Performance of Cockcroft-Gault, MDRD, and CKD-EPI in estimating prevalence of renal function and predicting survival in the oldest old.

BACKGROUND: The question for prevalence estimation and validation of the various eGFRs in old age is still under debate. To assess renal function with increasing age, we estimated mean eGFR, in subjects aged 20-85 years. Furthermore, we assessed prevalence of eGFR in a population-based sample of 85 year olds and investigated the performance of these eGFRs in predicting mortality in the oldest old. METHODS: Renal function with increasing age was assessed in subjects aged 20-85 years from the Bronovo Study Cohort. We estimated prevalences of eGFRs and mortality risks in a population-based study of persons aged 85 years and older, the Leiden 85-plus Study. The GFRs were estimated by three different formulas. RESULTS: After the age of 70 years, the C-G tended to give relatively lower eGFRs. An eGFR < 60 was found in 90% of the subjects aged 85 years as calculated by C-G, in 55% of the subjects using MDRD and in 68% of the 85 year old subjects as calculated by CKD-EPI. When renal function was <30 ml/min/1.73 m2, an increased mortality risk was observed by C-G (HR 1.9 (95% CI 1.1-3.3)), by MDRD (HR 3.5 (95% CI 1.8-6.7)), whereas by CKD-EPI significance was not reached (HR 2.4 (95% CI 0.9-6.4)). CONCLUSIONS: Our study demonstrates that in subjects above age 70, C-G gives lower estimates of renal function when compared to MDRD and CKD-EPI. Furthermore, prevalence of renal dysfunction (CKD stage 1-3) at age 85 years was highest for C-G (90%), lowest for MDRD (55%), and 68% for CKD-EPI. Moreover, we found that in subjects aged 85 years MDRD predicted mortality best.

Haemoglobin predicts length of hospital stay after hip fracture surgery in older patients.

OBJECTIVES: Treating anaemia in older patients who have undergone hip fracture surgery is to enhance functional recovery. The relationship between peri-operative haemoglobin levels and outcome after hip fracture surgery are controversial. We assessed whether higher haemoglobin levels predict length of hospital stay after hip fracture surgery in elderly subjects. STUDY DESIGN: A follow-up study in a historical cohort was performed in 317 patients aged 65 years old undergoing hip fracture surgery over the period 2004-2006 at the Leiden University Medical Centre. MEAN OUTCOME MEASURES: Linear regression analysis was used to assess the association between pre- and post-operative haemoglobin level and length of hospital stay after controlling for age and sex. RESULTS: Anaemia after hip fracture surgery was present among 86% of the patients. Length of hospital stay after hip fracture surgery in elderly subjects with post-operative anaemia (10.7 days) was significantly longer than in elderly subjects without post-operative anaemia (7.5 days, p=0.007). Post-operative haemoglobin levels and length of hospital stay were inversely related (p=0.013). The length of hospital stay was not related with pre-operative haemoglobin level. CONCLUSION: Higher postoperative haemoglobin levels predict shorter length of hospital stay after hip fracture surgery in the elderly. A definitive randomized clinical trial has to demonstrate whether this association is causal.

No increased mortality risk in older persons with unexplained anaemia.

BACKGROUND: in older persons, anaemia is associated with a number of unfavourable outcomes. In approximately 30% of older persons with anaemia, the cause of the anaemia is unexplained. We assessed the clinical differences between subjects with explained and unexplained anaemia and investigated whether these subjects have different mortality patterns compared with subjects without anaemia. DESIGN: observational prospective follow-up study. SETTING: the Leiden 85-plus study. PARTICIPANTS: four hundred and ninety-one persons aged 86 years. METHODS: the study population was divided in three groups: (i) no anaemia (reference group, n=377), (ii) explained anaemia (iron deficiency, folate deficiency, vitamin B12 deficiency, signs of myelodysplastic syndrome or renal failure, n=74) and (iii) unexplained anaemia, (n=40). Mortality risks were estimated with Cox-proportional hazard models. RESULTS: haemoglobin levels were significantly lower in subjects with explained anaemia than in subjects with unexplained anaemia (P<0.01). An increased risk for mortality was observed in subjects with explained anaemia [HR: 1.93 (95% CI: 1.47-2.52), P<0.001], but not in subjects with unexplained anaemia [HR: 1.19 (95% CI: 0.85-1.69), P=0.31]. Adjusted analyses (sex, co-morbidity, MMSE, institutionalised and smoking) did not change the observed associations for both explained and unexplained anaemic subjects. CONCLUSION: older subjects with unexplained anaemia had similar survival compared with non-anaemic subjects. Increased mortality risks were observed in subjects with explained anaemia compared with non-anaemic subjects.

An unusual complication 4 years after laparoscopic adjustable banding: jejunal obstruction due to the connecting tube.

Laparoscopic adjustable gastric banding (LAGB) is an often performed bariatric procedure for morbid obesity. Several complications are known, including surgery and port-side-associated complications. As rare but serious late complication of LAGB, we describe a 50-year-old patient with periodic incomplete intestinal constriction due to the silicone connecting tube, 4 years after laparoscopic adjustable gastric banding was performed. Abdominal CT scan showed an obstructive ileus due to a loop in the connecting tube. After surgical removal of the connecting tube, the patient recovered without sequelae.

Effect of erythropoietin levels on mortality in old age: the Leiden 85-plus Study.

BACKGROUND: The production of erythropoietin is triggered by impaired oxygen delivery to the kidney, either because of anemia or hypoxemia. High erythropoietin levels have been shown to predict the risk of death among patients with chronic heart failure. We investigated the prognostic value of elevated erythropoietin levels on mortality among very elderly people in the general population. METHODS: The Leiden 85-plus Study is a population-based prospective follow-up study involving 599 people aged 85 years in Leiden, the Netherlands, enrolled between September 1997 and September 1999. Erythropoietin levels were determined at age 86. For this analysis, we included 428 participants with a creatinine clearance of at least 30 mL/min. Mortality data, recorded until Feb. 1, 2008, were obtained from the municipal registry. RESULTS: During follow-up, 324 (75.7%) participants died. Compared with participants whose erythropoietin levels were in the lowest tertile (reference group), those whose levels were in the middle tertile had a 25% increased risk of death (hazard ratio [HR] 1.25, 95% confidence interval [CI] 0.95-1.64), and those whose levels were in the highest tertile had a 73% increased risk (HR 1.73, 95% CI 1.32-2.26) (p value for trend < 0.01). The association between erythropoietin levels and mortality remained largely unchanged after we adjusted for sex, creatinine clearance, hemoglobin level, comorbidity, smoking status and C-reactive protein level, and was similar for deaths from cardiovascular and noncardiovascular causes. INTERPRETATION: Among people aged 85 years and older, elevated erythropoietin levels were associated with an increased risk of death, independent of hemoglobin levels.

[Squamous cell carcinoma as a rare complication of hidradenitis suppurativa]. / Plaveiselcelcarcinoom als zeldzame complicatie van een hidradenitis suppurativa.

A 42-year-old Dutch woman with no previous relevant medical history presented with hidradenitis suppurativa in the left inguinal region. After surgical excision, pathological investigations confirmed a diagnosis of squamous cell carcinoma. Further investigations showed no signs of metastases and after 6 months of follow-up there were no signs of recurrence. Hidradenitis suppurativa is a common chronic skin condition, localised in the axillary, inguinal and perianal regions. Squamous cell carcinoma of the skin is a rare complication of hidradenitis suppurativa. It occurs in extra-axillary locations of the hidradenitis foci, and has a poor prognosis. Pathological examination of excised skin in patients with hidradenitis foci is recommended, especially in the case of extra-axillary lesions.

White blood cell count and C-reactive protein are independent predictors of mortality in the oldest old.

BACKGROUND: White blood cell (WBC) count is, like C-reactive protein (CRP), a clinical marker of inflammation and predicts cardiovascular disease and mortality in middle-aged populations. Limited data exist on the association between WBC count and mortality in the oldest old. Moreover, because CRP and WBC count are closely linked, it is not known whether WBC count and CRP are independent risk factors for mortality. We assessed the independent predictive value of WBC count and CRP levels in relation to mortality, both vascular and nonvascular, in very old participants. METHODS: A total of 599 women and men were evaluated longitudinally in the Leiden 85-plus Study. Blood samples and medical information were collected at age 85, and all participants were visited annually until age 90 or death. Mortality risks were estimated with Cox proportional hazard models. RESULTS: Increasing WBC count was associated with an increased risk for all-cause mortality (hazard ratio, HR [95% confidence interval, CI] = 1.26 [1.15-1.38]) after adjustment for sex and smoking status. CRP levels were also associated with an increased risk for mortality (HR [95% CI] = 1.22 [1.10-1.35]). The association between increasing WBC count and mortality remained significant after adjustment for CRP levels (HR [95% CI] = 1.20 [1.09-1.33]), whereas also the relation between increasing CRP levels and mortality remained significant after adjustment for WBC count (HR [95% CI] = 1.17 [1.05-1.30]). CONCLUSION: Our results suggest that WBC count and CRP levels both independently predict mortality in the oldest old.

Effect of anemia and comorbidity on functional status and mortality in old age: results from the Leiden 85-plus Study.

BACKGROUND: There is limited insight into the attributable effect of anemia and comorbidity on functional status and mortality in old age. METHODS: The Leiden 85-plus Study is a population-based prospective follow-up study of 562 people aged 85 years. Anemia was defined according to World Health Organization criteria. We measured 3 parameters of functional status at baseline and annually thereafter for 5 years: disability in basic and instrumental activities of daily living, cognitive function and the presence of depressive symptoms. We obtained mortality data from the municipal registry. RESULTS: The prevalence of anemia at baseline was 26.7% (150/562). Participants who had anemia at baseline had more disability in activities of daily living, worse cognitive function and more depressive symptoms than participants without anemia at baseline (p

Hematopoietic capacity and exceptional survival: the Leiden Longevity Study.

OBJECTIVES: To assess whether familial longevity can be attributed to sustained hematopoietic capacity. DESIGN: Prospective follow-up study of two independent population-based cohorts. SETTING: The Leiden Longevity Study and the Leiden 85-plus Study. PARTICIPANTS: From the Leiden Longevity Study, 1,001 nonagenarians with familial longevity were included. As age-matched controls, 260 nonagenarians without familial longevity were used from the Leiden 85-plus Study. MEASUREMENTS: Hemoglobin, leukocytes, and thrombocytes were measured for all subjects with and without familial longevity. Standardized mortality ratios, linear regression, and left-censored Cox regression were used for statistical analysis. RESULTS: Mortality in nonagenarians with familial longevity was 28% lower than in nonagenarians from the general population (standardized mortality ratio=0.72, 95% confidence interval (CI)=0.65-0.79, P<.001). No differences were found between hemoglobin, leukocyte, and thrombocyte count in nonagenarians with and without familial longevity (all P>.30). Nonagenarians with familial longevity had greater mortality risk when anemia was present (sex-adjusted hazard ratio=1.71, 95% CI 1.41-2.07, P<.001). No relationship was found between leukocytes, thrombocytes, and mortality in either study group (all P>.20). CONCLUSION: Hematopoietic capacity cannot explain the significantly better survival of nonagenarians with familial longevity, but in those with familial longevity, anemia may contribute to mortality.