SummaryBackground and objectives Autosomal dominant polycystic kidney disease (ADPKD), a frequent cause of end-stage renal disease, has no cure. V2-specific vasopressin receptor antagonists delay disease progression in animal models.Design, setting, participants, and measurements This is a prospectively designed analysis of annual total kidney volume (TKV) and thrice annual estimated GFR (eGFR) measurements, from two 3-year studies of tolvaptan in 63 ADPKD subjects randomly matched 1:2 to historical controls by gender, hypertension, age, and baseline TKV or eGFR. Prespecified end points were group differences in log-TKV (primary) and eGFR (secondary) slopes for month 36 completers, using linear mixed model (LMM) analysis. Sensitivity analyses of primary and secondary end points included LMM using all subject data and mixed model repeated measures (MMRM) of change from baseline at each year. Pearson correlation tested the association between log-TKV and eGFR changes.Results Fifty-one subjects (81%) completed 3 years of tolvaptan therapy; all experienced adverse events (AEs), with AEs accounting for six of 12 withdrawals. Baseline TKV (controls 1422, tolvaptan 1635 ml) and eGFR (both 62 ml/min per 1.73 m 2 ) were similar. Control TKV increased 5.8% versus 1.7%/yr for tolvaptan (P Ͻ 0.001, estimated ratio of geometric mean 0.96 [95% confidence interval 0.95 to 0.97]). Corresponding annualized eGFR declined: Ϫ2.1 versus Ϫ0.71 ml/min per 1.73 m 2 /yr (P ϭ 0.01, LMM group difference 1.1 ml/min per 1.73 m 2 /yr [95% confidence interval 0.24 to 1.9]). Sensitivity analyses including withdrawn subjects were similar, whereas MMRM analyses were significant at each year for TKV and nonsignificant for eGFR. Increasing TKV correlated with decreasing eGFR (r ϭ Ϫ0.21, P Ͻ 0.01).Conclusion ADPKD cyst growth progresses more slowly with tolvaptan than in historical controls, but AEs are common.
Since operative time and stone-free rates favor prone PCNL, but patient safety favors supine PCNL, the choice of patient position should be tailored to individual patient characteristics and the surgeon's preference.
PurposeAcute pyelonephritis (APN) with obstructive uropathy is not uncommon and often causes serious conditions including sepsis and septic shock. We assessed the risk factors for septic shock in patients with obstructive APN associated with upper urinary tract calculi.MethodsWe retrospectively studied 69 patients with obstructive APN associated with upper urinary tract calculi who were admitted to our hospital. Emergency drainage for decompression of the renal collecting system was performed for empirical treatment in cases of failure of initial treatment and for severe cases. We assessed the risk factors for septic shock by multivariate logistic regression analysis.ResultsOverall, 45 patients (65.2 %) underwent emergency drainage and 23 (33.3 %) patients showed septic shock. Poor performance status and the presence of diabetes mellitus (DM) in the septic shock group were more common than in the non-septic shock group (p = 0.012 and p = 0.011, respectively). The platelet count and serum albumin level in the septic shock group were significantly lower than in the non-septic shock group (p = 0.002 and p = 0.003, respectively). Positive rates of midstream urine culture and blood culture in the septic shock group were significantly higher than in the non-septic shock group (p = 0.022 and p = 0.001, respectively). Multivariate analysis showed that decreases in the platelet count (OR 5.43, p = 0.014) and serum albumin level (OR 5.88, p = 0.023) were independent risk factors for septic shock.ConclusionPatients with obstructive APN associated with upper urinary tract calculi who have decreases in platelet count and serum albumin level should be treated with caution against the development of septic shock.
Laparoscopic left adrenalectomy was performed on a 47 years old male patient with primary aldosteronism. Subcutaneous steel traction method was utilized in addition to intraperitoneal CO2 insufflation method. The combined use of steel traction method reduced CO2 insufflation pressure below 12 mmHg and might reduce possibility of CO2-related complications. A left adrenal gland was approached by a resection of phrenic colic ligament and a traction of a transverse and descending colon. Laparoscopic adrenalectomy has distinct advantages over open adrenalectomy in terms of avoidance of skin and muscle incision and rib resection, and early convalescence. This less invasive method might prevail in near future.
The prevalence and renal prognosis of diagnosed autosomal dominant polycystic kidney disease (ADPKD) in Japan were estimated. Hospital-based nationwide surveys were conducted in 1995. The number of ADPKD patients who visited hospitals but were not on chronic dialysis was estimated to be 10,000 (95% confidence interval: 8,200–11,900) and that of ADPKD patients on dialysis was 4,590, yielding a prevalence of ADPKD of 117 per million population at the end of 1994 (95% confidence interval: 102–132). The prevalence increased with age and reached a peak value of 261 per million population at the age group of 55–59 years. The rate of end-stage renal disease among living patients was calculated based on the assumption that the prevalence of ADPKD in the population under the age of 55 years was 261 per million population. The rate of end-stage renal disease increased with the progression of the patients’ age, reaching 49% at the age of 65–69 years and declining thereafter. Conclusion: The hospital-based prevalence of ADPKD is lower than the autopsy-based prevalence, suggesting that a fairly large number of these patients do not receive medical care in their lifetime. The probability of end-stage renal disease is at most 50% among ADPKD patients who visit a hospital.
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