Overall Survival Outcomes In Patients Research Articles

Association of a high SCORED value and chronic kidney disease following radical nephrectomy for renal masses

5117 Background: Radical nephrectomy (RN) represents the definitive surgical intervention for patients with renal masses suspicious for malignancy and a normal contralateral kidney. However, patients with renal masses are at risk for having or developing chronic kidney disease (CKD) stage III (GFR<60 ml/min/1.73m2) which places them at a higher risk for cardiac morbidity and mortality. We examined if a validated predictive model (SCORED) could help stratify the risk of CKD in patients with renal masses. Methods: We identified 293 consecutive patients who underwent RN for a renal mass without evidence of metastatic disease and with a normal contralateral kidney. Using preoperative risk factors, we stratified patients into low (<4) and high (≥4) SCORED values. Glomerular filtration rates (GFR) were estimated by the MDRD equation. Results: In our cohort, RN was performed for renal masses with an average size of 6.9 cm (range 2–24). A higher SCORED value was associated with a higher risk of patients having CKD stage III prior to surgery (38% vs 18% with a lower SCORED value, p <0.004). Furthermore, among patients with a pre-operative GFR ≥ 60 ml/min/1.73m2, a higher SCORED value was associated with a significantly higher risk for developing CKD stage III postoperatively, at a median follow up of 39.0 months (52% and 65% risk of CKD vs 25% and 32% risk of CKD in patients with lower SCORED value at 12 months, and at 24 months respectively, p=0.010). In multivariate analyses including the size of the mass and pre-operative GFR, the SCORED value was associated with development of CKD. Comparative analyses with another cohort of 171 patients undergoing nephron sparing approaches (NSA) revealed that NSAs significantly protected patients from developing CKD stage III post-operatively. Conclusions: Despite a normal contralateral kidney, patients with high SCORED values are at a significant risk of having or developing CKD following RN for renal masses. Nephron-sparing approaches should be used whenever possible. These findings assume greater importance when considering overall survival outcomes of patients with kidney cancer, as CKD stage III is an independent risk factor for cardiovascular morbidity and mortality. No significant financial relationships to disclose.

Outcomes of Patients with Hematological Malignancies Admitted to Critical Care.

INTRODUCTIONAdvent of lung protective ventilatory modes, non invasive ventilation, superior renal filtration modalities, better antifungals, better antivirals, antibacterials represent significant advances in intensive care medicine. This coupled with reduced intensity conditioning protocols and T cell depletion transplantation strategies, have translated to improved overall survival outcomes for patients with haematological malignancies undergoing intensive chemotherapy and haematopoietic stem cell transplants.METHODSWe report 43 consecutive admissions (41 patients) to our critical care unit over a 22 month period. Data was collected from the Electronic Patient Record System, patient notes and ICU databases.FINDINGS19 out of 43 (44.18%) admissions to critical care were due to sepsis. [Bacterial sepsis (n=6) [CNS (n=1), Serratia (n=1), Staph (n=1), Gram+ cocci (n=1), MRSA (n=1), Enterococci (n=1) ], viral sepsis(n=4) [(CMV (n=1), VZV (n=1), RSV(n=2) ], fungal sepsis (n=4), neutropenic sepsis without any positive blood cultures (n=5)]. Sepsis was associated with concomitant respiratory failure in 5 patients and renal failure in 3 patients.Respiratory failure accounted for 12 admissions [ARDS/ALI (n=10), Pleural effusions (n=1), T-cell lymphoma involving lungs (n=1)]. Renal failure (n=8) and other causes (n=4) included gastrointestinal [GI hemorrhage (n=1), splenic rupture (n=1)], Steven Johnson syndrome (n=1) and tumor lysis syndrome (n=1)]Of the patients who had been transplanted, there were 15 (34.88 %) admissions to critical care. (282 autologous and unrelated haematopoietic stem cell transplants were performed in the same period). 6 (37.5%) patients underwent autologous transplants [high dose Melphalan (n=3), BEAM (n=3)], 1 underwent a sibling allogeneic transplant, 2 patients underwent full intensity unrelated donor transplant [(Cyclo/TBI/Campath (n=1) and Melphalan/ TBI (n=1)] and the remaining 6 patients underwent reduced intensity transplants [ FMC conditioning (n=4), FM conditioning (n=1), Fludarabine/ Busulphan (n=1)].Among the patients receiving intensive chemotherapy there were 28 (65.11 %) admissions to critical care [AML (n=7), ALL (n=6), CLL (n=1), MM (n=1), NHL (n=10) Sezary syndrome (n=1) Amyloidosis (n=1) and TPLL (n=1)]Survival from the critical care unit, survival from the hospital admission, survival at 3 months and survival at 6 months were 26/ 43 (60.4%), 20/43 (46.5 %), 18/ 43 (41.8%) and 15/43 (34.88%) respectively.CONCLUSIONOur findings justify early availability of facilities for single organ support (Level 2/HDU care) and timely transfer to level 3 care (more than one organ support) for patients undergoing treatment with intensive chemotherapy for haematological malignancies. Haemato - oncologists, transplant physicians and intensivists need to do combined assessments of the critically ill haemato oncology patient at an early stage to decide who will benefit from escalation of care. As haematological malignancies are heterogeneous in nature, the current ICU scoring systems need to be modified according to disease type to prognosticate outcomes more effectively.