The reliability of pre-transplant donor renal biopsies (PTDB) in predicting the kidney state. A comparative single-centre study on 154 untransplanted kidneys.

BACKGROUND: Pre-transplant donor biopsy (PTDB) is a common practice in marginal donors, taking for granted that it represents the whole kidney state, but its reliability has not yet been thoroughly investigated. This prompted us to carry out a comparative study on a needle biopsy group (NBG) and a wedge biopsy group (WBG) and their corresponding untransplanted kidneys. METHODS: One hundred and fifty-four biopsies and matched kidneys were scored for four morphologic indexes, i.e. tubular atrophy, interstitial fibrosis, vascular damage and global glomerulosclerosis. Categorical indexes were statistically evaluated for concordance with the k index, and the percentage of sclerotic glomeruli with correlation and linear regression analysis. RESULTS: Agreement between biopsies and kidneys was similar in both NBG and WBG with high scores for vascular damage (k 0.74 and 0.75) and intermediate ones for tubular atrophy (k 0.54 and 0.50). Agreement as to fibrosis and glomerular sclerosis was intermediate in the WBG (k 0.56 and 0.55) and poor in the NBG (k 0. 34 and 0.18). Vascular damage was underscored and glomerulosclerosis overscored in both groups, whereas interstitial fibrosis was underscored in the NBG and overscored in WBG. The agreement for the total score, i.e. the sum of the single indexes, was high in the NBG (k 0.73) and intermediate in WBG (k 0.57). Agreement for glomerulosclerosis and total score rose consistently in both groups along with the increasing number of biopsy glomeruli. There was an agreement as to biopsy and kidney evaluation for fitness for transplantation in 85% of NBG and 81% of WBG. CONCLUSIONS: PTDB supplies reliable data on the actual kidney state, with better results for needle biopsy. Although the biopsy size plays a role, samples with over 10 glomeruli suffice for clinical purposes. Vascular damage is the most faithful single parameter, whereas global glomerulosclerosis estimation requires some caution.

Long-term mortality from pleural and peritoneal cancer after exposure to asbestos: Possible role of asbestos clearance.

Models based on the multistage theory of carcinogenesis predict that the rate of mesothelioma increases monotonically as a function of time since first exposure (TSFE) to asbestos. Predictions of long-term mortality (TSFE >or= 40 years) are, however, still untested, because of the limited follow-up of most epidemiological studies. Some authors have suggested that the increase in mesothelioma rate with TSFE might be attenuated by clearance of asbestos from the lungs. We estimated mortality time trends from pleural and peritoneal cancer in a cohort of 3,443 asbestos-cement workers, followed for more than 50 years. The functional relation between mesothelioma rate and TSFE was evaluated with various regression models. The role of asbestos clearance was explored using the traditional mesothelioma multistage model, generalized to include a term representing elimination over time. We observed 139 deaths from pleural and 56 from peritoneal cancer during the period 1950-2003. The rate of pleural cancer increased during the first 40 years of TSFE and reached a plateau thereafter. In contrast, the rate of peritoneal cancer increased monotonically with TSFE. The model allowing for asbestos elimination fitted the data better than the traditional model for pleural (p = 0.02) but not for peritoneal cancer (p = 0.22). The risk for pleural cancer, rather than showing an indefinite increase, might reach a plateau when a sufficiently long time has elapsed since exposure. The different trends for pleural and peritoneal cancer might be related to clearance of the asbestos from the workers' lungs.

[Mortality in the cohort of the asbestos cement workers in the Eternit plant in Casale Monferrato (Italy)]. / Mortalità nella coorte dei lavoratori del cemento amianto della Eternit di Casale Monferrato.

OBJECTIVE: The present report updates the mortality cohort study of "Eternit" workers in Casale Monferrato, one of the major plant for the production of corrugated and plain sheets, tubes and high-pressure pipes in asbestos-cement in Italy active between 1907-1986. DESIGN: Retrospective cohort study. SETTING: The cohort included 3,443 blue-collar workers (2,663 men and 780 women) active between 1950 and 1986. Nine subjects had been excluded because of incomplete data. The follow-up ended in 2003. Mortality in the cohort was compared to the cause-specific rates for age and period of the Piedmont population and the SMR values were calculated for the period 1965-2003. MAIN OUTCOME: Analysis of cause-specific mortality. RESULTS: Follow-up was completed for 99.0% of the subjects. At the end of follow-up, 42% of the subjects were alive, 57% deceased and 1% lost to follow-up or moved abroad. In both sexes, a statistically significant increase of morality for all causes (men: SMR 135.1; 1,438 obs vs 1,064.1 exp; p < 0.01; women: RSM 149.5; 371 obs vs 248.2 exp; p < 0.01) was observed. The SMRs for lung, pleural and peritoneal cancer and for asbestosis increased according to duration of exposure and latency. For pleural cancer, increasing risks at shorter latencies were observed as exposure length increased. In men, the increase in the SMRs for lung and pleural cancer was reduced in the category of longest latency; still increased but declining SMRs were also observed at longer time since first exposure. Mortality from peritoneal cancer and asbestosis on the contrary increased with latency and with time since last exposure. Among women, a significant increase of mortality for uterine cancer (SMR 2569; 15 obs vs 5.8 exp; p < 0.01), ovarian cancer (SMR 227.3; 9 obs vs 4.0 exp; p < 0.05) and rectum cancer (SMR 318.6; 9 obs vs 2.8 exp; p < 0.01) was observed. CONCLUSION: a significant increase in mortality from the main asbestos-related diseases was confirmed by duration of exposure. In relation to latency The SMRs for lung and pleural cancer present a curvilinear trend with a decrease for longest latency periods (after 30 years from the cessation of exposure). The SMRs for peritoneal cancer and asbestosis showed a monotonic increase.

Cancer mortality and incidence of mesothelioma in a cohort of wives of asbestos workers in Casale Monferrato, Italy.

BACKGROUND: Family members of asbestos workers are at increased risk of malignant mesothelioma (MM). Although the hazard is established, the magnitude of the risk is uncertain, and it is unclear whether risk is also increased for other cancers. Few cohort studies have been reported. OBJECTIVE: The "Eternit" factory of Casale Monferrato (Italy), active from 1907 to 1986, was among the most important Italian plants producing asbestos-cement (AC) goods. In this article we present updated results on mortality and MM incidence in the wives of workers at the factory. METHODS: We studied a cohort of 1,780 women, each married to an AC worker during his employment at the factory but not personally occupationally exposed to asbestos. Cohort membership was defined starting from the marital status of each worker, which was ascertained in 1988 from the Registrar's Office in the town where workers lived. At the end of follow-up (April 2003), 67% of women were alive, 32.3% dead, and 0.7% lost to follow-up. Duration of exposure was computed from the husband's period of employment. Latency was the interval from first exposure to the end of follow-up. RESULTS: The standardized mortality ratio (SMR) for pleural cancer [21 observed vs. 1.2 expected; SMR = 18.00; 95% confidence interval (CI), 11.14-27.52] was significantly increased. Mortality for lung cancer was not increased (12 observed vs. 10.3 expected; SMR = 1.17; 95% CI, 0.60-2.04). Eleven incident cases of pleural MM were observed (standardized incidence ratio = 25.19; 95% CI, 12.57-45.07). CONCLUSIONS: Household exposure, as experienced by these AC workers' wives, increases risk for pleural MM but not for lung cancer.

Endoscopy or surgery for malignant GI outlet obstruction?

BACKGROUND: The treatment of gastroduodenal outflow obstruction (GOO) caused by malignant diseases represents a significant challenge. Open surgical gastrojejunostomy (GJ) has been the treatment of choice, but it has high morbidity and mortality rates. More recently, endoscopic placement of self-expanding metallic stents (SEMS) has been proposed and the results of small, preliminary studies are encouraging. This study compared technical and clinical success, morbidity, mortality, and hospital stay in patients undergoing endoscopic and surgical treatment of GOO. METHODS: Medical records of 60 consecutive patients with GOO seen between April 1997 and November 2002 were retrospectively reviewed. Because of extremely short life expectancy, 13 patients were treated by insertion of a double-lumen nasogastric-jejunal tube. The remaining 47 patients (28 men, 19 women; mean age 73.5 years, range 48-92 years) with unresectable pancreatic (33), gastric (7), metastatic lymph nodal (4), papillary (2), and biliary (1) tumors were treated by placement of a SEMS (24) or open surgical GJ (23). RESULTS: The technical success rates were similar, but clinical success was lower in the GJ group (92% vs. 56%, p = 0.0067). The SEMS group had a shorter length of hospital stay (3.0 [1.4] days vs. 24.1 [10.3], p < 0.001). Thirty-day mortality was 30% in the GJ group, and 0% in the SEMS group ( p = 0.004). Morbidity was higher in the GJ compared with the SEMS group (61% vs. 17%, p = 0.0021). Mean survival was longer in the SEMS group (96.1 [9.6] days vs. 70.2 [36.2] days, p = 0.0165 for a single test of hypothesis; Bonferroni correction for a multiple testing removes this significance), consequently, out-of-hospital survival was longer for the SEMS group (93.2 [9.3] days vs. 46.0 [31.5] days, p < 0.001). None of the endoscopic procedures required the assistance of an anesthesiologist or the use of an operating room. CONCLUSIONS: The results of this retrospective study suggest that SEMS insertion is better than surgical GJ for palliation of patients with GOO in terms of clinical success, morbidity, and mortality. Technical success rates were similar. SEMS placement should be proposed as the first-line treatment for relief of GOO. However, a randomized, comparative, prospective study of SEMS vs. laparoscopic GJ is needed.