Management of congenital ichthyoses: European guidelines of care, part two

These guidelines for the management of congenital ichthyoses have been developed by a multidisciplinary group of European experts following a systematic review of the current literature, an expert conference held in Toulouse in 2016, and a consensus on the discussions. These guidelines summarize evidence and expert-based recommendations and intend to help clinicians with the management of these rare and often complex diseases. These guidelines comprise two sections. This is part two, covering the management of complications and the particularities of some forms of congenital ichthyosis.

Blood Pressure Goals in Patients with CKD: A Review of Evidence and Guidelines

Hypertension affects the vast majority of patients with CKD and increases the risk of cardiovascular disease, ESKD, and death. Over the past decade, a number of hypertension guidelines have been published with varying recommendations for BP goals in patients with CKD. Most recently, the American College of Cardiology/American Heart Association 2017 hypertension guidelines set a BP goal of <130/80 mm Hg for patients with CKD and others at elevated cardiovascular risk. These guidelines were heavily influenced by the landmark Systolic Blood Pressure Intervention Trial (SPRINT), which documented that an intensive BP goal to a systolic BP <120 mm Hg decreased the risk of cardiovascular disease and mortality in nondiabetic adults at high cardiovascular risk, many of whom had CKD; the intensive BP goal did not retard CKD progression. It is noteworthy that SPRINT measured BP with automated devices (5-minute wait period, average of three readings) often without observers, a technique that potentially results in BP values that are lower than what is typically measured in the office. Still, results from SPRINT along with long-term follow-up data from the Modification of Diet in Renal Disease and the African American Study of Kidney Disease and Hypertension suggest that a BP goal <130/80 mm Hg will reduce mortality in patients with CKD. Unfortunately, data are more limited in patients with diabetes or stage 4-5 CKD. Increased adverse events, including electrolyte abnormalities and decreased eGFR, necessitate careful laboratory monitoring. In conclusion, a BP goal of <130/80 is a reasonable, evidence-based BP goal in patients with CKD. Implementation of this intensive BP target will require increased attention to measuring BP accurately, assessing patient preferences and concurrent medical conditions, and monitoring for adverse effects of therapy.

Kidney Damage Biomarkers and Incident Chronic Kidney Disease During Blood Pressure Reduction: A Case-Control Study

BACKGROUND

Whether the increased incidence of chronic kidney disease (CKD) during intensive systolic blood pressure (SBP) lowering is accompanied by intrinsic kidney injury is unknown.

OBJECTIVE

To compare changes in kidney damage biomarkers between incident CKD case participants and matched control participants as well as between case participants in the intensive (<120 mm Hg) versus the standard (<140 mm Hg) SBP management groups of SPRINT (Systolic Blood Pressure Intervention Trial).

DESIGN

Nested case-control study within SPRINT.

SETTING

Adults with hypertension without baseline kidney disease.

PARTICIPANTS

Case participants (n = 162), who developed incident CKD during trial follow-up (128 in the intensive and 34 in the standard group), and control participants (n = 162) without incident CKD, who were matched on age, sex, race, baseline estimated glomerular filtration rate, and randomization group.

MEASUREMENTS

9 urinary biomarkers of kidney damage were measured at baseline and at 1 year. Linear mixed-effects models were used to estimate 1-year biomarker changes.

RESULTS

Higher concentrations of urinary albumin, kidney injury molecule-1, and monocyte chemoattractant protein-1 at baseline were significantly associated with greater odds of incident CKD (adjusted odds ratio per doubling: 1.50 [95% CI, 1.14 to 1.98], 1.51 [CI, 1.05 to 2.17], and 1.70 [CI, 1.13 to 2.56], respectively). After 1 year of blood pressure intervention, incident CKD case participants in the intensive group had significantly greater decreases in albumin-creatinine ratio (ACR), interleukin-18, anti-chitinase-3-like protein 1 (YKL-40), and uromodulin than the matched control participants. Compared with case participants in the standard group, those in the intensive group had significantly greater decreases in ACR, β2-microglobulin, α1-microglobulin, YKL-40, and uromodulin.

LIMITATION

Biomarker measurements were available only at baseline and 1 year.

CONCLUSION

Incident CKD in the setting of intensive SBP lowering was accompanied by decreases, rather than elevations, in levels of kidney damage biomarkers and thus may reflect benign changes in renal blood flow rather than intrinsic injury.

PRIMARY FUNDING SOURCE

National Institute for Diabetes and Digestive and Kidney Diseases.

Effects of Intensive Blood Pressure Lowering on Kidney Tubule Injury in CKD: A Longitudinal Subgroup Analysis in SPRINT

BACKGROUND

Random assignment to the intensive systolic blood pressure (SBP) arm (<120mmHg) in the Systolic Blood Pressure Intervention Trial (SPRINT) resulted in more rapid declines in estimated glomerular filtration rates (eGFRs) than in the standard arm (SBP<140mmHg). Whether this change reflects hemodynamic effects or accelerated intrinsic kidney damage is unknown.

STUDY DESIGN

Longitudinal subgroup analysis of clinical trial participants.

SETTINGS & PARTICIPANTS

Random sample of SPRINT participants with prevalent chronic kidney disease (CKD) defined as eGFR<60mL/min/1.73m² by the CKD-EPI (CKD Epidemiology Collaboration) creatinine-cystatin C equation at baseline.

OUTCOMES & MEASUREMENTS

Urine biomarkers of tubule function (β₂-microglobulin [B2M], α₁-microglobulin [A1M]), and uromodulin), injury (interleukin 18, kidney injury molecule 1, and neutrophil gelatinase-associated lipocalin), inflammation (monocyte chemoattractant protein 1), and repair (human cartilage glycoprotein 40) at baseline, year 1, and year 4. Biomarkers were indexed to urine creatinine concentration and changes between arms were evaluated using mixed-effects linear models and an intention-to-treat approach.

RESULTS

978 SPRINT participants (519 in the intensive and 459 in the standard arm) with prevalent CKD were included. Mean age was 72±9 years and eGFR was 46.1±9.4mL/min/1.73m² at baseline. Clinical characteristics, eGFR, urinary albumin-creatinine ratio, and all 8 biomarker values were similar across arms at baseline. Compared to the standard arm, eGFR was lower by 2.9 and 3.3mL/min/1.73m² in the intensive arm at year 1 and year 4. None of the 8 tubule marker levels was higher in the intensive arm compared to the standard arm at year 1 or year 4. Two tubule function markers (B2M and A1M) were 29% (95% CI, 10%-43%) and 24% (95% CI, 10%-36%) lower at year 1 in the intensive versus standard arm, respectively.

LIMITATIONS

Exclusion of persons with diabetes, and few participants had advanced CKD.

CONCLUSIONS

Among participants with CKD in SPRINT, random assignment to the intensive SBP arm did not increase any levels of 8 urine biomarkers of tubule cell damage despite loss of eGFR. These findings support the hypothesis that eGFR declines in the intensive arm of SPRINT predominantly reflect hemodynamic changes rather than intrinsic damage to kidney tubule cells.

Feasibility and Results of Cancer Registry and Noncommunicable Disease Cohort Data Linkages in India

Background: Cancer registries worldwide are vital to determine cancer burden, plan cancer control measures, and facilitate research. Population-based cancer registries are a priority for LMICs by the UICC; the National Cancer Registry Program (NCRP) of India oversees 28 such registries. A primary function of registries is to combine data for the same individual from multiple sources. For other disease cohorts where cancer is an outcome of interest, registries can potentially connect information by linking datasets together. Barriers to successful registration and linkages include systems in which cancer is not a notifiable disease, no universal unique individual identifier exists, and lack of trained personnel. This study utilizes technology and infrastructure to develop better linkages, surveillance, and outcomes. Aim: To assess the feasibility of linking large cohorts designed for cardio-metabolic disease research with cancer registries in New Delhi and Chennai; determine additional steps required for linkage accuracy and completeness; and develop detailed protocols for future applications. Methods: A pilot protocol for linkage between a large diabetes cohort and cancer registries in Delhi and Chennai was developed using MatchPro, a probabilistic record linkage program developed for cancer registries. Probabilistic software links datasets together in the presence of uncertainty (eg misspelled or abbreviated names) to identify record pairs with high probability of representing the same individual. For this study, algorithms were developed to address unique aspects of names and demographics in India. The software and algorithms focused on: detecting duplicates in cancer registries; and linking registries with external files from diabetes cohorts. In Delhi, 3 1-year datasets covering 3 years (2010, 2011, 2012) were linked with the diabetes cohort; in Chennai, the linkage included 3 5-year datasets covering 15 years (2000-04, '05-'09, '10-'14). The unique ID (Aadhaar) is not collected or linked systematically between different systems at this point in time. Results: Linkage attempts yielded potential matches ranked according to probabilistic scores; highest scores were reviewed to determine true matches. In Chennai, this process yielded: (2010-2014) 21% self-reported (SR) cases matching perfectly, 36% requiring follow-up, 13 nonreported (NR) cases found; 2005-2009: 33% SR cases matched perfectly, 1 NR case found; 2000-2004: 1 NR case. Also, 2 training workshops on data linkages and software were held. Conclusion: Linkages between cancer registries and other data sources are feasible in LMICs using probabilistic record linkage software augmented by manual matching. Future efforts to use existing epidemiologic resources (cohorts) and cancer research infrastructure (registries and clinical centers) can enhance research including understanding shared risk factors and pathophysiologic mechanisms e.g., between cancer and other NCD.

Results of trabecular metal augments in Paprosky IIIA and IIIB defects

Aims

The advent of trabecular metal (TM) augments has revolutionized the management of severe bone defects during acetabular reconstruction. The purpose of this study was to evaluate patients undergoing revision total hip arthroplasty (THA) with the use of TM augments for reconstruction of Paprosky IIIA and IIIB defects.

Patients and Methods

A retrospective study was conducted at four centres between August 2008 and January 2015. Patients treated with TM augments and TM shell for a Paprosky grade IIIA or IIIB defect, in the absence of pelvic discontinuity, and who underwent revision hip arthroplasty with the use of TM augments were included in the study. A total of 41 patients with minimum follow-up of two years were included and evaluated using intention-to-treat analysis.

Results

There were 36 (87.8%) patients with a Paprosky IIIA defect and five (12.2%) patients with a Paprosky IIIB defect. The mean age was 56.7 years (28 to 94). There were 21 (51.2%) women and 20 (48.8%) men. The mean follow-up was 39.4 months (12 to 96). One (2%) patient died after eight years. No failures were noted in the series. The mean survivorship was 100% at the time of latest follow-up.

Conclusion

The results of this multicentre study showed encouraging short- and mid-term results for the use of TM augments in the management of Paprosky grade IIIA and IIIB defects. Cite this article: Bone Joint J 2018;100-B:903–8.

Outcomes of lower eyelid retractor recession and lateral horn lysis in lower eyelid elevation for facial nerve palsy

PurposeTo report outcomes and complications of lower eyelid retractor recession and lateral horn lysis (RR) for lower eyelid elevation in patients with facial nerve palsy (FNP).Patients and methodsRetrospective review. Patients with FNP undergoing RR alone (group 1) or with adjunctive procedures (canthal suspension-group 2, tarsorrhaphy-group 3, and full-thickness skin graft-group 4) during a 5-year period were included. Patient demographics, lagophthalmos, occurrence of eyelid malpositions, recurrent retraction, and repeat procedures were noted from medical records. Measures of lower eyelid height (LEH) and lid lag on downgaze were obtained from standard photographs.ResultsForty-two patients (23 females, mean age was 59 years) were included. Mean follow-up was 24 months (range 6-77). Median improvement in LEH following surgery was significant in Group 1 (0.90 mm, IQR: 0.37-0.91, P=0.20) and in Group 2 (0.51 mm, IQR: 0.30-1.37, P<0.001), respectively. Median improvement in blink lagophthalmos was 3.00 mm (IQR: 3.00-3.50, P=0.02) in Group 1 and 3.50 mm (IQR: 1.75-5.00, P<0.001) in Group 2. Median improvement in lagophthalmos on gentle eye closure was 2.00 mm (IQR: 1.50-3.00, P=0.02) in Group 1 and 1.00 mm (IQR: 0-2.13, P=0.006) in Group 2. No new cases of ectropion were noted. 23.5% of patients required a repeat RR at a mean interval of 20 (range 1-70) months and a further 9.8% required a third procedure at a mean interval of 21 (range 18-29) months.ConclusionRR improves lower eyelid retraction and lagophthalmos in FNP either alone or when combined as an adjunctive procedure. It does not aggravate paralytic ectropion although repeated retractor recessions may be required to improve retraction.

The Effect of Extended Release Niacin on Markers of Mineral Metabolism in CKD

BACKGROUND AND OBJECTIVES

Niacin downregulates intestinal sodium-dependent phosphate transporter 2b expression and reduces intestinal phosphate transport. Short-term studies have suggested that niacin lowers serum phosphate concentrations in patients with CKD and ESRD. However, the long-term effects of niacin on serum phosphate and other mineral markers are unknown.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health Trial was a randomized, double-blind, placebo-controlled trial testing extended release niacin in persons with prevalent cardiovascular disease. We examined the effect of randomized treatment with niacin (1500 or 2000 mg) or placebo on temporal changes in markers of mineral metabolism in 352 participants with eGFR<60 ml/min per 1.73 m2 over 3 years. Changes in each marker were compared over time between the niacin and placebo arms using linear mixed effects models.

RESULTS

Randomization to niacin led to 0.08 mg/dl lower plasma phosphate concentrations per year of treatment compared with placebo (P<0.01) and 0.25 mg/dl lower mean phosphate 3 years after baseline (3.32 versus 3.57 mg/dl; P=0.03). In contrast, randomization to niacin was not associated with statistically significant changes in plasma intact fibroblast growth factor 23, parathyroid hormone, calcium, or vitamin D metabolites over 3 years.

CONCLUSIONS

The use of niacin over 3 years lowered serum phosphorous concentrations but did not affect other markers of mineral metabolism in participants with CKD.

Higher defibrillation threshold in methamphetamine cardiomyopathy patients with implantable cardioverter-defibrillator

INTRODUCTION

Identification of patients with an increased risk of high defibrillation thresholds (DFTs) is important in planning implantable cardioverter-defibrillator (ICD) procedures. Clinical observations have suggested that patients with methamphetamine cardiomyopathy (MACMP) have significantly elevated defibrillation thresholds. We hypothesized that MACMP patients would have higher DFT thresholds than controls and would require procedural changes during ICD implantation to accommodate higher thresholds.

METHODS

We identified consecutive patients with MACMP undergoing ICD implantation at the academic center from 2003 to 2007. We then compared DFTs against age-and sex-matched controls.

RESULTS

The MACMP (n = 10) group showed significantly increased DFT thresholds (23.7 ± 6.7 J) compared with age and sex-matched controls (14.5 ± 4.6 J, p < 0.005). Additionally, patients with MACMP had evidence of more severe congestive heart failure, with increased B-type natrieutic protein (BNP) levels (1173 ± 784 vs 260 ± 349, p = 0.02) and decreased left ventricular ejection fraction (LVEF) (17.8 ± 9.4 vs 35.9 ± 15.2, p = 0.02). MACMP patients required high output devices than controls (50% versus 0%, p = 0.03). Differences between groups remained significant despite adjusting for LVEF.

CONCLUSIONS

Planning for ICD implantation should take into consideration a history of methamphetamine abuse, mandating DFT testing and empiric consideration of high output devices for such patients.

Performance of the Surprise Question Compared to Prediction Models in Hemodialysis Patients: A Prospective Study

BACKGROUND

The surprise question (SQ) ("Would you be surprised if this patient were still alive in 6 or 12 months?") is used as a mortality prognostication tool in hemodialysis (HD) patients. We compared the performance of the SQ with that of prediction models (PMs) for 6- and 12-month mortality prediction.

METHODS

Demographic, clinical, laboratory, and dialysis treatment indicators were used to model 6- and 12-month mortality probability in a HD patients training cohort (n = 6,633) using generalized linear models (GLMs). A total of 10 nephrologists from 5 HD clinics responded to the SQ in 215 patients followed prospectively for 12 months. The performance of PM was evaluated in the validation (n = 6,634) and SQ cohorts (n = 215) using the areas under receiver operating characteristics curves. We compared sensitivities and specificities of PM and SQ.

RESULTS

The PM and SQ cohorts comprised 13,267 (mean age 61 years, 55% men, 54% whites) and 215 (mean age 62 years, 59% men, 50% whites) patients, respectively. During the 12-month follow-up, 1,313 patients died in the prediction model cohort and 22 in the SQ cohort. For 6-month mortality prediction, the GLM had areas under the curve of 0.77 in the validation cohort and 0.77 in the SQ cohort. As for 12-month mortality, areas under the curve were 0.77 and 0.80 in the validation and SQ cohorts, respectively. The 6- and 12-month PMs had sensitivities of 0.62 (95% CI 0.35-0.88) and 0.75 (95% CI 0.56-0.94), respectively. The 6- and 12-month SQ sensitivities were 0.23 (95% CI 0.002-0.46) and 0.35 (95% CI 0.14-0.56), respectively.

CONCLUSION

PMs exhibit superior sensitivity compared to the SQ for mortality prognostication in HD patients.

Association Between More Intensive vs Less Intensive Blood Pressure Lowering and Risk of Mortality in Chronic Kidney Disease Stages 3 to 5: A Systematic Review and Meta-analysis

Importance

Trials in patients with hypertension have demonstrated that intensive blood pressure (BP) lowering reduces the risk of cardiovascular disease and all-cause mortality but may increase the risk of chronic kidney disease (CKD) incidence and progression. Whether intensive BP lowering is associated with a mortality benefit in patients with prevalent CKD remains unknown.

Objectives

To conduct a systematic review and meta-analysis of randomized clinical trials (RCTs) to investigate if more intensive compared with less intensive BP control is associated with reduced mortality risk in persons with CKD stages 3 to 5.

Data Sources

Ovid MEDLINE, Cochrane Library, EMBASE, PubMed, Science Citation Index, Google Scholar, and clinicaltrials.gov electronic databases.

Study Selection

All RCTs were included that compared 2 defined BP targets (either active BP treatment vs placebo or no treatment, or intensive vs less intensive BP control) and enrolled adults (≥18 years) with CKD stages 3 to 5 (estimated glomerular filtration rate <60 mL/min/1.73 m2) exclusively or that included a CKD subgroup between January 1, 1950, and June 1, 2016.

Data Extraction and Synthesis

Two of us independently evaluated study quality and extracted characteristics and mortality events among persons with CKD within the intervention phase for each trial. When outcomes within the CKD group had not previously been published, trial investigators were contacted to request data within the CKD subset of their original trials.

Main Outcome and Measure

All-cause mortality during the active treatment phase of each trial.

Results

This study identified 30 RCTs that potentially met the inclusion criteria. The CKD subset mortality data were extracted in 18 trials, among which there were 1293 deaths in 15 924 participants with CKD. The mean (SD) baseline systolic BP (SBP) was 148 (16) mm Hg in both the more intensive and less intensive arms. The mean SBP dropped by 16 mm Hg to 132 mm Hg in the more intensive arm and by 8 mm Hg to 140 mm Hg in the less intensive arm. More intensive vs less intensive BP control resulted in 14.0% lower risk of all-cause mortality (odds ratio, 0.86; 95% CI, 0.76-0.97; P = .01), a finding that was without significant heterogeneity and appeared consistent across multiple subgroups.

Conclusions and Relevance

Randomization to more intensive BP control is associated with lower mortality risk among trial participants with hypertension and CKD. Further studies are required to define absolute BP targets for maximal benefit and minimal harm.

Outcomes for severe aponeurotic ptosis using posterior approach white-line advancement ptosis surgery

PurposeThe purpose of the study was to report the outcome of posterior approach white-line advancement surgery for severe involutional aponeurotic ptosis.Patients and methodsThis was a retrospective review of an interventional case series of all patients undergoing surgery for severe involutional aponeurotic ptosis during a 42-month period at a single center. The inclusion criteria were severe involutional ptosis (upper eyelid margin reflex distance (MRD) ≤1 mm) undergoing posterior approach surgery. There was minimum 3-month follow-up. The main outcome measures were type of ptosis (primary or recurrent), preoperative margin reflex distance, levator function and eyelid skin crease height, presence of visible iris sign (VIS), documented unusual intraoperative findings, postoperative complications, and follow-up time.ResultsOf the 836 procedures for ptosis, 122 procedures (76 patients) met the inclusion criteria for this study. Mean postoperative follow-up was 28 (median 18, range 12-98) weeks. Success rates were 80.3% (98/122) overall, 81.5% (66/81) in the non-VIS group, and 78% (32/41) in the VIS group. There was no significant difference between the two groups (P=0.411). Failures were due to undercorrection, with <2 mm MRD in 75% (18/24), overcorrection with >4.5 mm MRD in 16.7% (4/24), and inter-eyelid height asymmetry of >1 mm in 8.3% (2/122).ConclusionsOutcomes of ptosis surgery for severe aponeurotic ptosis using a posterior approach white-line advancement are comparable to, and possibly better than, anterior approach in eyelids with VIS.