Ylian S. Liem

Preference-Based Quality of Life of Patients on Renal Replacement Therapy : A Systematic Review and Meta-Analysis

OBJECTIVES Various utility measures have been used to assess preference-based quality of life of patients with end-stage renal disease (ESRD). The purposes of this study were to summarize the literature on utilities of hemodialysis (HD), peritoneal dialysis (PD), and renal transplantation (RTx) patients, to compare utilities between these patient groups, and to obtain estimates for quality-of-life adjustment in economic analyses. METHODS We searched the English literature for studies that reported visual analog scale (VAS), time trade-off (TTO), standard gamble (SG), EuroQol-5D (EQ-5D), and health utilities index (HUI) values of ESRD patients. We extracted patient characteristics and utilities and calculated mean utilities and 95% confidence intervals (CIs) for categories defined by utility measure and treatment modality using random-effects models. RESULTS We identified 27 articles that met the inclusion criteria. VAS articles were too heterogeneous to summarize quantitatively and we found only one study reporting HUI values. Thus, we summarized utilities from TTO, SG, and EQ-5D studies. Mean TTO and EQ-5D-index values were lower for dialysis compared to RTx patients, though not statistically significant for TTO values (TTO values: HD 0.61, 95% CI 0.54-0.68; PD 0.73, 95% CI 0.61-0.85; RTx 0.78, 95% CI 0.63-0.93; EQ-5D-index values: HD 0.56, 95% CI 0.49-0.62; PD 0.58, 95% CI 0.50-0.67; RTx 0.81, 95% CI 0.72-0.90). Mean HD versus PD associated TTO, EQ-5D-index and EQ-VAS values were not statistically significantly different. CONCLUSION RTx patients tended to have a higher utility than dialysis patients. Among HD and PD patients, there were no statistically significant differences in utility.

Early living-donor kidney transplantation: a review of the associated survival benefit.

Avoidance of dialysis-related morbidity, improvement in quality of life, and reduction of costs have been mentioned as advantages of preemptive kidney transplantation. However, this therapeutic option is underutilized. Previous studies assessing the patient survival benefit of preemptive kidney transplantation compared it with postdialysis kidney transplantation. These studies may have been subjected to lead-time bias. When comparing patient survival of preemptive kidney transplant patients with waitlisted dialysis patients, there is a clear patient survival advantage in favor of preemptive kidney transplantation. This benefit justifies encouragement of preemptive kidney transplantation.

Using heparin therapy to reverse protein-losing enteropathy in a patient with CDG-Ib

Background A 22-year-old female presented with edema, diarrhea, hypoalbuminemia and pancytopenia. She had previously been diagnosed with congenital disorder of glycosylation type Ib, and had a history of congenital hepatic fibrosis, portal hypertension and esophageal varices. In the past she had refused mannose therapy because of associated diarrhea and abdominal pain.Investigations Laboratory examinations, abdominal ultrasonography, bacterial and viral cultures of blood, urine and stools, double-balloon enteroscopy and fecal excretion test using 51Cr-labeled albumin.Diagnosis Protein-losing enteropathy.Management Infusion of albumin followed by intravenous and subcutaneous therapy with unfractionated heparin.

Retrograde catheterization of haemodialysis fistulae and grafts: angiographic depiction of the entire vascular access tree and stenosis treatment

BACKGROUND The European Best Practice Guidelines on Vascular Access propose magnetic resonance angiography (MRA) of dysfunctional dialysis fistulae and grafts if visualization of the complete arterial inflow and outflow vessels is needed. In a prospective multi-centre study we determined the technical success rate of complete vascular access tree depiction by digital subtraction angiography (DSA) as an alternative to MRA. Instead of a more invasive brachial artery of femoral artery approach, we performed a retrograde catheterization of the venous outflow or graft, and stenoses were treated in connection with DSA. METHODS A catheter was advanced into the central arterial inflow after retrograde puncture of the venous outflow or graft for depiction of the complete inflow, access region and complete outflow. Access DSA through femoral artery puncture was done if the retrograde approach failed to depict the complete vascular access tree. Stenoses with a luminal diameter reduction >or=50% were treated, if possible, in connection with DSA. RESULTS A total of 116 dysfunctional haemodialysis fistulae and 50 grafts were included. Retrograde DSA depicted the complete vascular tree in 162 patients (97.6%). The arteriovenous anastomosis of four fistulae could not be negotiated by a catheter. DSA demonstrated 247 significant stenoses: 30, 128 and 89 were located in the arterial inflow (12.1%), AV anastomosis and graft region (51.8%) and venous outflow (36.0%), respectively. Ten patients (6.0%) had no stenosis. Eight (4.8%), 55 (33.1%) and 33 (19.9%) patients demonstrated stenoses in only inflow, access region or outflow, respectively. Stenoses in two or three vascular territories were present in 53 (31.9%) and 7 (4.2%) patients, respectively. A technically successful endovascular intervention was obtained in 135 of the 139 patients (97.1%) who underwent angioplasty and/or stent placement. Additional sheath insertion by antegrade outflow puncture was needed in 46 patients (33.1%) for the treatment of coexisting venous outflow stenoses, located downstream from the retrograde positioned sheath. Two minor complications were observed at DSA/angioplasty. CONCLUSION As an alternative to MRA, full retrograde DSA is safe and effective for stenosis detection and stenosis treatment. However, access evaluation by a non-invasive imaging modality such as colour duplex ultrasound will be sufficient in most cases as proximal inflow stenoses are encountered in a minority of patients. Full retrograde DSA, including complete arterial inflow depiction, may then be reserved for cases with an unsuccessful outcome following endovascular intervention of stenoses depicted at ultrasound.

Complex regional pain syndrome type 1 may be associated with menstrual cycle disorders: A case—control study

BACKGROUND Complex regional pain syndrome type 1 (CRPS1) can develop after severe trauma or surgery in the limbs, and presents with chronic, changes in temperature, edema and dysfunction. Seventy-five percent of CRPS1 patients are female. While neurological and inflammatory components have been proposed, the etiology remains unclear. No consensus on optimal management of CRPS1 exists. In traditional Chinese medicine, menstrual disorders are related to the state of womens constitution and therefore identify their pain patterns. A classification by constitution might improve the pain management in CRPS1 patients. It is unknown whether associations exist between menstrual-cycle-conditions and CRPS1. AIM To investigate whether a specified menstrual condition is associated with the risk of developing CRPS1. METHODS A population-based case-control study of CRPS1 was conducted among Dutch women aged 18-82; i.e. 34 women with CRPS1 and 147 controls. A standard questionnaire consisting of 59 menstrual-cycle-symptom-based questions was administered. From this questionnaire, 15 CRPS1-related questions (DRQ 15) were analyzed. We used multivariate logistic regression to obtain odds ratios and 95% confidence intervals (CI) for specified menstrual disorders adjusting for age, oral contraceptives, hysterectomy and age at menarche < or = 12 and > or = 17 years. RESULTS On the basis of the DRQ 15, women with CRPS1 were 5.3 (95%CI 2.1, 12.9) times more likely to have menstrual disorders than comparable controls. CONCLUSION Our results suggest that selected menstrual conditions are associated with the risk of developing CRPS1.