Age, thyroglobulin levels and ATA risk stratification predict 10-year survival rate of differentiated thyroid cancer patients.

INTRODUCTION: Differentiated thyroid cancer (DTC) is the most common of endocrine cancers. Many studies have focused on recurrence-free survival of DTC patients, however, few studies have addressed overall survival rates. Given its very good prognosis, estimating overall or long-term survival in patients with DTC seems rational. So far, neither the impact of pre- and post-ablation thyroglobulin, nor that of initial American Thyroid Association (ATA) risk stratification on long-term disease-specific survival, have been sufficiently studied. OBJECTIVE: The aim of this study was to determine the factors that influence long-term disease-specific survival and thyroglobulin levels in patients with DTC who have been previously treated with thyroidectomy and radioactive iodine (RAI) remnant ablation. PATIENTS AND METHODS: This observational retrospective study included 1093 patients who were treated for DTC between 1995 and 2010 and are still monitored in our tertiary center. Only patients who needed RAI ablation after thyroidectomy were included in this study. Patients who were treated with RAI following rhTSH stimulation, patients who presented positive anti-thyroglobulin antibodies, and patients who had micro-cancers were excluded. Pre-ablation stimulated thyroglobulin (Pre-ablation sTg) was measured after thyroid hormone withdrawal (THW), just before RAI. RESULTS: According to ATA standards, 29 patients (2.7%) were classified as high-risk patients. Initial ATA high-recurrence risk rating (HR 21.9; 95% CI: 8.5-56.3), age>55 years (HR 23.8; 95%-CI: 7.5-75.3) and pre-ablation sTg≥30 µg/l (HR 8.4; 95% CI: 4.6-15.3) significantly impacted ten-year survival. Moreover, age over 45 years, ATA moderate-risk and follicular DTC were also significant. Ten-year survival was lower in ATA high-risk patients (51% vs 95% and 93% for the low and intermediate risk; p<10-7), patients older than 55 years (82% vs 98%; p<10-7), and in patients with pre-ablation sTg≥30 (78% vs 95%; p<10-7). Three rates of long-term survival were distinguished: excellent (survival rate of 99% in patients<55 years with pre-ablation sTg <30µg/l) representing 59% of the cohort, moderate (survival rate of 94.5% in patients <55 years with pre-ablation sTg ≥30µg/l or ≥55 years with pre-ablation sTg <30 µg/l) representing 38% of the cohort, and low (survival rate of 49% in patients ≥55 years with pre-ablation sTg ≥30µg/l) representing 3% of the cohort. CONCLUSION: Initial ATA high-risk classification, age over 55 years old and pre-ablation sTg ≥30 µg/l are the main negative factors that influence the ten-year survival in DTC. We suggest three categories of overall survival rates. Patients older than 55 years with pre-ablation sTg ≥30 µg/l have the worst survival rate.

Constipation in Peritoneal Dialysis Patients.

Constipation in peritoneal dialysis (PD) is an infrequent but potentially serious condition affecting the mechanical properties of dialysis techniques and predisposing to bacterial intestinal translocation and eventual enteric peritonitis. Despite the importance of the problem, published literature is scarce, consisting mostly of uncontrolled single-center trials. This inconsistency may be attributed to the large number of clinical, radiological, and endoscopic tools that have been used in the studies with a lack of generally accepted core primary outcomes.The current narrative review discusses the pathophysiological associations between chronic kidney disease, PD, and constipation with related complication.

Gastrointestinal Disorders in Peritoneal Dialysis Patients.

BACKGROUND: Gastrointestinal (GI) disorders in peritoneal dialysis (PD) patients are relatively understudied in the literature, even though they have a serious impact in the morbidity parameters and the quality of life for this group of patients. Various diagnostic tools have been used, including instrumental methods and questionnaires, invariably validated in comparative studies. SUMMARY: The prevalence of GI disorders is very high in PD patients. Compared to the haemodialysis patients they present a higher prevalence of reflux, eating dysfunction, gastroesophageal reflux, intestinal obstruction or adhesions and abdominal hernia. They may be divided into Gastric disorders (Gastroesophageal reflux disease, pathological Gastric emptying, Dyspepsia, Helicobacter pylori infection, peptic ulcers) and Intestinal disorders (Peritonitis, Diverticulosis, Constipation). Key Messages: The current paper is a review of the literature involving GI disorders in PD patients. This special group of patients with a special role of the peritoneal cavity and the GI motility in the physiology of their dialysis merit a larger number of studies dealing with the interrelation of the GI tract and the PD physiological, functional and pathophysiological parameters.

Vaccination practices in dialysis patients: A narrative review.

In a period of turmoil concerning vaccination practices, there is a serious conflict between scientifically reasonable, evidence-based guidelines and the far-fetched rumors or misconceptions concerning the vaccination practices in the general population. When a significant portion of the medical and paramedical personnel may be deliberately unvaccinated against common biological agents, achieving effective vaccination rates in the dialysis population may be complicated. Vaccination rates are unacceptably low in dialysis patients and seroconversion rates are even lower; further, serological follow-up is generally poor. The particularly anergic immune system of the advanced chronic kidney disease patients is partly a cause of both high rates of infection and low rates of seroconversions. This narrative review is an effort to summarize current knowledge concerning the vaccination practices in dialysis patients with some specific recommendations based on these facts. Of particular interest is a new vaccine, the Zoster Recombinant, Adjuvanted Vaccine (Shingrix), which we will include in our discussion.

Comparison of the hemodynamic tolerance and the biological parameters of four acetate-free hemodialysis methods.

PURPOSE: Acetate in hemodialysis solutions exerts inflammatory, vasodilatatory and cardio-depressive effects. Citrate has been proposed as an optimal substitute. The aim of the present trial was the comparison of the hemodynamic and biological parameters on a group of patients dialysed consecutively with 4 acetate-free haemodialysis techniques. METHODS: In a prospective crossover manner, we measured the hemodynamic and biological effects of four acetate-free hemodialysis methods: he acetate-free biofiltration with variable potassium (AFBK) and three methods with a citrate buffer: onventional hemodialysis (HD), on-line hemodiafiltration (HDF) and on-line hemofiltration (HF). Fourteen chronic hemodialysis patients (9 males mean age 72.21±11.21 years old) underwent 6 four-hour dialysis sessions for 2 weeks on each of the 4 studied techniques. RESULTS: The AFBK technique presented less intradialytic hypotensive episodes (1 in 84 sessions) compared to the other techniques (HD: 29/84, HDF 22/82 and HF: 14/78; P<0.001). The blood pressure after one, two, three hours of dialysis and at the end of the hemodialysis session was significantly higher in the AFBK technique. On AFBK the net ultrafiltration (UF) (P<0.001) and the UF as a percentage of the dry weight (P=0.005) were significantly higher. A significant correlation between the prevalence of hypotensive episodes and the change of serum potassium levels (P=0.002) during the first hour of dialysis was detected. CONCLUSIONS: AFBK is associated with a better intradialytic hemodynamic tolerance and could be an optimal method for frail hypotension-prone hemodialysis patients.

Comparison of intradialytic hemodynamic tolerance between on-line hemodiafiltration and acetate-free biofiltration with profiled potassium dialysate concentration.

Intradialytic hypotensive episodes are deleterious for hemodialysis (HD) patients. Acetate-free biofiltration with profiled potassium (AFBK) dialysate concentration may improve their cardiovascular stability. The aim of the present crossover study was to compare intradialytic hemodynamic tolerance and biological parameters between online hemodiafiltration (olHDF) and AFBK. Ten frail HD patients (8 males) with a mean age of 66.71- ± 12.31 years were studied for three months on olHDF and AFBK. There was a significant reduction of the hypotensive episodes during the AFBK period compared to the olHDF period. Mean intradialytic systolic and diastolic blood pressures were significantly higher during the AFBK period. There was a significant postdialytic increase in serum sodium concentration with the AFBK compared to olHDF. The dry weight and ultrafiltration indices were significantly higher, and the Kt/V was significantly lower during the AFBK period. Serum albumin concentration significantly increased during the AFBK period. AFBK leads to a significantly improved intradialytic tolerance in hemodynamically instable HD patients.

Vitamins in dialysis: who, when and how much?

Despite the significant technical evolution of the blood purification methods, cardiovascular morbidity and mortality in dialysis patients is still several times higher than that observed in the general population. Vitamins are playing a crucial role in multiple key metabolic pathways. Due to multiple factors, dialysis patients present very often hypo- or hypervitaminosis for a broad range of vitamins. Dialysis in the context of renal replacement therapy is associated with a non-physiological potassium-sparing dietetic regime. Additionally, there is a non-selective intradialytic loss of micro- and macronutrients, deranged intracellular kinetics and gastrointestinal malabsorption due to uratemia. Frequent treatment with antibiotics due to infections associated with the acquired uremia-related immunosuppression may derange the vitamin-producing intestinal microflora. Certain agents prescribed in the context of renal failure or other conditions may reduce the absorption of vitamins from the gastrointestinal tract. These factors may deplete a dialysis patient from vitamins, especially the ones with antioxidant activity that may be associated with cardioprotective properties. In other cases, vitamins metabolized and excreted by the kidneys may be accumulated and exert toxic effects. The scope of this paper is to describe the main issues on vitamin therapy in dialysis patients in view of the ever contradictory opinions and practices.