BackgroundThe Kidney Failure Risk Equation (KFRE) uses the 4 variables of age, sex, urine albumin-to-creatinine ratio (ACR), and estimated glomerular filtration rate (eGFR) in individuals with chronic kidney disease (CKD) to predict the risk of end stage renal disease (ESRD), i.e., the need for dialysis or a kidney transplant, within 2 and 5 years. Currently, national guideline writers in the UK and other countries are evaluating the role of the KFRE in renal referrals from primary care to secondary care, but the KFRE has had limited external validation in primary care. The study’s objectives were therefore to externally validate the KFRE’s prediction of ESRD events in primary care, perform model recalibration if necessary, and assess its projected impact on referral rates to secondary care renal services.Methods and findingsIndividuals with 2 or more Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) eGFR values < 60 ml/min/1.73 m2 more than 90 days apart and a urine ACR or protein-to-creatinine ratio measurement between 1 December 2004 and 1 November 2016 were included in the cohort. The cohort included 35,539 (5.6%) individuals (57.5% female, mean age 75.9 years, median CKD-EPI eGFR 51 ml/min/1.73 m2, median ACR 3.2 mg/mmol) from a total adult practice population of 630,504. Overall, 176 (0.50%) and 429 (1.21%) ESRD events occurred within 2 and 5 years, respectively. Median length of follow-up was 4.7 years (IQR 2.8 to 6.6). Model discrimination was excellent for both 2-year (C-statistic 0.932, 95% CI 0.909 to 0.954) and 5-year (C-statistic 0.924, 95% 0.909 to 0.938) ESRD prediction. The KFRE overpredicted risk in lower (<20%) risk groups. Reducing the model’s baseline risk improved calibration for both 2- and 5-year risk for lower risk groups, but led to some underprediction of risk in higher risk groups. Compared to current criteria, using referral criteria based on a KFRE-calculated 5-year ESRD risk of ≥5% and/or an ACR of ≥70 mg/mmol reduced the number of individuals eligible for referral who did not develop ESRD, increased the likelihood of referral eligibility in those who did develop ESRD, and referred the latter at a younger age and with a higher eGFR. The main limitation of the current study is that the cohort is from one region of the UK and therefore may not be representative of primary care CKD care in other countries.ConclusionsIn this cohort, the recalibrated KFRE accurately predicted the risk of ESRD at 2 and 5 years in primary care. Its introduction into primary care for referrals to secondary care renal services may lead to a reduction in unnecessary referrals, and earlier referrals in those who go on to develop ESRD. However, further validation studies in more diverse cohorts of the clinical impact projections and suggested referral criteria are required before the latter can be clinically implemented.
Para-hisian APs can be safely and effectively ablated at the NCC. Compared with the ablation at the RAS, RF delivered at the NCC has a higher immediate success, lower complication rate, and good long-term outcome.
Background An accurate, reproducible, and comfortable immobilization device is essential for stereotactic radiotherapy (SBRT) in patients with lung cancer. This study compared thermoplastic masks (TMP) and vacuum cushion (VCS) system to assess the differences in interfraction and intrafraction setup accuracy and the impact of body mass index (BMI) with respect to the immobilization choice. Methods This retrospective study was conducted on patients treated with lung SBRT between 2012 and 2015 at the Zhejiang cancer hospital. The treatment setup accuracy was analyzed in 121 patients. A total of 687 cone beam computed tomography (CBCT) scans before treatment and 126 scans after treatment were recorded to determine the uncertainties, and plan target volume margins. Data were further stratified and analyzed by immobilization methods and patients’ BMI. The t-test (Welch) was used to assess the differences between the two immobilization systems when stratified by the patients’ BMI. Results For patients with BMI ≥ 24, the mean displacements for the TMP and VCS systems were 1.4 ± 1.2 vs. 2.4 ± 2.0 mm at medial-lateral (ML) direction ( p < 0.001); 2.0 ± 1.9 vs. 2.0 ± 1.9 mm at cranial-caudal (CC) direction ( p = 0.917); and 2.4 ± 1.4 vs. 2.6 ± 2.1 mm at anterior-posterior (AP) direction, ( p = 0.546). The rate of acceptable errors increased dramatically when immobilized by TMP. In the case of patients with BMI < 24, the mean displacements for the TMP and VCS systems were 1.8 ± 1.4 vs. 2.1 ± 1.8 mm at ML direction ( p = 0.098); 2.9 ± 2.3 vs. 2.2 ± 2.2 mm at CC direction ( p = 0.001); and 1.8 ± 1.8 vs. 2.3 ± 2.0 mm at CC direction, ( p = 0.006). The proportion of acceptable errors increased after immobilization by VCS. No difference was detected in the intrafraction setup error by different immobilization methods. Conclusions The immobilization choice of SBRT for lung tumors depends on the BMI of the patients. For patients with BMI ≥ 24, TMP offers a better reproducibility with significantly less interfractional setup displacement than VCS, resulting in fewer CBCT scans. However, VCS may be preferred over TMP for the patients with BMI < 24. Therefore, an optimal immobilization system needs to be considered in different BMI groups for lung SBRT.
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