Actuarial Patient Survival Research Articles

Long-term outcome of idiopathic steroid-resistant nephrotic syndrome: a multicenter study

Long-term outcome of idiopathic steroid-resistant nephrotic syndrome was retrospectively studied in 78 children in eight centers for the past 20 years. Median age at onset was 4.4 years (1.1-15.0 years) and the gender ratio was 1.4. Median follow-up period was 7.7 years (1.0-19.7 years). The disease in 45 patients (58%) was initially not steroid-responsive and in 33 (42%) it was later non-responsive. The main therapeutic strategies included administration of ciclosporine (CsA) alone (n = 29; 37%) and CsA + mycophenolate mofetil (n = 18; 23%). Actuarial patient survival rate after 15 years was 97%. Renal survival rate after 5 years, 10 years and 15 years was 75%, 58% and 53%, respectively. An age at onset of nephrotic syndrome (NS) > 10 years was the only independent predictor of end-stage renal disease (ESRD) in a multivariate analysis using a Cox regression model (P < 0.001). Twenty patients (26%) received transplants; ten showed recurrence of the NS: seven within 2 days, one within 2 weeks, and two within 3-5 months. Seven patients lost their grafts, four from recurrence. Owing to better management, kidney survival in idiopathic steroid-resistant nephrotic syndrome (SRNS) has improved during the past 20 years. Further prospective controlled trials will delineate the potential benefit of new immunosuppressive treatment.

Is Liver Resection Justified in Advanced Hepatocellular Carcinoma? Results of an Observational Study in 464 Patients

Background and ObjectiveThe role of liver resection in advanced hepatocellular carcinoma (multinodular or with macroscopic vascular involvement) is still controversial. The aim of this study is to evaluate the role of surgical resection compared to other therapeutic modalities in patients with advanced hepatocellular carcinoma (HCC). MethodsFour hundred sixty four patients with HCC observed from 1991 to 2007 were included in the study. All the patients were evaluated for the treatment of HCC in relation to the severity of liver impairment and tumor stage. All the patients included in the study had no evidence of distant metastases. ResultsMedian follow up time for surviving patients was 25 months (range 1–155). Two-hundred and eighty-three patients were in Child–Pugh class A, 161 in class B, and 20 in class C. Two-hundred and seventy-one patients had single HCC, 121 patients had two or three HCCs, and 72 more than three HCCs. One-hundred and thirty-six patients (29.3%) were submitted to liver resection (LR), 232 (50.0%) to local ablative therapies (LAT) (ethanol injection, radiofrequency ablation, chemoembolization), eight (1.7%) to liver transplantation (LT), and 88 (19%) to supportive therapy (ST). Median survival time for all patients was 36 months (95% CI 24–36). Median survival time was 57 months for LR, 30 months for LAT, and 8 months for ST, with a 5-year survival of 47%, 20%, and 2.5%, respectively (p = 0.001). Actuarial 5-year survival for patients submitted to LT was 75%. Overall survival was significantly shorter in patients with multiple HCCs compared to single HCC, with median survival times of 39, 16, and 11 months for patients with a single HCC, with two to three HCCs, and with more than three HCCs, respectively (p = 0.01). Survival for patients with single HCC was significantly longer in patients submitted to LR compared to LAT and ST with median survival times of 57, 37, and 14 months, respectively (p = 0.02). Also, in patients with multinodular HCCs (2–3 HCCs) LR showed the best results with a median survival time of 58 months compared to 22 and 8 months for LAT and ST (p = 0.01). In patients with more than three HCCs, LR did not show different results compared to LAT and ST. Seventy-three patients had evidence of macroscopic vascular involvement; median survival in this subgroup of patients was significantly shorter compared to patients without vascular involvement, 10 and 36 months, respectively. Survival for patients with macroscopic vascular involvement submitted to LR or LAT was significant longer compared to ST, with mean survivals of 27, 30, and 12 months, respectively (p = 0.01). ConclusionsThe present study shows that the surgery can achieve good results in patients with single HCC and good liver function. Also, patients with multinodular HCCs (two to three nodules) could benefit from LR where survival is longer than after LAT or ST. In patients with more than three HCCs, LR have similar results of LAT. Macroscopic vascular invasion is a major prognostic factor, and the LR is justified in selected patients, where it can allow good long-term results compared to ST.

Indications for and Results of Liver Retransplantation

Liver retransplantation (LReTx) is the therapeutic option for the irreversible failure of a hepatic graft. Our aim was to evaluate the rate of and indications for LReTx and actuarial patient survivals. Among 1260 LTx were 79 LReTx (6.3%). During the first LTx, there were no apparent differences between patients who did or did not required LReTx. The most frequent reasons were hepatic artery thrombosis (31.6%), recurrence of the VHC cirrhosis (30.4%), and primary graft failure (21.5%). The actuarial survivals at 1 and 5 years were 83% and 69% among those without LReTx versus 71% and 61% among early LReTx, and 64% and 34% among late LReTx ( P < .001). Although there exists high morbidity and mortality with LReTx, it seems that this therapeutic alternative continues to be valid for patients with early hepatic loss, but not when the graft loss was late. It becomes necessary to define the minimal acceptable results that patient can benefit from LReTx.

Kidney Transplantation: Charles Nicolle Hospital Experience

The aim of our retrospective study was to analyze the short- and long-term follow-up of 298 renal transplantations performed between June 1986 and May 2005. All were first transplantations except 4 cases, with 54 from cadaveric and 244 from living donors. The recipients included 196 males and 102 females of overall mean age of 31.21 ± 8.9 years (range, 16–61 years). A combination of prednisolone and azathioprine was presented for 212 patients or mycophenolate mofetil for 86 patients. Polyclonal or monoclonal antibodies were used as induction therapy in 183 cases. Cyclosporine was administered to 188 cases and tacrolimus only to 16. HLA matching was 0 mismatches (MM) in 65 cases; 1 or 2 MM in 113; 3 MM in 99; and ≥4 MM in 21. Acute tubular necrosis occurred in 45 cases. One hundred eighteen patients experienced at least 1 acute rejection episode: 102 cases (41.8%) among living and 16 (29.6%) among cadaveric kidneys donor ( P = .0007). The actuarial patient and graft survival rates at 1, 5, 10, 15, and 20 years were 95.9%, 87.4%, 77.5%, 65.6%, and 60.8%, and 94.9%, 84.5%, 75.4%, 65.4%, and 53%, respectively. Sixty-three patients died and 72 patients returned to dialysis. Our results were comparable to experienced centers. However, the member of kidney transplantations does not match the increased number of patients on renal replacement therapy. It is advisable to promote obtaining organs from brain-dead donors.

Asymptomatic Severe Mitral Valve Regurgitation

Management of patients with mitral valve regurgitation (MR) has changed dramatically over the past 20 years; this change is largely attributable to 3 factors. First, there have been significant improvements in operative techniques that have led to predictable and durable results after valve repair. In current practice at our clinic, >95% of patients with pure MR caused by degenerative diseases have valve repair rather than prosthetic replacement, and with modern, simplified methods of leaflet repair and annuloplasty, the risk of reoperation after correction of MR is no greater than that after mitral valve replacement.1 Article p 797 The second major shift in mitral valve disease is the change in pathology and pathophysiology of MR. In current practice, almost 80% of patients having mitral valve operations have pure regurgitation rather than valve stenosis or mixed regurgitation and stenosis, and the cause is most often degenerative or myxomatous disease; there is a declining frequency of postinflammatory disease in North America and many other areas of the world. The third important change in the management of patients with mitral valve disease is the better understanding of the natural history of MR, which has been made possible by both detailed natural history studies and improved techniques of 2-dimensional and Doppler echocardiography.2–4 The article by Kang et al5 in this issue of Circulation provides important new and confirmatory information on the outcome of asymptomatic patients with severe MR. Before the 1990s, most clinicians viewed MR as a relatively benign condition, and surgery was reserved for patients who were severely symptomatic or failed medical management.6,7 Reluctance to proceed with operation was related to the likelihood of prosthetic valve replacement and to the notion that asymptomatic patients with severe MR were a …

Longitudinal Changes of Cardiothoracic Ratio and Vascular Pedicle Width as Predictors of Volume Status during One Year in Chinese Peritoneal Dialysis Patients

Background: Volume overload is an important contributing factor of cardiovascular disease (CVD) in peritoneal dialysis (PD) patients. Vascular pedicle width (VPW) and cardiothoracic ratio (CTR) in routine chest radiograph are indicators of intravascular volume. Longitudinal changes of VPW and CTR may be important prognostic factors of PD patients. Method: We studied 212 PD patients. Longitudinal changes in VPW (ΔVPW) and CTR (ΔCTR) were calculated. The relationship between radiologic measurements and clinical outcome was analyzed. Results: During the 12 months prior to enrollment, VPW rose from 53.35 ± 5.66 to 55.40 ± 6.30 mm (p < 0.001) and CTR rose from 53.3 ± 7.1 to 56.0 ± 7.8% (p < 0.001). After adjusting for confounding variables by Cox regression model, ΔCTR is an independent predictor of hospitalization-free survival; 1% increase in CTR confers 2.9% higher risk of hospitalization (95% confidence interval 0.2–5.7%, p = 0.034). None of the radiologic measurements correlated with actuarial patient survival. Conclusions: In chronic PD patients, ΔCTR is an independent predictor of hospitalization-free survival. This simple radiological parameter may serve as an important parameter for the risk stratification of PD patients.

Subclinical Peripheral Artery Disease in Patients Undergoing Peritoneal Dialysis: Risk Factors and Outcome

Peripheral artery disease (PAD) is highly prevalent among patients in end-stage renal disease. The ankle-brachial index (ABI) is believed to be highly correlated with the subclinical PAD of lower extremities but little is known about the associated risk factors and outcome for PAD and ABI in patients on peritoneal dialysis (PD). We performed a cohort study of 153 patients from a single center receiving stable PD for more than 3 months. These patients were screened for subclinical PAD using the ABI measurement. The ABI was measured and a ratio of <0.9 was considered abnormal. Clinical outcomes included actuarial patient and technique survival in this study. 30 patients were classified into a subclinical PAD group. The prevalence of PAD (subclinical and overt) in our PD center was 19.61% (30/153). Advanced age, preexisting diabetes, preexisting cardiovascular and/or cerebrovascular disease (CVD), lower renal Kt/V urea, lower renal creatinine clearance (WCrCl), lower serum albumin level, and higher serum triglyceride level were risk factors for PAD in our PD center. Bivariate analysis showed that ABI was positively correlated with residual renal Kt/V urea and WCrCl, but was not correlated with peritoneal Kt/V urea and WCrCl. Patient and technique survival rates were significantly lower in the low ABI group than in the normal ABI group. ABI is highly correlated with advanced age, preexisting diabetes, preexisting CVD, serum albumin, serum triglyceride, and residual renal clearance in PD patients. Also, lower ABI is independently associated with a high risk of patient mortality and PD technique failure.

Outcomes of Simultaneous Kidney–Pancreas Transplantation With Positive Cross-Match

We studied 72 consecutive simultaneous pancreas kidney transplant (SPKT) recipients. There were 14 patients with positive pretransplant cross-matches (positive CDC- B cell and/or positive flow T or B cross-match). The control group included all 58 SPKT recipients with a negative crossmatch. The study group received induction with low dose intravenous immunoglobulin (IVIg), rabbit antithymocyte globulin (rATG; total dose 6 mg/kg), or alemtuzumab (30 mg single dose) and maintenance with tacrolimus, mycophenolate mofetil (MMF), and corticosteroids. The control group was treated similarly, but with steroid avoidance and no IVIg. Biopsy-proven acute rejection (BPAR) of the kidney allograft occurred in 7 study patients (50%) compared with 10% in the control group ( P = .022). One patient experienced acute cellular rejection (ACR); the other 6 (43%), antibody-mediated rejection (AMR). None of the cross-match negative patients had AMR ( P = .001). The mean follow-up period was 18.7 months in the study group, and 18.3 months in the control group. The 1-year actuarial patient survival was 91.7% in the study group and 97% in the control group. Kidney allograft survival was 91.7% in the study group and 95.2% in the control group. Pancreas allograft survival was 76.9% in study group and 89.6% in the control group ( P = .088). We concluded that patients with a positive pretransplant CDC-B cross-match and/or positive flow cross-match have an increased risk of AMR; more intensive desensitization is needed with low-dose IVIg and induction with either rATG or alemtuzumab.

Liver transplantation in 48 patients with fulminant hepatic failure

Fulminant hepatic failure (FHF) is the most dramatic hepatic disease and is associated with high mortality. Urgent liver transplantation (LT) is the treatment of choice for these patients. From January 2002 to November 2008, 86 patients presented to the hospital with FHF. All patients met the King's College criteria at the time of listing for urgent LT. Drug hepatotoxicity was the most common etiology, affecting 37% of the patients. Methyldopa was the most frequent agent. Thirty-five percent of the patients had cryptogenic FHF, and 14% due to acute hepatitis B virus infection. From 86 patients with FHF, 48 were submitted to LT (36 women and 12 men). During this period there were 181 patients submitted to nonurgent LT. The mean time interval between listing and LT was 2.2 days. MELD scores ranged between 26 and 61 by the time of LT (mean, 41). Patients' median age was 37 years (range, 16 to 70). According to the Briceno score, 75% of hepatic grafts were retrieved from extended criteria donors. Donors were 40 years old or more in 54% of the cases (mean age of 41 years). The 1-year patient actuarial survival rate of transplanted patients with FHF was 57.1% and the 3-year actuarial survival rate was 54.1%. Forty-two percent of the patients died early after the transplant. The main cause of early mortality was sepsis/multisystem organ failure, and late mortality was related to immunosuppressive therapy noncompliance. The mean patient follow-up was 16 months (range, 0 to 57). Another 36 patients with FHF referred to us died while awaiting LT. Only one patient survived without LT. In conclusion, despite the high mortality rate, urgent LT is still the best therapy for patients with FHF.

Dual grafts in adult-to-adult living donor liver transplantation: A single center experience in Taiwan

Volume mismatch is encountered when a single live donor cannot provide adequate graft volume to the recipient with a remnant liver volume which is safe for donation. Our objective is to present our experience in living donor liver transplantation using dual grafts. Record review of 4 dual graft recipients was done. The results were compared with 122 consecutive patients who received a single right lobe. All dual graft recipients were surviving with satisfactory liver function at a median follow-up of 21 months. Two recipients received 1 right and 1 left lobe graft, while the other 2 recipients received 2 left lobe grafts. One donor developed biloma and was managed by percutaneous drainage. The first recipient required re-laparotomy for postoperative bleeding. The second recipient underwent re-laparotomy for bile leak. The third recipient developed grade II decubitus ulcers due to a prolonged sedentary position. When compared with recipients who received a single right lobe, the operative time was prolonged in the dual graft group. There was no apparent increase in the rate of vascular and biliary complications or the incidence of acute cellular rejection. Actuarial patient survivals were comparable in both groups. Dual graft transplantation provides sufficient volume in the recipient without jeopardizing donor safety.

Treatment of AML in First Remission (CR1) with Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) Using Unrelated Donors (UD).

Introduction/Methods: A key component of improving the success rate of allogeneic HSCT for AML in CR1 is to reduce non-relapse mortality (NRM), which, if excessive, will deny the benefit of the graft-versus-leukemia effect. UD HSCT has traditionally been associated with high NRM rates. We reported previously on the significant reduction of NRM using the conditioning regimen of fludarabine 40mg/m2, IV busulfan 130 mg/m2 for 4 days and thymoglobulin. Here we analyze the outcomes of all patients (n=37) with AML in CR1 treated with this regimen and UD HSCT in our institution from January 2002 to December 2007. High-resolution allele level HLA typing was performed for all donorrecipient pairs for HLA-A, -B, -C, DRB1 and DQB1; up to one mismatch was allowed (9/10). Median follow up is 30 months (range, 9–72).Results: Median age was 48 years (range, 13–68); 30% (n=11) were older than 54 years and 51% (n=19) were male. Eleven patients (30%) had secondary AML. Prognostic cytogenetics classification was poor and intermediate in 53% and 47% of the cases, respectively. Stem cell source was bone marrow (BM) in 68% (n=25) and peripheral blood (PB) in 32% (n=12). Graft-versus-host disease (GVHD) prophylaxis was tacrolimus and mini-methotrexate with and without pentostatin (1 or 1.5 mg/m2 on days 8, 15, 22 and 30) in 46% (n=17) and 54% of the cases (n=20), respectively. Donor-recipient HLA match was 9/10 and 10/10 in 14% and 86% of the cases. Median infused total nucleated and CD34+ cells was 3.72 x 108 (range, 0.57 – 11.78) and 3.77 x 106 (range, 0.45 – 12.4), respectively. Median time to neutrophil and platelet engraftment was 12 days (range, 8–18) and 14 days (range, 8–101), respectively. All but one patient engrafted. Grade II–IV acute (a) GVHD rate was 13% (n=2) and 50% (n=10) for patients that received and not received pentostatin-based prophylaxis. Grade III–IV aGVHD rate was 0% versus 15% (n=3) for patients receiving and not receiving pentostatin. Chronic GVHD was diagnosed in 55% (n=18) of all patients (extensive in 10). 100-day and 3-year NRM rate was 11% (n=4) and 20% (n=4), respectively, and was due to engraftment failure (n=1) and aGVHD (n=3). Eight patients (22%) have relapsed, and 8 (22%) have died (4 of relapse, and 4 of NRM causes). Relapse rate was 18% (3/17) and 25% (5/20) for patients that received and not received pentostatin as part of GVHD prophylaxis. Actuarial 3-year event-free and overall survival (figure) is 68% and 78%, respectively. Actuarial 3-year overall survival for patients receiving BM and PB is 80% and 75%, respectively.Conclusion: Long-term disease control can be achieved in a significant fraction of high-risk AML patients undergoing UD transplants as described in this abstract. Use of pentostatin in this context deserves further prospective evaluation. [Display omitted]

Does nephrectomy of failed allograft influence graft survival after re-transplantation?

The aim of the study was to determine the effect of removal of a failed kidney allograft on the outcome of subsequent transplant. Retrospective analytical study comparing graft survival for patients (1993-2005) who had previous graft nephrectomy with those who had not. Of 89 patients with kidney re-transplants, 68 had had a transplant nephrectomy (Group I) while 21 had retained failed grafts (Group II). There was no significant difference in the two groups in the PRA level at the time of re-transplantation (37% versus 29%). Mean follow-up was 47 months. Acute rejections in Group I were 49.1% and in Group II, 31.2% (P = 0.20). Twenty (29%) grafts failed in Group I and four (19%) in Group II. One, three and five years' actuarial graft survival in Group I was 83.8%, 76% and 66.2%, while in Group II, it was 94.7%, 86.8% and 69.5%, respectively (P = 0.66). Five-year actuarial patient survival in Groups I and II was 94.1% and 87.5%, respectively (P = 0.69). Multivariate analysis showed that PRA level significantly influenced graft survival independent of nephrectomy (P = 0.04). Nephrectomy of a failed allograft does not seem to significantly influence the survival of a subsequent graft.

Significant influence of the primary liver disease on the outcomes of hepatic retransplantation

There are many indications for hepatic retransplantation. To identify factors influencing retransplantation needs and outcomes. Retransplantation records from January 1993 to March 2005 were analysed. Patient and disease characteristics and survival outcomes for retransplantation were compared between various groups. Totally, 286 primary and 42 hepatic retransplantations were performed. Retransplantation indications included primary sclerosing cholangitis (PSC), primary biliary cirrhosis, chronic hepatitis C (HCV), chronic active hepatitis (CAH), and alcohol-related disease. Mean follow-up post-retransplantation was 31 +/- 9 months. Actuarial patient survival at 3 months, 1 year, 3 years, 5 years, and at the end of study was 71.4, 69, 59.5, 54.7, and 50%, respectively. Early and late retransplantation had 1-year survival of 73 and 68.5%, respectively. Retransplantation need was significantly higher for PSC, HCV, and CAH. Hepatic retransplantation remains a successful salvage option for transplant complications; however, its need is significantly influenced by the primary liver disease.

Relationship Between β1-Adrenergic Receptor Polymorphisms and Cardiovascular Disease in Peritoneal Dialysis Patients

Recent studies show that a common gain-of-function polymorphism of β1-adrenergic receptor (389 Gly→Arg) plays an important role in the pathogenesis of hypertension and heart failure in patients with normal renal function. We studied the relationship between β1-adrenergic receptor polymorphism and cardiovascular disease in peritoneal dialysis (PD) patients. We studied 189 new PD patients. The β 1-adrenergic receptor genotype was determined by polymerase chain reaction-restriction fragment length polymorphism assay. They were then prospectively followed for the development of cardiovascular events. All-cause mortality and duration of hospitalization were also recorded. There were 95 male cases. The mean age was 56.2 ± 14.8 years. Eighty-six (45.5%) patients were diabetic; 81 (42.9%) received beta-blocker therapy. Only one case was homozygous for the mutant CC genotype. The prevalence of GG, GC, and CC genotypes were 34.9%, 64.6%, and 0.5%, respectively. The genotype distribution was significantly different from that predicted by the assumption of Hardy-Weinberg equilibrium ( p < 0.0001). There was no difference in the prevalence of pre-existing cardiovascular disease between genotype groups. Actuarial patient survival was 80.2% and 85.1% at 24 months for the GG and GC/CC genotypes, respectively ( p = 0.53). Event-free survival was 63.6% and 71.5% at 24 months, respectively ( p = 0.26), and the duration of hospitalization was 15.9 ± 3.0 and 16.6 ± 2.3 days per year, respectively ( p = 0.8). The results remained similar when patients with and without beta-blocker treatment were separately analyzed. Our study demonstrates that the β 1-adrenergic receptor polymorphism is not related to cardiovascular disease in PD patients. Nevertheless, the low prevalence of mutant CC genotype in new PD patients suggests that PD patients represent a highly biased population.

Factors predicting in-breast tumor recurrence after breast-conserving surgery

The main objectives of this study were to identify risk factors for local in-breast tumor recurrence after breast-conservation and to evaluate the impact of IBTR (in-breast tumor recurrence) on overall survival. A total of 335 consecutive patients with 346 invasive and in situ breast cancers were treated with breast conserving therapy. Univariate and multivariate statistical analysis were performed and survival rates were calculated and analyzed using the Kaplan-Meier method. With a median follow-up period of 70.6 months 14 patients (4%) developed an IBTR. Overall survival and the disease-free 8-year actuarial survival of patients were 95% and 93%, respectively. The overall survival of patients with tumour recurrence on any site was significantly shorter than of those without recurrence (64% versus 85% after 8 years of follow-up; P < 0.0001). Similarly, overall survival was significantly reduced in patients with distant metastases compared to all others without distant disease (88% versus 40% after 8 years; P < 0.0001). In contrast, overall survival of patients who experienced IBTR did not differ significantly from the group of patients who never developed IBTR (87% versus 70% after 8 years of follow-up). By univariate analysis, lobular carcinoma, high grade tumours, multifocality, concomitant LCIS and DCIS, the absence of estrogene and progesterone receptor status, as well as R1-status, were significant predictors of IBTR. By multivariate analysis, only R1-status (P < 0.002) and the presence of LCIS around the invasive tumour (P < 0.03) remained as significant factors predicting IBTR. Concomitant lobular carcinomas in situ, as well as R1 surgical status are independent significant risk factors for in breast tumor recurrence after breast conserving therapy.

Balloon Aortic Valvuloplasty in Adults—A 10-Year Review of Auckland's Experience

Patients with severe aortic stenosis, ineligible for surgical aortic valve replacement (AVR), may instead be offered balloon aortic valvuloplasty (BAV). However, initial international enthusiasm for BAV has waned due to early restenosis and symptom recurrence. We retrospectively reviewed consecutive adult patients who had BAVs in Auckland over a 10-year period from 1997 to 2006 and recorded their clinical, echocardiographic, haemodynamic and follow-up data. Twenty-nine patients (17F) underwent 35 BAV procedures. There were 26 elderly patients (mean age 87; median logistic EuroSCORE 26%) and 3 patients requiring "bridging" prior to intended AVR at a later interval. Mean changes in left ventricular systolic pressure, aortic systolic pressure and mean gradient were -8%, +16% and -43%, respectively. In the 26 elderly patients, median time to death or recurrence of symptoms was nine months. There was a significant reduction in the number of cardiac-related admissions six months after BAV compared to six months before (p=0.02). Actuarial survival of the elderly patients at 6 months, 1 year and 2 years was 88%, 64%, 31%, respectively. Complications of BAV were 2 reversible neurological events, 2 haematomas and 1 pseudoaneurysm. Re-do BAVs in 5 patients on >or=2 occasions resulted in an improved median actuarial survival of 36 months. In our experience, BAV has a useful role in symptom palliation in severe aortic stenosis when surgical valve replacement is declined or inappropriate, and can be performed in selected patients with relatively few complications. Re-do BAVs in suitable patients may prolong symptom relief and survival.

Hepatic Resection for Liver Metastases as Part of the “Oncosurgical” Treatment of Metastatic Breast Cancer

Metastatic breast cancer is considered an incurable disease despite new therapies. Recent studies suggest that liver resection associated with systemic treatment may improve patient survival. Patient selection criteria were: good performance status, the feasibility of a complete and safe surgical procedure, and absence of uncontrolled extrahepatic metastases. The information was collected prospectively and analyzed retrospectively from our database. Between 1988 and 2006, 13 liver resections were performed in 12 patients owing to metastatic breast cancer. Two patients had synchronous metastases and ten metachronous metastases. One patient had extrahepatic bone metastases at the time of liver resection. Median follow-up was 35.9 months (range 12-113.4 months). Median age at liver resection was 58.4 years (range 36-76 years). Median hospital stay was 8 days (range 6-24 days); two patients had biliary leak but none died during the postoperative course. Seven patients (58.3%) developed hepatic recurrence. One-, 3-, and 5-year actuarial patient survival was 100%, 79%, and 33%, respectively. Patients who developed liver metastases within the first 24 months and after the first 24 months post-breast surgery had 1-, 3-, and 5-year actuarial patient survival of 100%, 0%, and 0% and 100%, 83%, and 60%, respectively (P < 0.025). Liver resection for breast cancer liver metastases has an important role in the oncosurgical treatment of metastatic breast cancer with excellent 3-year survival.

Excellent Long-Term Results in De Novo Renal Transplant Recipients Treated With Proliferation Signal Inhibitors and Reduced Calcineurin Inhibitors Exposure

Background A new class of immunosuppressants, proliferation signal inhibitors (PSI)—sirolimus and everolimus—has the potential to prevent chronic allograft nephropathy (CAN). This retrospective analysis reports a 6-year practice using PSI at a single center, comparing a regimen based on reduced-dose calcineurin inhibitors (CNI) and PSI versus full-dose CNI and mycophenolic acid (MPA). Methods The study population included 70 patients (group A) who received de novo PSI therapy in combination with reduced dose of CNI, standard steroids, and basiliximab induction, and 216 patients (group B) with full-dose CNI, MPA, steroids, and basiliximab induction. Results No statistically significant differences were recorded in the baseline donor and recipient characteristics. A difference was observed in cold ischemia time, which could represent a bias for the analysis. No differences were recorded in actuarial patient survival, delayed graft function, biopsy-proven acute rejection rates, and renal function analysis. A significant difference was recorded in the actuarial graft survival rate at years 2, 3, and 4 ( P < .01), as well as overall graft survival rates ( P = .025). Discussion The reduction of cold preservation time seemed to be an important factor to improve both short- and long-term renal function. This regimen revealed a long-term trend toward better renal function and graft survival. The use of PSI with reduced doses of CNI seems to be indicated for suboptimal grafts, especially when a reduced quality of the kidney is associated with prolonged cold ischemia time.

Pediatric Kidney Transplantation: A Snapshot 10 Years Later

Herein we report the outcomes of pediatric kidney recipients who underwent transplantation at least 10 years prior. A cohort of 36 patients (mean age, 26.4 ± 6 years) with a mean follow-up time of 14.2 ± 4 years was selected for the study. Immunosuppression consisted of cyclosporine and steroids. Actuarial patient and graft survivals 15 years after the transplantation were 97% and 86%, respectively. Only 1 patient died due to a complicated sclerosant peritonitis. Graft function was good with a mean serum creatinine of this selected cohort of 1.5 ± 0.6 mg/dL. Eighteen percent were class 1, 33% class 2, and 49% chronic kidney disease. Hypertension was treated in almost 80% of the patients. The majority of patients were smaller than the average population with a final height (between 0 and −2) standard deviation score (HSDS) but only 27% had a severe growth impairment (HSDS >−2). Regarding nutritional status, fewer than 30% were overweight and only 1 patient was obese with a body mass index (BMI) >30. The majority of patients, except 2 mentally retarded individuals, are or have been attending normal school and achieved full-time employment. In conclusion, long-term survivors of a kidney transplant received during childhood reached a high degree of rehabilitation despite a long period of immunosuppression.

Simultaneous Pancreas-Kidney Transplantation: A Single-Center Experience and Prospective Analysis

In patients with end-stage chronic kidney disease (CKD) and type 1 diabetes mellitus (DM 1), simultaneous pancreas-kidney (SPK) transplantation is currently considered the gold standard therapy. The aim of this study was to analyze and report the long-term clinical outcomes of the 23 SPK transplantations performed at our institution over an 84-month period (January 1, 2000 to December 31, 2006). A prospective analysis of these patients included donor, recipient, and transplantation characteristics. The only requirements for transplantation were blood group compatibility and a negative cross-match. Bladder drainage via pancreaticoduodenocystostomy was performed in all of the patients. Due to a pulmonary embolus 1 patient (4.3%) died at 2 months. The actuarial patient survival rates at 3 months and 1, 3, and 5 years were 95.6%. Causes for the renal graft loss were chronic allograft nephropathy in 3 cases (13%) and death of the patient in 1 case (4.3%). The actuarial censored renal allograft survival rates at 3 months and at 1 year were 100%, and at 3 and 5 years were 91.3%. Causes for the renal graft loss were chronic rejection in 1 case (4.3%) and patient death in 1 case (4.3%). The actuarial censored pancreatic allograft survival rates at 3 months and at 1 and 3 years were 100%, and at 5 years was 95.6%. The results of this work add further evidence that SPK is the gold standard therapy for selected patients with end-stage CKD due to DM 1.