Urgent-Start Peritoneal Dialysis as a Bridge to Definitive Chronic Renal Replacement Therapy: Short- and Long-Term Outcomes.

Background: The peritoneal dialysis (PD) urgent-start pathway, without typical 2-week break-in period, was meant for late-referral patients able and prone to join PD-first program, with its main advantages such as: keeping the vascular system intact, preserving their residual renal function and retaining life-style flexibility. We compared the short- and long-term outcomes of consecutive 35 patients after urgent- and 94 patients after the planned start of PD as the first choice. Methods: The study included all incident end-stage renal disease patients starting PD program between January 2005 and December 2015, classified into two groups: those with urgent (unplanned) and those with elective (planned) start. Urgent PD was initiated as an overnight automatic procedure (APD) with dwell volume gradually increased, and after 2-3 weeks, target PD method was established. Results: The mean time between catheter implantation and PD start was 3.5 ± 2.3 in urgent and 16.2 ± 1.7 days in planned-start groups (p < 0.00001). 51% of the patients in the urgent-start group required PD during first 48 h after catheter insertion. Mean follow-up of 17.6 ± 11.09 months (median: 19.0) was in the urgent-start group and 28.6 ± 26.6 months (median: 19.5) in the planned-start group. The early mechanical complications were observed more often in the urgent-start group (29 vs. 4%, p = 0.00005). The only significant predictors of early mechanical complications were serum albumin (p = 0.02) and time between the catheter insertion and PD start. The first year patient survival and technique survival censored for death and kidney transplantation were not significantly different between groups. In Cox proportional analysis the independent risk factors for patient survival as well as for method and patient survival appeared Charlson Comorbidity Index CCI (HR 1.4; p = 0.01 and 1.24; p = 0.02) and time from catheter implantation to PD start with HR 5.11; p = 0.03 and 4.29; p = 0.04 for <2 days, while time >14 days lost its predictive value (p = 0.07). Conclusion: Peritoneal dialysis may be a feasible and safe alternative to HD in patients who need to start dialysis urgently without established dialysis access, with an acceptable complications rates, as well as patient and technique survival.

Surgical treatment of hyperinsulinism during the course of pancreatic cancer (insulinoma) - one center experience.

UNLABELLED: Endogenic hyperinsulinism is mainly caused by neuroendocrine tumors (insulinomas) which autonomously secrete insulin. Because the symptoms are often aspecific, a considerably delay in diagnosis occurs. The treatment consists of operative removal of the tumor from the pancreas, preceded by pre-operative localization. In this article we describe our experience with surgical removal of insulinomas. MATERIAL AND METHODS: We retrospectively analyzed all patients with insulinoma which were treated in our center. Definitive diagnosis was made using a 72-hours glucoses fasting test. We describe the symptoms, localization techniques and the outcomes after surgery. RESULTS: Between January 2002 and May 2011, 45 patients (35.6% men and 64.4% female) were treated in our center. The most prevalent symptoms were altered consciousness and general malaise. The combination of CT-scan and endoscopic ultrasound had the highest (90%) sensitivity to localize tumors pre-operatively. During surgery, in 40 patients (89%) the tumor could be removed by enucleation. In the other five patients partial pancreas resection was required. In 22 patients (49%) we used intra-operative insulin level measurements to confirm complete tumor resection. Within the first month after surgery, two patients (4.4%) developed acute pancreatitis, four patients (8.8%) developed a pancreatic fistula. One patient died of multi-organ-failure. All patients were free from symptoms of hyperinsulinism after the surgery and after a median follow-up of 4.5 years. CONCLUSIONS: Based on the experience with 45 patients, surgical removal, aided by pre-operative localization with CT and endoscopic ultrasonography, is an effective and safe treatment for insulinomas.

Late aneurysm rupture after endovascular abdominal aneurysm repair.

OBJECTIVES: The goal of endovascular repair is to protect the patient from aneurysm rupture. Careful surveillance should be performed postoperatively in order to select patients with aneurysm growth and, therefore, the highest rupture risk. The aim of the study was to present our experience with aneurysm rupture in long-term follow-up after endovascular abdominal aneurysm repair. METHODS: Between 1998 and 2006, 445 patients with abdominal aortic aneurysms were treated endovasculary in our Department. All patients were followed-up postoperatively according to the EUROSTAR protocol, with a CT scan performed postoperatively in the 3rd, 6th and 12th month and annually thereafter with good compliance. Because of this we had the opportunity for early treatment of complications, especially endoleaks which may cause aneurysm growth and subsequent rupture. RESULTS: In three presented patients aneurysm rupture occurred in the late follow-up period after endovascular treatment. In all cases open aneurysmectomy was performed without any major complications. We also analyzed the reason for the rupture: in all cases it was due to endoleak type I, that was not present during postoperative CT-scans. The mechanism of its recurrence was proximal cuff migration 29 months after endovascular aneurysm treatment in the first patient. In the second case endoleak type I appeared 32 months postoperatively due to aneurysm lengthening, what could have been the consequence of persistent, small endoleak type II. In the third case the reason of aneurysm rupture was late endoleak type I due to migration of proximal seal of the stentgraft. CONCLUSIONS: Although the risk of aneurysm rupture after EVAR is low, all patients treated endovascularly should be routinely monitored, in order to select cases with potential endoleaks or stentgraft migration which may lead to fatal complications. When rupture occurs open aneurysmectomy is feasible, although it requires careful management in these high-risk patients.

Secondary kidney transplantation in a patient 16 years after simultaneous pancreas and kidney transplantation--a case report.

Simultaneous pancreas and kidney transplantation (spktx) is currently the most effective method of treatment of type 1 diabetes complicated by renal insufficiency. The first successful spktx in Poland was performed in the Department of General, Vascular and Transplant Surgery of the Warsaw Medical University on the 4th of February 1988. Since then 70 spktx were performed in our Department. We present a 44-year-old patient who after 16 years of good function of both transplanted organs presented with elevated creatinine levels (>4 mg/dl) as a result of chronic rejection of the kidney allograft. On the 22nd of January 2005 the patient underwent secondary kidney transplantation. The immunosuppresive protocol consisted of MMF, CsA and steroids. Humanized anti-lL-2 monoclonal antibodies (daclizumab) were used as pre-procedure induction. Using a mid-line incision the new kidney graft was anastomosed to the recipient left external iliac vessels. The ureter was anastomosed with the bladder without anti reflux procedures and the allograft was placed in the retroperitoneum below the previously transplanted kidney. Graftectomy of the first kidney allograft was not performed. After surgery, normal creatinine parameters were restored to a level of 1, 1 mg/dl and an increase in urine output was noted from 1 to 4 liters per day. Oral intake of foods was resumed on the 4th postoperative day and no early complications were observed. 12 months observation period confirmed stabile function of both transplanted organs. Secondary kidney transplantation in patients after spktx is technically possible and may be considered an option in patients with diminishing function of the first kidney allograft.

A retrospective study of steroid elimination in simultaneous pancreas and preemptive kidney transplant (Sppre-Ktx) recipients.

OBJECTIVES: The feasibility and timing of corticosteroid elimination and its impact on lipid metabolism in simultaneous pancreas and preemptive kidney transplantation were examined. MATERIAL AND METHODS: A retrospective study was conducted on 14 recipients of pancreas and preemptive kidney grafts transplanted form April 2003 to March 2004. All recipients received ATG induction. Tacrolimus (Tac) was administered according to trough concentration 8-15 ng/ml. Mycophenolate mofetil (MMF) was administered at doses of 2 g per day with subsequent dosage adjustment based on tolerability. All recipients received corticosteroids with subsequent dose tapering. Total cholesterol and triglyceride levels before transplantation and after steroid withdrawal were assessed. RESULTS: One year recipient survival rate was 100%. Cumulative one year panaceas and kidney survival rates were: 85% and 100%, respectively. After transplantation of fasting glycemia and HbAIC were normalized. Serum creatinine decreased from 4.35 +/- 1.61 mg/dl before transplantation to 1.1 + 0.25 mg/dl after surgery (p < 0.05). Corticosteroids were eliminated between the 2nd and 16th month (mean 6 months) after transplantation. Cholesterol and triglyceride levels were wiyhin normal range, in addition significantly decreased after transplantation and steroid withdrawal, from 194.5 +/- 35.6 mg/dl to 162.4 +/- 36.8 mg/dl and 142.5 +/- 65 94.8 +/- 42.5 mg/dl, respectively (p < 0.05). CONCLUSIONS: It is possible to eliminate steroids 6 months after transplantation using immunossupression based on MMF and Tac. Withdrawal of steroids could be partially contributed to the normalization of lipid metabolism.

The comparison of treatment results of type 1 diabetes mellitus complicated by end-stage diabetic nephropathy in patients undergoing simultaneous pancreas and pre-emptive kidney transplantation (SPPkTx) and patients enrolled into the dialysis program--a cohort study.

OBJECTIVE: A cohort study was conducted to compare treatment of patients with type 1 diabetes mellitus and end-stage diabetic nephropathy. PATIENTS AND METHODS: 47 type 1 diabetic patients required renal replacement therapy in years: 2001-2005 were enrolled. Simultaneous pancreas and preemptive kidney transplant (sppktx) was performed in 18 (group I). Group II consisted of 29 patients who entered dialysis program. Survival rate for patients from both groups was estimated. Transplanted organ function was evaluated for group II. Lipid profile and its correlation with thickness of carotid media was assessed. Impact of sppktx on diabetic retinopathy was investigated. Cost and life quality were compared between groups. RESULTS: Two-year cumulative recipient survival rate for group I and II was 100% and 96%, respectively. One-year cumulative survival rate for transplanted pancreas was 88% and for kidney grafts 94%. In group I cholesterol and triglyceride level before transplantation were: 207 +/- 38 mg/dl and 133 +/- 65 mg/dl and decreased after transplantation to 155 +/- 20 mg/dl and 78 +/- 25 mg/dl, respectively (p < 0.05). No difference of carotid media thickness was observed between groups. Stabilization of retinopathy was observed in 91.6% non-blind recipients. During the first year of the follow-up the costs of transplantation doubled those of dialysis therapy but in the second year the costs of dialysis exceeded the costs required for transplanted patients. CONCLUSION: Despite of major surgery and introduction of immunosuppression in group I, results did not differ significantly between groups during a two-year follow-up. After sppktx, stabilization of the carotid media was slower than the normalization of lipids. At the second year, transplantation is less expensive than dialysis.