Association of erythropoiesis-stimulating agents and the incidence risk of cancer diagnosis among chronic dialysis patients: a nested case-control study.

BACKGROUND: Erythropoiesis-stimulating agents (ESAs) are the cornerstone of the treatment for anemia in end-stage renal disease (ESRD) patients. Although a correlation has been established between ESAs and increased tumor growth among patients with cancer-related anemia, an association with a higher incidence of cancer among chronic dialysis patients remains relatively unclear. METHODS: We completed a nested case-control study in a cohort of 4574 patients who began chronic dialysis treatment between 1 January 2001 and 31 December 2007 in Quebec, Canada, utilizing dialysis registry and administrative databases exclusively to extract our data. We excluded patients with a prior diagnosis of cancer. Eligible cases were identified by the time of initial cancer diagnosis obtained from either the hospital's discharge or physician billing form. We then randomly selected up to 10 controls for each case. ESA exposure was evaluated between 6 and 9 months prior to the initial cancer diagnosis. The mean weekly exposure was used to categorize ESA usage as either a low dose (<30 µg/week), moderate dose (30-70 µg/week) or high dose (>70 µg/week). We estimated the association between ESAs and the risk of developing cancer using a multivariable conditional logistic regression. RESULTS: We identified 419 cases of cancer and 3895 matched controls during the study period. The use of ESAs was associated with a higher risk of cancer {odds ratio [OR] 1.04 [95% confidence interval (CI) 1.02-1.07]}. Specifically, patients in the high exposure group (>70 µg/week) had an increased risk of developing cancer [OR 1.77 (95% CI 1.18-2.66)] compared with patients in the unexposed group. CONCLUSION: High-dose ESA was associated with an increased incidence risk of new cancer diagnosis among chronic dialysis patients.

Comparison of oral and intravenous alfacalcidol in chronic hemodialysis patients.

BACKGROUND: Activated vitamin D is the mainstay of treatment for secondary hyperparathyroidism (SHPT) in chronic hemodialysis patients. However, the optimal route of administration is still debated. The aim of our study was to compare efficacy of oral vs intravenous (IV) administration of alfacalcidol in hemodialysis. A secondary objective was to determine the cost-effectiveness advantage of oral administration. METHODS: Eighty-eight chronic hemodialysis patients receiving IV alfacalcidol three times a week were included in the study. All were switched to the same dose of alfacalcidol given orally three times a week during the hemodialysis session. A budget impact analysis was performed. RESULTS: Mean patient age was 64 years old and 43% were males. The mean alfacalcidol dose administered was 2.1 µg three times a week. After three months, serum parathormone (PTH) levels decreased from 80 to 59 pmol/L (p = 0.001) and total serum calcium levels increased from 2.34 to 2.40 mmol/L (p = 0.002). After six months, total serum calcium levels were still significantly higher. Alfacalcidol dosage was significantly decreased during study period; the mean reduction was 0.44 µg per dose. Finally, oral administration was associated with an annual cost reduction of 197 678$CAN and an annual nursing time reduction of 25 days. CONCLUSION: Our findings support that switching IV to oral administration of alfacalcidol during hemodialysis sessions may lead to a similar control of SHPT with lower doses of activated vitamin D. This is a good strategy for optimizing compliance and may allow a dose reduction because of a greater efficacy to suppress PTH. Oral administration also has significant cost-effectiveness advantages.

Magnitude of discordance between registry data and death certificate when evaluating leading causes of death in dialysis patients.

BACKGROUND: Discordance between dialysis registry and death certificate reported death has been demonstrated. Since cause of death is measured using registry data in dialysis patients and death certificate data in the general population, comparisons of cause of death proportions between dialysis patients and the general population may be biased. Our aim was to compare the proportion of deaths attributed to cardiovascular disease (CVD), malignancy, and infections between patients receiving dialysis and the general population using death certificates for both, and to quantify the magnitude of discrepancy between registry and death certificate estimates in dialysis patients. METHODS: A retrospective cohort study of 5858 patients initiating maintenance dialysis between 2001 and 2007 was conducted. Cause of death was obtained from both registry and death certificate data for dialysis patients, and from death certificate data for the general population. RESULTS: Compared to the general population, use of death certificate data in dialysis patients resulted in smaller differences in the proportion of deaths attributed to CVD or infection than that from the registry. In the general population, the proportion of deaths due to CVD is 29.3% for men and 28.2% for women, and the proportion of deaths due to infection is 3.3% for men and 3.6% for women. For men, the proportion of deaths in dialysis patients due to CVD using registry data is 41.5%, compared with a proportion of 32.1% using death certificate data. Similarly for women, the proportion of deaths due to CVD using registry data is 35.2% and that using death certificate data 24.3%. The proportion of deaths due to infection in dialysis patients follows the same pattern: for men, the proportion of deaths due to infection using registry data is 9.9% and that from death certificate data at 5.0%; while for women the proportions are 11.6% and 4.8%, respectively. CONCLUSIONS: While absolute cause-specific mortality rates did differ, evaluation of causes of death using death certificate in dialysis patients in Quebec revealed that they do not have substantially different proportion of death due to CVD or infections than the general population. Infections appeared to be a frequent complication leading to death, suggesting that infections are an important target to consider for reducing mortality in dialysis populations.

Characterizing Hypertension Specialist Care in Canada: A National Survey.

Background: The hypertension specialist often receives referrals of patients with young-onset, severe, difficult-to-control hypertension, patients with hypertensive emergencies, and patients with secondary causes of hypertension. Specialist hypertension care compliments primary care for these complex patients and contributes to an overall hypertension control strategy. The objective of this study was to characterize hypertension centres and the practice patterns of Canadian hypertension specialists. Methods: Adult hypertension specialists across Canada were surveyed to describe hypertension centres and specialist practice in Canada, including the following: the patient population managed by hypertension specialists; details on how care is provided; practice pattern variations; and differences in access to specialized hypertension resources across the country. Results: The survey response rate was 73.5% from 25 hypertension centres. Most respondents were nephrologists and general internal medicine specialists. Hypertension centres saw between 50 and 2500 patients yearly. A mean of 17% (± 15%) of patients were referred from the emergency department and a mean of 52% (± 24%) were referred from primary care. Most centres had access to specialized testing (adrenal vein sampling, level 1 sleep studies, autonomic testing) and advanced therapies for resistant hypertension (renal denervation). Considerable heterogeneity was present in the target blood pressure in young people with low cardiovascular risk and in the diagnostic algorithms for investigating secondary causes of hypertension. Conclusions: These results summarize the current state of hypertension specialist care and highlight opportunities for further collaboration among hypertension specialists, including standardization of the approach to specialist care for patients with hypertension.

Contexte: Le spécialiste de l'hypertension reçoit souvent des patients orientés pour une hypertension sévère, d'apparition précoce et difficile à maîtriser, pour une urgence hypertensive ou pour des causes secondaires de l'hypertension. Les soins spécialisés de l'hypertension complètent les soins primaires pour ces cas complexes et font partie d'une stratégie globale de maîtrise de l'hypertension. Cette étude avait pour objectif de caractériser les centres de traitement de l'hypertension et les habitudes de pratique des spécialistes canadiens qui traitent l'hypertension. Méthodologie: Un sondage a été mené auprès de spécialistes de l'hypertension adulte de l'ensemble du Canada afin de décrire les centres de traitement de l'hypertension et la pratique des spécialistes au Canada, notamment les éléments suivants : la population de patients prise en charge par des spécialistes de l'hypertension, les renseignements sur la façon dont les soins sont prodigués, les variations dans les habitudes de pratique ainsi que les différences relatives à l'accès aux ressources spécialisées en hypertension à l'échelle du pays. Résultats: Le taux de réponse au sondage a été de 73,5 % dans 25 centres de l'hypertension. La plupart des répondants étaient des néphrologues et des spécialistes en médecine interne générale. Les centres de l'hypertension recevaient entre 50 et 2500 patients par année. En moyenne, 17 % (± 15 %) des patients provenaient du service des urgences et 52 % (± 24 %) provenaient d'une unité de soins primaires. La plupart des centres avaient accès à des tests spécialisés (prélèvements veineux surrénaliens, études du sommeil de niveau 1, tests autonomes) et à des traitements avancés pour l'hypertension résistante (dénervation rénale). Une hétérogénéité considérable a été constatée en ce qui concerne la pression artérielle cible chez les jeunes présentant un faible risque cardiovasculaire et les algorithmes diagnostiques pour étudier les causes secondaires de l'hypertension. Conclusions: Ces résultats résument la situation actuelle des soins spécialisés de l'hypertension et font ressortir des occasions d'accroître la collaboration entre les spécialistes de l'hypertension, notamment en ce qui concerne une normalisation de l'approche des soins spécialisés pour les patients hypertendus.

Multidisciplinary Perspectives of Current Approaches and Clinical Gaps in the Management of Hyperphosphatemia.

Population-based studies have shown that most patients with advanced chronic kidney disease (CKD) do not have optimal phosphate levels. Meta-analyses suggest that there is a morbidity and mortality benefit associated with the lowering of serum phosphate levels. However, to date there is no conclusive evidence from randomized controlled trials (RCTs) that lowering serum phosphate levels reduces the risk of morbidity and mortality. However, hyperphosphatemia may pose a risk to patients and treatment should be considered. We therefore sought to conduct a multidisciplinary review to help guide clinical decision-making pending results of ongoing RCTs. Restricting dietary phosphate intake is frequently the first step in the management of hyperphosphatemia. Important considerations when proposing dietary restriction include the patient's socioeconomic status, lifestyle, dietary preferences, comorbidities, and nutritional status. While dietary phosphate restriction may be a valid strategy in certain patients, serum phosphate reductions achieved solely by limiting dietary intake are modest and should be considered in conjunction with other interventions. Conventional dialysis is also typically insufficient; however phosphate removal may be augmented by increased frequency or duration of dialysis, or through enhanced methods such as hemodiafiltration. Phosphate binders have been shown to reduce absorption of dietary phosphate and lower serum phosphate levels. There are several phosphate binders available, and while they all lower phosphate levels to variable degrees, they differ with respect to their pill burden, potential to induce or exacerbate vascular calcification or ectopic calcification, tissue accumulation, safety, and tolerability. The widespread treatment of hyperphosphatemia requires convincing data from RCTs to ascertain whether lowering serum phosphate levels improves patient-important outcomes, as well as the optimal method and degree of phosphate control. In the interim, the decision and approach used to treat hyperphosphatemia should be based on the best available data, as well as patient needs and clinical judgment.

Pharmacokinetics of Tobramycin Administered at the Beginning of Intermittent Hemodialysis Session (ESRD Study).

BACKGROUND AND OBJECTIVES: There is a renewed interest in the successful use of aminoglycosides due to increasing resistance in gram-negative infections. Few studies to date have examined the pharmacokinetics (PK) of intradialytic infusions of tobramycin. This study sought to characterize the pharmacokinetic profile of intradialytically administered tobramycin in infected patients receiving chronic intermittent hemodialysis and to determine whether it is possible to achieve favorable PK targets. DESIGN SETTING PARTICIPANTS AND MEASUREMENTS: In this prospective pharmacokinetic study, a single dose (5 mg/kg) of tobramycin was administered intradialytically to 11 noncritically ill patients undergoing chronic intermittent hemodialysis. Blood samples were collected at selected time to determine tobramycin serum concentrations. The PK analysis was performed using Phoenix™ NLME. The efficacy exposure outcome for nonsevere gram-negative infections sensitive to tobramycin with a minimum inhibitory concentration ≤1 were maximum concentration (Cmax ≥ 10 mg/L) and area under the curve (AUC24 h > 30 mg⋅h/L). For toxicity, the goal was to identify plasma trough concentrations <2 mg/L. RESULTS: Tobramycin disposition was best described by a one-compartment model using a total clearance composed of the systemic clearance and a transitory hemodialysis clearance. Tobramycin mean (SD) Cmax, trough levels, and AUC24h were 13.1 (1.3) mg/L, 1.32 (0.47) mg/L, and 61 (23) mg⋅h/L, respectively. Monte Carlo simulation run with 1000 virtual patients showed that a 5 mg/kg dose of tobramycin administered intradialytically can outperformed the usual low-dose postdialysis dosing (80% meeting all targets versus <1%, respectively). CONCLUSIONS: A single high dose of tobramycin can achieve favorable PK outcome when administered using intradialytic infusions in hemodialysis patients. This practical dosing regimen may represent an effective and safer alternative to the usual dosing in the treatment of nonsevere gram-negative infections.

CONTEXTE ET OBJECTIFS: La résistance croissante des infections à Gram négatif suscite un regain d'intérêt pour l'utilisation efficace des aminoglycosides. À ce jour, peu d'études ont examiné la pharmacocinétique (PK) des infusions intradialytiques de tobramycine. La présente étude a tenté de caractériser le profil pharmacocinétique de la tobramycine administrée par infusion intradialytique chez des patients malades recevant des traitements intermittents d'hémodialyse de façon chronique. L'étude visait également à déterminer s'il est possible d'atteindre des objectifs de pharmacocinétique favorables. MÉTHODOLOGIE: Pour cette étude de pharmacocinétique prospective, une dose unique (5 mg/kg) de tobramycine a été administrée par infusion intradialytique à onze patients suivant des traitements d'hémodialyse intermittente de façon chronique ne nécessitant pas une admission aux soins intensifs. Des échantillons de sang ont été prélevés à des moments précis afin de mesurer les concentrations sériques de tobramycine. L'analyse de la PK a été effectuée à l'aide du PhoenixMC NLME. Les issues d'exposition d'efficacité avec une concentration minimale inhibitrice inférieure ou égale à 1 pour les infections à Gram négatifs non graves sensibles à la tobramycine étaient la concentration maximum (Cmax: ≥10 mg/L) et la surface sous la courbe (SSC24h: >30 mg⋅h/L). Quant à la toxicité, l'objectif était l'observation de concentrations plasmatiques inférieures à 2 mg/L. RÉSULTATS: La disponibilité de la tobramycine a été mieux décrite par un modèle à un compartiment utilisant une clairance totale composée de la clairance systémique et de la clairance transitoire de l'hémodialyse. La Cmax moyenne, la concentration minimale et la SSC24h de la tobramycine (écart-type) s'établissaient respectivement à 13,1 (1,3) mg/L, à 1,32 (0,47) mg/L et à 61 (23) mg⋅h/L. Une simulation de Monte Carlo réalisée avec 1 000 patients virtuels a montré qu'une dose unique de 5 mg/kg de tobramycine administrée par infusion intradialytique surpasse la faible dose normalement administrée après la dialyse (80 % des objectifs atteints pour la dose unique contre moins de 1 %, respectivement). CONCLUSIONS: Une dose unique élevée de tobramycine permet d'atteindre des paramètres pharmacocinétiques favorables si elle est administrée par infusion intradialytique chez les patients hémodialysés. Ce schéma posologique peut représenter une solution de remplacement efficace et plus sûre au dosage normalement administré pour le traitement des infections à Gram négatifs non graves.

Single-Pill Combinations in the Treatment of Hypertension in Adults: Beyond Convenience.

Adequate blood pressure control in patients with hypertension remains the pillar of cardiovascular-event prevention. Smoking cessation, reduced dietary salt intake, physical exercise and weight loss contribute to better blood pressure control and reduced cardiovascular morbidity, but alone, they are often insufficient in doing so, and their success is highly dependent on individual patient motivation. Pharmacologic therapy, thus, remains necessary for most patients, and our conception of the optimal way of approaching this therapy has evolved over the past decade. Traditionally, monotherapy using a first-line drug was initiated and uptitrated, with the addition of other antihypertensive agents as needed. The latest Hypertension Canada guidelines, however, now recommend first-line treatment with single-pill combinations in patients without compelling indications for treatment. In this review, we discuss the evidence behind this recommendation and how single-pill combinations can improve patient care.

The 2017 American College of Cardiology/American Heart Association vs Hypertension Canada High Blood Pressure Guidelines and Potential Implications.

In this report we examine the differences between the 2017 Hypertension Canada and 2017 American College of Cardiology and American Heart Association (ACC/AHA) blood pressure (BP) guidelines regarding the proportions of individuals with a diagnosis of hypertension, BP above thresholds for treatment initiation, and BP below targets using the CARTaGENE cohort. Compared with the 2017 Canadian guidelines, the 2017 ACC/AHA guidelines would result in increases of 8.7% in hypertension diagnosis and 3.4% of individuals needing treatment, with 17.2% having a different BP target. In conclusion, implementing the 2017 ACC/AHA hypertension guidelines in Canada could result in major effects for millions of Canadians.

Association of Neutrophil-to-Lymphocyte Ratio With Inflammation and Erythropoietin Resistance in Chronic Dialysis Patients.

BACKGROUND: Neutrophil-to-lymphocyte ratio (NLR) was widely studied as a prognostic marker in various medical and surgical specialties, but its significance in nephrology is not yet established. OBJECTIVE: We evaluated its accuracy as an inflammation biomarker in a dialysis population. DESIGN SETTING: Single-center retrospective study. PATIENTS: The records of all 550 patients who were treated with hemodialysis (HD) or peritoneal dialysis (PD) from September 2008 to March 2011 were included. MEASUREMENTS: NLR was calculated from the monthly complete blood count. METHODS: Association between NLR and markers of inflammation (C-reactive protein [CRP], serum albumin, and erythropoietin resistance index [ERI]) was measured using Spearman coefficient. RESULTS: In total, 120 patients were eligible for the correlation analyses. We found a positive correlation between NLR and CRP (all patients: r = 0.45, P < .001; HD: r = 0.47, P < .001; PD: r = 0.48, P = .13). NLR and albumin were inversely correlated (r = -0.51, P < .001). Finally, high NLR was associated with a nonsignificant increased ERI, but we have not demonstrated a direct correlation. LIMITATIONS: CRP and albumin are not measured routinely and were ordered for a specific clinical reason leading to an indication bias. Also, no relationship with clinical outcome was established. CONCLUSIONS: NLR seems to be a good inflammatory biomarker in dialysis in addition to being easily available. However, controlled studies should be conducted to properly assess and validate NLR levels that would be clinically significant and relevant, as well as its prognostic significance and utility in a clinical setting.

CONTEXTE: La qualité de marqueur pronostique du ratio neutrophiles/lymphocytes a fait l'objet d'études approfondies dans plusieurs disciplines médicales et spécialités chirurgicales. En revanche, son importance n'est toujours pas établie dans le domaine de la néphrologie. OBJECTIF DE L'ÉTUDE: Nous avons voulu évaluer l'efficacité du ratio neutrophiles/lymphocytes comme biomarqueur de l'inflammation chez une population de patients dialysés. MODÈLE DE L'ÉTUDE: Il s'agit d'une étude rétrospective restreinte à un seul établissement. PARTICIPANTS: Les dossiers médicaux des 550 patients ayant été traités par hémodialyse (HD) ou par dialyse péritonéale (DP) entre septembre 2008 et mars 2011 ont été retenus pour cette étude. MESURES: Le ratio neutrophiles/lymphocytes a été calculé à partir de la formule sanguine complète prélevée mensuellement. MÉTHODOLOGIE: On a utilisé le coefficient de Spearman pour mesurer la corrélation entre le ratio neutrophiles/lymphocytes et certains marqueurs de l'inflammation : la protéine C-réactive, l'albumine sérique et l'index de résistance à l'érythropoïétine (IRE). RÉSULTATS: De tous les dossiers médicaux retenus, seuls 120 patients étaient admissibles à l'analyse de corrélation. Nous avons pu établir une corrélation positive entre le ratio neutrophiles/lymphocytes et la protéine C-réactive (r=0,45; p<0,001 pour l'ensemble des patients, r=0,47; p<0,001 chez les patients en HD, et r=0,48; p=0,13 chez les patients sous DP), alors que la corrélation était inversée dans le cas de l'albumine sérique (r=0,51; p<0,001). Nous avons également observé qu'un ratio neutrophiles/lymphocytes élevé était associé à une élévation non significative de l'IRE, sans toutefois établir une corrélation directe. LIMITES DE L'ÉTUDE: Règle générale, l'albumine sérique et la protéine C-réactive ne sont mesurées que lorsqu'une raison d'ordre clinique le demande, ce qui pourrait signaler un biais. De plus, aucun lien n'a été établi entre le ratio neutrophiles/lymphocytes et les devenirs cliniques des patients. CONCLUSION: Le calcul du ratio neutrophiles/lymphocytes semble être un bon indicateur de l'état inflammatoire chez les patients dialysés. Qui plus est, les données nécessaires pour évaluer ce ratio sont faciles à obtenir. Néanmoins, des études contrôlées devraient être menées pour déterminer les valeurs de ratio neutrophiles/lymphocytes qui seraient significatives du point de vue clinique, de même que pour établir l'importance du ratio neutrophiles/lymphocytes sur le plan du pronostic et sa pertinence dans un cadre clinique.

Conversion of oral alfacalcidol to oral calcitriol in the treatment of secondary hyperparathyroidism in chronic hemodialysis patients.

PURPOSE: The optimal vitamin D3 therapy for the treatment of secondary hyperparathyroidism (SHPT) in chronic hemodialysis patients is still controversial. Recent studies suggest that uremia in end-stage renal disease is associated with enzymatic hepatic dysfunction altering 25-hydroxylation of vitamin D3. The goal of our study was to compare the efficacy of calcitriol, the fully hydroxylated active form of vitamin D3, to alfacalcidol which needs 25-hydroxylation to be effective, for the treatment of SHPT in chronic hemodialysis patients. METHODS: We retrospectively reviewed 45 chronic hemodialysis patients who were switched from oral alfacalcidol to oral calcitriol for the treatment of SHPT. Parathyroid hormone (PTH), serum calcium and serum phosphorus levels were compared pre- and post-conversion using paired Student's t tests. RESULTS: The mean dose of active vitamin D3 decreased from 3.50 mcg/week at baseline to 2.86 mcg (P < 0001) after the switch from alfacalcidol to calcitriol. PTH significantly decreased from 94.4 to 82.6 pmol/L (-11.8 pmol/L, P = 0.02). The mean corrected calcium increased from 2.17 to 2.25 mmol/L (+0.08 mmol/L, P < 0.001) without any clinically significant hypercalcemia, and phosphorus levels were stable. Results were similar in a subgroup of patients (n = 17) for whom the medication was administrated during the hemodialysis session, ensuring a complete compliance. CONCLUSIONS: According to our study, calcitriol in equal dosage is more effective than alfacalcidol in lowering serum PTH level in chronic hemodialysis patients. This suggests that calcitriol may be the optimal active vitamin D3 for the treatment of SHPT in chronic hemodialysis patients.

Retrospective Study Looking at Cinacalcet in the Management of Hyperparathyroidism after Kidney Transplantation.

Objectives. The primary objective of this study is to evaluate the use of cinacalcet in the management of hyperparathyroidism in kidney transplant recipients. The secondary objective is to identify baseline factors that predict cinacalcet use after transplantation. Methods. In this single-center retrospective study, we conducted a chart review of all patients having been transplanted from 2003 to 2012 and having received cinacalcet up to kidney transplantation and/or thereafter. Results. Twenty-seven patients were included with a mean follow-up of 2.9 ± 2.4 years. Twenty-one were already taking cinacalcet at the time of transplantation. Cinacalcet was stopped within the first month in 12 of these patients of which 7 had to restart therapy. The main reason for restarting cinacalcet was hypercalcemia. Length of treatment was 23 ± 26 months. There were only 3 cases of mild hypocalcemia. There was no statistically significant association between baseline factors and cinacalcet status a year later. Conclusions. Discontinuing cinacalcet within the first month of kidney transplantation often leads to hypercalcemia. Cinacalcet appears to be an effective treatment of hypercalcemic hyperparathyroidism in kidney transplant recipients. Further studies are needed to evaluate safety and long-term benefits.

Hypertension Canada's 2017 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults.

Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension. This year, we introduce 10 new guidelines. Three previous guidelines have been revised and 5 have been removed. Previous age and frailty distinctions have been removed as considerations for when to initiate antihypertensive therapy. In the presence of macrovascular target organ damage, or in those with independent cardiovascular risk factors, antihypertensive therapy should be considered for all individuals with elevated average systolic nonautomated office blood pressure (non-AOBP) readings ≥ 140 mm Hg. For individuals with diastolic hypertension (with or without systolic hypertension), fixed-dose single-pill combinations are now recommended as an initial treatment option. Preference is given to pills containing an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in combination with either a calcium channel blocker or diuretic. Whenever a diuretic is selected as monotherapy, longer-acting agents are preferred. In patients with established ischemic heart disease, caution should be exercised in lowering diastolic non-AOBP to ≤ 60 mm Hg, especially in the presence of left ventricular hypertrophy. After a hemorrhagic stroke, in the first 24 hours, systolic non-AOBP lowering to < 140 mm Hg is not recommended. Finally, guidance is now provided for screening, initial diagnosis, assessment, and treatment of renovascular hypertension arising from fibromuscular dysplasia. The specific evidence and rationale underlying each of these guidelines are discussed.

Retroperitoneal fibrosis: retrospective descriptive study on clinical features and management.

INTRODUCTION: Retroperitoneal fibrosis (RPF) is a rare condition characterized by the presence of inflammatory and fibrous retroperitoneal tissue that often encases the ureters or abdominal organs. This study describes the clinical characteristics, diagnostic methods, and treatments and their effects on renal function. METHODS: We conducted a retrospective analysis of patients diagnosed with RPF at Maisonneuve-Rosemont Hospital. RESULTS: We identified 17 patients with RPF between 1998 and 2013. Eight patients were females (47%), and the mean age was 62±18 years. Eleven patients were idiopathic. Back pain was the most common symptom. All diagnoses were made based on the finding of a retroperitoneal mass on the computed tomography scan. Three patients had histological diagnosis of RPF and seven patients had unspecific changes on their biopsy. Twelve patients needed double-J stents, three patients had a temporary percutaneous nephrostomy, two patients had to have a nephrectomy for refractory ureteral obstruction, and one patient required hemodialysis. Ten patients with idiopathic RPF received medical treatment. In the treated group, only two patients had complete remission of the disease and five patients had improvement of their lesions. There were no deteriorations and only one relapse. Seven patients did not receive any treatment; two of them achieved complete remission, one of them deteriorated, and two of them had no changes. CONCLUSION: Most of our cases of RPF were idiopathic. Almost all treated patients received prednisone and seemed to respond, at least partially. There was a lot of heterogeneity in patient management, which makes it difficult to compare treatment effects. However, treated patients seemed to have more favorable outcomes than those who were not.