stage kidney disease: The last 12 months.

BACKGROUND: Chronic kidney disease (CKD) is increasingly prevalent in Australia's ageing population. Over the past decade, there has been growing recognition that dialysis does not benefit every patient with end-stage kidney disease (ESKD). Patients with advanced age, significant comorbidities and poor functional status may not gain a survival benefit with dialysis when compared with being managed conservatively. These developments have implications for general practitioners (GPs). A further development has been the emergence of renal supportive care, a patient-centred approach that integrates the principles of palliative care into nephrology. OBJECTIVE: The aim of this article is to outline salient aspects in the care of patients with ESKD. DISCUSSION: Salient aspects throughout the trajectory of ESKD are discussed, including symptoms of CKD, relevant management, prognostication, advance care planning discussions and end-of-life care. The role of the GP is vital, and it is recommended that GPs are involved early in a patient's CKD trajectory.

Membrane transport status does not predict peritonitis risk in patients on peritoneal dialysis.

AIM: The aim of this study is to determine whether peritoneal membrane transport status (MTS) is associated with peritonitis or poor peritoneal dialysis-related outcomes. METHODS: This retrospective cohort study analysed data of incident adult patients on peritoneal dialysis in Western Sydney between 1 October 2003 and 31 December 2012. Only patients who underwent peritoneal equilibration and adequacy tests within 6 months of commencement were included. Kaplan-Meier survival curves for time until first peritonitis and time until composite endpoint of peritonitis, death or technique failure, censored for transplant, were constructed. RESULTS: About 397 patients, mean age 58.8(+/-2SD29) years, body mass index (BMI) 26.6(+/-5) kg/m2 and serum albumin 35.4(+/-5) g/L were included. About 59.2% had high/high-average peritoneal MTS; 45.8% were past and current smokers; 51.9% developed at least one episode of peritonitis; 7.6% changed to haemodialysis; 6.3% underwent transplantation; 8.8% died; and 25.4% remained free of the aforementioned events over a mean follow-up period of 22.5 months (range 0-115 months). Peritoneal MTS was not associated with time to first peritonitis (p = 0.67) or composite endpoint of peritonitis, death or technique failure (p = 0.12). Smoking and hypoalbuminaemia independently predicted time to first peritonitis. Past and current smokers had a hazard ratio of 1.38 (95% CI 1.03-1.86) for shorter time to first peritonitis, significant after adjustment for serum albumin (p = 0.033). Serum albumin <32 g/L had a hazard ratio of 1.74 (95% CI 1.13-2.67) for shorter time to first peritonitis, significant after adjusting for smoking (p = 0.012). CONCLUSION: Smoking and hypoalbuminaemia, but not MTS, were associated with shorter time to first peritonitis and composite endpoint of peritonitis, death and technique failure.

Correlation between metal allergy and treatment outcomes after ankle fracture fixation.

PURPOSE: To determine correlation between metal hypersensitivity and long-term foot and ankle function and pain after internal fixation using stainless steel implants. METHODS: 60 men and 46 women (mean age, 47 years) who underwent internal fixation for ankle fractures completed a questionnaire 13 to 38 (mean, 26) months after surgery to assess their existing medical condition, history of metal hypersensitivity, problems and outcome of the implant (revision or removal), and the American Academy of Orthopaedic Surgeons (AAOS) foot and ankle score. A subset of 12 men and 15 women then underwent patch testing for metal hypersensitivity to molybdenum, chromium, iron, manganese, and nickel. Patients with positive and negative reactions were compared. RESULTS: 21 of the 106 patients underwent removal of the metal implants. The AAOS score was not associated with any of the variables, except for a history of metal hypersensitivity from dental implants and irritation around the surgical scar. Multiple linear regression analysis showed that only irritation around the surgical scar remained associated with poorer AAOS scores. Five of the 27 tested patients had a positive reaction. The mean AAOS scores did not differ significantly between patients with positive and negative reactions (34 vs. 31, p=0.73). Gender was not associated with the test results (p=0.63). None of the 5 patients with a positive reaction underwent revision surgery or reported any history of asthma or metal hypersensitivity. Of the 27 patients, one of the 8 who reported itching, irritation, redness or rash around the surgical scar had a positive reaction, compared to 4 of 19 patients who reported no such symptoms (p=1). Two of the 27 patients reported development of eczema after fixation, one of whom had a positive reaction. Only one of the 27 patients reported a history of metal hypersensitivity to jewellery, but had a negative reaction.. CONCLUSION: Neither a history of metal hypersensitivity nor positive patch testing correlated with poor outcomes after internal fixation for ankle fractures using stainless steel implants.

Erk1/2 signaling is required for Tgf-beta 2-induced suture closure.

Transforming growth factors beta (Tgf-betas) act by means of Smad signaling pathways and may also interact with the mitogen-activated protein kinase pathway. The hypothesis was tested that Erk1/2 signaling is required for Tgf-beta2-induced suture closure, by culturing embryonic mouse calvariae in the presence of Tgf-beta2 with or without Erk1/2 inhibitor PD98059 (PD). Suture widths were measured daily, and microdissected sutures and bones were homogenized and protein analyzed by Western blots. Tgf-beta2 induced narrowing of the sutures after 72 hr, an effect inhibited by treatment with PD. Erk1/2 and Egf but not Smad2/3 protein expression was up-regulated by Tgf-beta2 calvarial tissues at 72 hr. PD inhibited endogenous and Tgf-beta2-stimulated Erk1/2 protein as well as Tgf-beta2-stimulated Egf, but increased Smad2/3 protein expression. In tissues harvested 0, 15, and 30 min after exposure to Tgf-beta2, Erk1/2 phosphorylation was up-regulated after 15 min, an effect abrogated by the simultaneous addition of PD. In summary, Tgf-beta2 stimulated Erk1/2 phosphorylation and induced Egf and Erk1/2 expression, associated with suture closure after 72 hr. Blocking Erk1/2 activity with PD inhibited these effects but increased Smad2/3 expression. We postulate that Tgf-beta2 regulates suture closure directly by means of phosphorylation of Erk1/2 and indirectly by up-regulating Erk1/2, a substrate for Fgf receptor signaling required for Fgf induction of premature suture obliteration.