How effective is nephrectomy in curing hypertension in children with unilateral poorly functioning kidney? A systematic review.

PURPOSE: Some children with hypertension (HTN) have unilateral poorly functional kidney (PFK). This provides an opportunity for the clinician to cure the HTN by removal of the PFK, thereby avoiding the problems of long-term medication. However, there is sparse data in children regarding the effect of PFK nephrectomy on curing HTN. In this review, we analysed the etiology of PFK causing HTN and the effectiveness of nephrectomy in curing HTN in children. METHODS: We searched the databases to identify papers between January 2000 to December 2020 pertaining to children with PFK and HTN who underwent nephrectomy. Outcome analyzed was the resolution of HTN following nephrectomy. Duplicate publications, review articles and incomplete articles were excluded. Meta-analysis of heterogeneity was reported with I2statistics. Forest plot was constructed to compare the pooled prevalence of HTN resolution. RESULTS: Five articles with 88 patients were included. Majority (43%) of PFK were due to the unilateral atrophic kidney with or without vesicoureteral reflux (VUR); ureteropelvic junction obstruction and multicystic dysplastic kidney together accounted for 35% of cases and renovascular pathology for 22% of cases. With a follow-up of 1.5 to 3.3 years, nephrectomy was effective to cure HTN in 65.9% (95% CI 55-75%) children. CONCLUSIONS: In children with HTN and a unilateral PFK, nephrectomy cured the HTN in two-thirds of children. Unilateral atrophic kidney due to VUR was the most common cause of PFK. An increase in the utilisation of laparoscopy was observed in recent publications, hence laparoscopic nephrectomy may be considered a first choice of treatment in these children.

Impact of renal denervation on patients with coronary microvascular dysfunction: study rationale and design.

AIMS: Long-standing hypertension may cause an impairment in microvascular coronary circulation, which is involved in many different cardiac conditions. Renal sympathetic denervation (RDN) has been successfully proven as a valuable therapeutic choice for patients with resistant hypertension; moreover, the procedure looks promising in other settings, such as heart failure and atrial fibrillation, given its ability to downregulate the sympathetic nervous system, which is a recognized driver in these conditions as well as in microvascular dysfunction progression. The aim of this study is to explore the effect of RDN on coronary physiology in patients with ascertained coronary microvascular dysfunction and resistant hypertension. METHODS: This is a multicenter, prospective, nonrandomized, open-label, interventional study. Consecutive patients with resistant hypertension, nonobstructive coronary artery disease (NOCAD) and documented microvascular dysfunction will be enrolled. Patients will undergo RDN by Spyral Symplicity 3 (Medtronic Inc, Minneapolis, Minnesota, USA) and reassessment of coronary microvascular function 6 months after the procedure. Primary endpoint will be the difference in the index of microcirculatory resistance. CONCLUSION: The IMPRESSION study seeks to evaluate if there is any pleiotropic effect of the RDN procedure that results in modulation of microvascular function; if observed, this would be the first evidence showing RDN as a valuable therapy to revert hypertension-related microvascular dysfunction.

Impact of renal denervation on cardiac remodeling in resistant hypertension: A meta-analysis.

Twelve studies involving 433 patients were included. After RDN treatment, LVMI decreased by 13.08 g/m2 (95% confidence interval [CI]: -18.38, -7.78; p < .00001), PWTd decreased by 0.60 mm (95% CI: -0.87, -0.34; p < .00001), IVSTd decreased by 0.78 mm (95% CI: -1.06, -0.49; p < .00001), and LVEF increased by 1.80% (95% CI: 0.71, 2.90; p = .001). However, there were no statistically significant improvements in LVIDd (95% CI: -1.40, 0.24; p = .17) and diastolic function (E/A) (95% CI: -0.04, 0.14; p = .28). Drug treatment for resistant hypertension (RH) is challenging. Renal denervation (RDN) is one of the most promising treatments for RH. Although studies have shown RDN can control blood pressure, the impacts of RDN on cardiac remodeling and cardiac function are unclear. This meta-analysis evaluated the effect of RDN on cardiac structure and function in patients with RH. PubMed, Embase, and Cochrane were used to conduct a systematic search. The main inclusion criteria were studies on patients with RH who received RDN and reported the changes in echocardiographic parameters before and after RDN. Echocardiographic parameters included left ventricular mass index (LVMI), end-diastolic left ventricular internal dimension (LVIDd), left ventricular end-diastolic posterior wall thickness (PWTd), end-diastolic interventricular septum thickness (IVSTd), E/A, and left ventricular ejection fraction (LVEF). Data was analyzed using RevMan. Twelve studies involving 433 patients were included. After RDN treatment, LVMI decreased by 13.08g/m2 (95%confidence interval [CI]: -18.38, -7.78, p < .00001), PWTd decreased by 0.60mm (95% CI: -0.87, -0.34, p < 0.00001), IVSTd decreased by 0.78mm (95% CI: -1.06, -0.49, p < .00001), and LVEF increased by 1.80% (95% CI: 0.71, 2.90, p = .001). However, there were no statistically significant improvements in LVIDd (95% CI: -1.40, 0.24, p = .17) and diastolic function (E/A) (95% CI: -0.04, 0.14, p =.28). This meta-analysis finds that RDN can improve left ventricular hypertrophy and ejection fraction in patients with RH but has no significant effect on LVIDd and diastolic function. However, more studies are warranted due to the lack of a strict control group, a limited sample size, and research heterogeneity.

[Prevalence and risk factors of sarcopenia after radical gastrectomy for gastric cancer].

Objective: To investigate the prevalence and risk factors of sarcopenia in patients following radical gastrectomy with the aim of guiding clinical decisions. Methods: This was a retrospective observational study of data of patients who had undergone radical gastrectomy between June 2021 and June 2022 at the Department of General Surgery, First Medical Center of Chinese PLA General Hospital. Participants were reviewed 9-12 months after surgery. Inclusion criteria were as follows: (1) radical gastrectomy with a postoperative pathological diagnosis of primary gastric cancer; (2) no invasion of neighboring organs, peritoneal dissemination, or distant metastasis confirmed intra- or postoperatively; (3) availability of complete clinical data, including abdominal enhanced computed tomography and pertinent blood laboratory tests 9-12 after surgery. Exclusion criteria were as follows: (1) age <18 years; (2) presence of gastric stump cancer or previous gastrectomy; (3) history of or current other primary tumors within the past 5 years; (4) preoperative diagnosis of sarcopenia (skeletal muscle index [SMI) ≤52.4 cm²/m² for men, SMI ≤38.5 cm²/m² for women). The primary focus of the study was to investigate development of postoperative sarcopenia in the study cohort. Univariate and multivariate logistic regression were used to identify the factors associated with development of sarcopenia after radical gastrectomy. Results: The study cohort comprised 373 patients of average age of 57.1±12.3 years, comprising 292 (78.3%) men and 81 (21.7%) women. Postoperative sarcopenia was detected in 81 (21.7%) patients in the entire cohort. The SMI for the entire group was (41.79±7.70) cm2/m2: (46.40±5.03) cm2/m2 for men and (33.52±3.63) cm2/m2 for women. According to multivariate logistic regression analysis, age ≥60 years (OR=2.170, 95%CI: 1.175-4.007, P=0.013), high literacy (OR=2.512, 95%CI: 1.238-5.093, P=0.011), poor exercise habits (OR=3.263, 95%CI: 1.648-6.458, P=0.001), development of hypoproteinemia (OR=2.312, 95%CI: 1.088-4.913, P=0.029), development of hypertension (OR=2.169, 95%CI: 1.180-3.984, P=0.013), and total gastrectomy (OR=2.444, 95%CI:1.214-4.013,P=0.012) were independent risk factors for postoperative sarcopenia in post-gastrectomy patients who had had gastric cancer (P<0.05). Conclusion: Development of sarcopenia following radical gastrectomy demands attention. Older age, higher education, poor exercise habits, hypoproteinemia, hypertension, and total gastrectomy are risk factors for its development post-radical gastrectomy.

Triad of cluster-like headaches, hypertension and hypercoagulability a pointer to pheochromocytoma.

We report the case of a middle-aged hypertensive woman presenting to the neurology department with short-lasting episodic headaches for 4 years. She was initially diagnosed and treated with cluster headaches for one year. Following this, she presented with right lower limb arterial claudication. Arterial Doppler of lower limbs showed thrombosis of the bilateral common femoral arteries. Further computed tomography (CT) angiogram of the lower limbs confirmed extensive arterial thrombosis in bilateral lower limbs. The CT angiogram incidentally detected a left adrenal lesion. She had elevated urinary vanillylmandelic Acid and 24-hour metanephrines suggesting the presence of a pheochromocytoma. She was initially medically managed and later underwent left open adrenalectomy. Histopathology examination of the sections proved pheochromocytoma. Postsurgery, the patient's symptoms improved remarkably. This case highlights the importance of diagnosing pheochromocytoma when you encounter a patient with refractory short-lasting headaches, hypertension and hypercoagulability.

Risk of Subsequent Fusion After Isolated Decompression of Lumbar Facet Cysts.

INTRODUCTION: Lumbar facet cysts represent a potential source of nerve root compression in elderly patients. Isolated decompression without fusion has proven to be a reasonable treatment option in properly indicated patients. However, the risk of lumbar fusion after isolated decompression and facet cyst excision has yet to be elucidated. METHODS: The PearlDiver database was reviewed for patients undergoing isolated laminectomy for lumbar facet cyst from January 2015 to December 2018 using Current Procedural Terminology coding. Patients undergoing concomitant fusion or additional decompression, as well as those diagnosed with preexisting spondylolisthesis or without a minimum of 5-year follow-up, were excluded. Rates of subsequent lumbar fusion and potential risk factors for subsequent fusion were identified. Statistical analysis included descriptive statistics, chi square test, and multivariate logistic regression. Results were considered significant at P < 0.05. RESULTS: In total, 10,707 patients were ultimately included for analysis. At 5-year follow-up, 727 (6.79%) of patients underwent subsequent lumbar fusion after initial isolated decompression. Of these, 301 (2.81% of total patients, 41.4% of fusion patients) underwent fusion within the first year after decompression. Multivariate analysis identified chronic kidney disease, hypertension, and osteoarthritis as risk factors for requiring subsequent lumbar fusion at 5 years following the index decompression procedure ( P < 0.033; all). CONCLUSION: Patients undergoing isolated decompression for lumbar facet cysts undergo subsequent lumbar fusion at a 5-year rate of 6.79%. Risk factors for subsequent decompression include chronic kidney disease, hypertension, and osteoarthritis. This study will assist spine surgeons in appropriately counseling patients on expected postoperative course and potential risks of isolated decompression.

Screening of Associated Factors for Erectile Dysfunction after Radical Prostatectomy and Construction of a Clinical Risk Assessment Model: A Retrospective Study.

OBJECTIVE: In this article, the associated factors for erectile dysfunction (ED) after radical prostatectomy (RP) were explored, and a clinical risk assessment model was constructed. METHODS: A total of 155 patients who underwent RP in People's Hospital of Hunan Province from November 2020, to November 2021, were selected as the study group. In accordance with the results of International Index of Erectile Function (IIEF-5) at 6 months after surgery, 88 patients were included in the ED group (IIEF-5 <22), and 67 patients were included in the non-ED group (IIEF-5 ≥22). Univariate and multivariate logistic regression analyses were conducted to screen the risk factors for ED after RP, and a risk model was constructed on this basis. In addition, 43 patients with ED after RP and 41 patients with non-ED after RP from January 2022, to January 2023, were included in the test group to evaluate the predictive efficacy of the clinical risk assessment model on the basis of the receiver operating characteristic curve. RESULTS: The study group had a lower postoperative IIEF-5 score than before surgery (p < 0.001). The incidence of ED after RP in the study group was 56.77% (88/155). Multivariate analysis showed that advanced age (odds ratio (OR) = 1.155), large prostate volume (OR = 1.077), smoking (OR = 5.676), drinking (OR = 3.495), hypertension (OR = 8.079), diabetes (OR = 6.082), low preoperative serum testosterone (T) level (OR = 0.684) and high preoperative serum endothelin-1 (ET-1) level (OR = 1.192) were risk factors for ED after RP (p < 0.05). A risk model was constructed as follows: Z = 0.144 × (age) + 0.074 × (prostate volume) + 1.736 × (smoking) + 1.251 × (drinking) + 2.089 × (hypertension) + 1.805 × (diabetes) - 0.380 × (preoperative serum T) + 0.175 × (preoperative serum ET-1). The area under curve (AUC), sensitivity, specificity and 95% CI of this model were 0.906, 97.70%, 73.20%, and 0.848-0.964, respectively (p < 0.001). CONCLUSIONS: The clinical risk assessment model constructed on the basis of the above factors provides some references for the scientific prevention and treatment of ED after RP.

Clinical and biochemical outcomes after adrenalectomy for primary aldosteronism in tertiary and quaternary referral centers: data from SOPRANO study.

Hypertension cure following adrenalectomy in unilateral primary aldosteronism (PA) remains uncertain. Previous meta-analyses have shown highly variable surgical outcomes. Our study aimed to determine the unknown proportion of complete clinical and biochemical success in tertiary and quaternary referral centers. We conducted a systematic review and meta-analysis of studies reporting surgical outcomes of unilateral PA patients within the Surgical Outcome of PRimary Aldosteronism progNostic mOdels (SOPRANO) study. From 27 publications we identified 32 eligible studies, of which 22 were judged to be at low risk of bias. Eighteen were single-center studies, while fourteen were multi-center studies, with patients recruited from 132 referral centers worldwide. Adrenalectomy was performed on 5887 patients, with 4861 (83%) included in the final analysis. The pooled estimates of complete clinical and biochemical success for all studies were 39% (95% CI: 34-44%) and 99% (95% CI: 96-99%), respectively, similar to that found for studies at low risk of bias. Multivariate meta-regression analyses for all studies and low-bias risk studies revealed that BMI (P < 0.01), recruitment time period (P < 0.01), and hypertension duration (P < 0.05) inversely correlated with complete clinical success, while BMI (P < 0.05) and the number of enrolled centers (P < 0.05) inversely correlated with complete biochemical success. In summary, our findings offer robust estimates of complete clinical and biochemical success rates following adrenalectomy for unilateral PA in tertiary and quaternary referral centers and identify new potential effect modifiers that can help clinicians to inform and counsel patients about post-surgery expectations, guaranteeing effective treatment and ultimately enhancing outcomes.

Comment on "renal denervation for hypertension".

We have attentively reviewed the article "Renal Denervation for Hypertension" and commend the author's dedication to addressing this intricate subject. However, we wish to highlight a few points that, in our assessment, could enhance the overall quality of the article.

A Randomized Controlled Trial Investigating the Impact of a Low-Calorie Dietary Approach to Stop Hypertension (DASH) on Anthropometric and Glycemic Measures in Patients Experiencing Weight Regain 2 Years Post Sleeve Surgery.

PURPOSE: To evaluate the effect of a low-calorie dietary approach to stop hypertension (DASH) compared to a low-calorie diet on weight control, body composition and glycemic measures in post sleeve patients with weight regain. MATERIALS AND METHODS: Participants were randomly allocated to either the low-calorie DASH diet group (intervention) or the low-calorie diet group (control) for a duration of 16 weeks. Both groups had a prescribed caloric intake of 1000-1200 calories. The DASH diet group made dietary adjustments in accordance with the DASH pattern. RESULTS: At the end of the study, both interventions significantly reduced anthropometric and body composition parameters (P-value < 0.001), with a greater decrease observed in the low-calorie DASH diet group (P-value < 0.001). Insulin levels and homeostatic model assessment for insulin resistance (HOMA-IR) decreased significantly in both groups, but the magnitude of these changes was not statistically different between the two groups. After adjusting for confounders, a significant difference was observed in post-intervention values and changes in weight, body mass index, and fat mass and fat-free mass. CONCLUSION: In summary, adhering to a calorie-restricted DASH diet for 16 weeks improved weight loss, body mass index, and fat mass reduction in post-bariatric patients who experienced weight regain 2 years after surgery, compared to a calorie-restricted control diet. However, there was no significant difference in the effect on blood glucose, insulin, and HOMA-IR between the two diets.

Renal Denervation in End-Stage Renal Disease: Current Evidence and Perspectives.

In patients with end-stage renal disease (ESRD) undergoing haemodialysis, hypertension is of common detection and frequently inadequately controlled. Multiple pathophysiological mechanisms are involved in the development and progression of the ESRD-related high blood pressure state, which has been implicated in the increased cardiovascular risk reported in this hypertensive clinical phenotype. Renal sympathetic efferent and afferent nerves play a relevant role in the development and progression of elevated blood pressure values in patients with ESRD, often leading to resistant hypertension. Catheter-based bilateral renal nerves ablation has been shown to exert blood pressure lowering effects in resistant hypertensive patients with normal kidney function. Promising data on the procedure in ESRD patients with resistant hypertension have been reported in small scale pilot studies. Denervation of the native non-functioning kidney's neural excitatory influences on central sympathetic drive could reduce the elevated cardiovascular morbidity and mortality seen in ESRD patients. The present review article will focus on the promising results obtained with renal denervation in patients with ESRD, its mechanisms of action and future perspectives in these high risk patients.

Sleeve Gastrectomy Surgery makes Obstructive Sleep Apnea Worse or Better?: a Multi-Center Observational Study in Patients with Obesity.

BACKGROUND AND OBJECTIVE: Obstructive sleep apnea (OSA) is highly prevalent in the bariatric surgical population, with rates ranging from 50 to 70%. The impact of laparoscopic sleeve gastrectomy (LSG) on OSA and its associated risk factors remain relatively understudied. The aim of this study is to assess the effect of LSG on OSA and investigate predictors of new or worsening OSA postoperatively. Additionally, the study aims to provide evidence for the individualized selection of LSG procedures based on patient characteristics. METHODS: This multi-center observational study enrolled 119 patients with obesity who underwent LSG and were subdivided into two groups based on their preoperative AHI: AHI < 15 and AHI ≥ 15. The patients were followed up and evaluated before and 30 days after LSG. The study utilized univariate and multivariate analyses to assess risk factors for postoperative AHI development. RESULTS: Following LSG, there was a significant decrease in the mean AHI, leading to the resolution of OSA symptoms in 67.6% of patients with AHI ≥ 15. Neck circumference and the number of METS were also identified as independent risk factors for postoperative OSA. Furthermore, preoperative hypertension was found to be a significant predictor of new or worsened OSA after LSG. CONCLUSION: LSG demonstrated effectiveness in improving OSA among patients with obesity. The study highlights the importance of preoperative hypertension evaluation and postoperative management in patients undergoing LSG. Further long-term, multicenter, and large-scale studies are recommended to validate and generalize these findings to diverse patient populations.

Effects of renal denervation on kidney function in patients with chronic kidney disease: a systematic review and meta-analysis.

The present study aims to evaluate the clinical outcomes following renal denervation (RDN) for hypertensive patients with chronic kidney disease (CKD). Prospective studies published between January 1, 2010 and November 15, 2022 where systematically identified for RDN outcomes on office and ambulatory blood pressure, estimated glomerular filtration rate (eGFR), creatinine and procedural characteristics from three online databases (Medline, PubMed, EMBASE). Random effects model to combine risk ratios and mean differences was used. Where possible, clinical outcomes were pooled and analyzed at 6, 12 and 24 months. Significance was set at p ≤ 0.05. 11 prospective trials, with a total of 226 patients with treatment resistant HTN receiving RDN met the inclusion criteria. Age ranged from 42.5 ± 13.8 to 66 ± 9. Main findings of this review included a reduction in systolic and diastolic office blood pressure at 6 [-19.8 (p < 0.00001)/-15.2 mm Hg (p < 0.00001)] and 12 months [-21.2 (p < 0.00001)/-9.86 mm Hg (p < 0.0005)] follow-up compared to baseline. This was also seen in systolic and diastolic 24-hour ambulatory blood pressure at 6 [-9.77 (p = 0.05)/-3.64 mm Hg (p = 0.09)] and 12 months [-13.42 (p = 0.0007)/-6.30 mm Hg (p = 0.001)] follow-up compared to baseline. The reduction in systolic and diastolic 24-hour ambulatory blood pressure was maintained to 24 months [(-16.30 (p = 0.0002)/-6.84 mm Hg (p = 0.0010)]. Analysis of kidney function through eGFR demonstrated non-significant results at 6 (+1.60 mL/min/1.73 m2, p = 0.55), 12 (+5.27 mL/min/1.73 m2, p = 0.17), and 24 months (+7.19 mL/min/1.73 m2, p = 0.36) suggesting an interruption in natural CKD progression. Similar results were seen in analysis of serum creatinine at 6 (+0.120 mg/dL, p = 0.41), 12 (+0.100 mg/dL, p = 0.70), and 24 months (+0.07 mg/dL, p = 0.88). Assessment of procedural complications deemed RDN in a CKD cohort to be safe with an overall complication rate of 4.86%. With the current advances in RDN and its utility in multiple chronic diseases beyond hypertension, the current study summarizes critical findings that further substantiate the literature regarding the potential of such an intervention to be incorporated as an effective treatment for resistant hypertension and CKD.

Renal Denervation in the Management of Resistant Hypertension: A Comprehensive Review of Literature.

Resistant hypertension is a condition in which blood pressure remains elevated despite using 3 or more antihypertensive medications. Though contemporary antihypertensive drug therapies have been essential in treating hypertension, in recent years different studies have explored renal denervation (RDN) as an adjunctive or a replacement modality. Here we summarize an open-label, Symplicity HTN 2 trial and 7 randomized, sham-controlled clinical trials: Spyral-HTN OFF MEDS (Spyral Pivotal), Spyral-HTN ON MEDS, RADIANCE-HTN SOLO, RADIANCE-HTN TRIO, RADIANCE II, SYMPLICITY-HTN 1, and SYMPLICITY-HTN 3, which evaluated safety and efficacy of multiple renal denervation systems (RDN) at lowering blood pressure from baseline, and in comparison, to control group. Prior systematic reviews and meta-analyses evinced a modest reduction of ambulatory and office blood; however, these trials and analyses were limited by short-term follow-up. In our updated comprehensive literature review we summarize the short-term, and long-term effects of RDN, based on the latest randomized clinical trials. Our conclusions based on each summary are unanimous with previous literature findings.

The rationale for nephron-sparing surgery in unilateral non-syndromic Wilms tumour.

The central question of nephron-sparing surgery in unilateral non-syndromic Wilms tumour sits at a crossroads between surgery, oncology, and nephrology. There has been a significant paradigm shift in paediatric oncology towards reducing toxicity and addressing long-term treatment-related sequalae amongst childhood cancer survivors. After paediatric nephrectomy and 30-50 years of follow-up, 40% of patients will have chronic kidney disease, including 22% with hypertension and 23% with albuminuria. It is difficult to predict which patients will progress to develop hypertension, reduced glomerular filtration rate, albuminuria, and a higher cardiovascular risk. For these reasons, nephron-sparing surgery when it is technically feasible must be considered. To decrease the incidence of positive surgical margins (viable tumour present at a resection margin), incomplete lymph node sampling, and complications, these procedures should be performed at specialist and experienced reference centres. Based on the impacts of individual treatment pathways, survivors of childhood WT need to be followed through adulthood for early detection of chronic kidney disease, hypertension, and prevention of cardiovascular events.

Multiple radiologist review of adrenal CT still frequently misses lateralized surgical primary aldosteronism.

Patients with primary aldosteronism (PA) have increased morbidity and mortality compared to those with essential hypertension. Accurate detection of lateralized PA is important so that affected patients can receive potentially curative adrenalectomy. However, around 40% of patients with lateralized PA have "normal" adrenal glands on computed tomography (CT). Additional independent review of imaging has been shown to improve diagnostic accuracy in many areas of imaging. Therefore, the authors sought to establish if multi-reader re-assessment of previously reported normal CT scans would result in increased detection of surgically remediable disease. The authors found that re-assessment of CT imaging by one, two, or three additional radiologists (or a combination thereof) slightly increased the detection of lateralized disease, but these differences were not statistically significant (p > .05). Readers had low inter-observer agreement (kappa = 0.17). If detection of a discrete nodule on CT was made a prerequisite for adrenal vein sampling (AVS), a second read by another reviewer would still result in an excess of missed cases (84.2%, 36.8%, and 65.8%, respectively, for each of the three independent reviewers). Therefore, a "normal" CT does not preclude the possibility of lateralized PA. Adrenal vein sampling should still be strongly considered wherever available and whenever surgery is considered for treatment of PA, irrespective of CT findings.