在英國2100位洗腎患者，給予主動和被動的注射補充鐵劑，追蹤2年，有差別嗎？
https://www.nejm.org/doi/full/10.1056/NEJMoa1810742
之前的教育是認為，當洗腎患者貧血合併鐵質不夠時，才補充鐵劑，之所以如此被動補充鐵劑是因為擔心它的副作用，感染。然而事實真是如嗎？
實驗採取：prospective, randomized, open-label, blinded end-point, 分成2組
組1) High-dose group: 400 mg of iron sucrose per month, to be administered intravenously, was prescribed to the patients, with safety cutoff limits (ferritin concentration of 700 μg per liter or a transferrin saturation of 40%) (每個月主動補充鐵劑，超過cutoff limit就暫停注射鐵劑，等抽血數值下降再繼續）
組2) Low-dose group received a monthly dose of 0 mg to 400 mg of iron sucrose as required to maintain a minimum target ferritin concentration of 200 μg per liter and a transferrin saturation of 20%, in line with accepted clinical guidelines. （目前的guideline：當鐵質不夠時，ferritin 少於 200 and transferrin saturation 少於 20%才被動補充鐵劑）
結果：
1) High-dose group needed fewer blood transfusions and received lower doses of erythropoiesis-stimulating agents (ESA).
2) Infection rates did not differ between the groups.
註：看起來是好事，主動補充鐵劑組有較少輸血的機會，也使用較少量的ESA，在這2年的觀察也沒有較高的感染機會。High dose組相對於現今gulideline支持的low dose組，算是noninferior！
2018年10月31日 星期三
2018年10月27日 星期六
ACEI和ARB相比有較高肺癌機會
ACEI除了比較會引起乾咳外，和ARB相比有較高肺癌的機會。
https://www.bmj.com/content/363/bmj.k4209
英國一個99萬人觀察型研究，要探討ACEI和ARB相比，是不是有較高肺癌機會？
收入了自1995至2015年服用以上降血壓藥的患者，平均追蹤6.4年，發現使用ACEI和ARB相比肺癌的機會增加：(incidence rate 1.6 v 1.2 per 1000 person years; hazard ratio 1.14, 95% confidence interval 1.01 to 1.29)。
使用ACEI時間愈久，肺癌危險機會愈高，用藥5年後開始有差異 (hazard ratio 1.22, 1.06 to 1.40) ，用藥到了第10年差異最大(1.31, 1.08 to 1.59)。
作者提出假說：可能是ACEI導致會降血壓的bradykinin累積， 刺激了肺細胞癌化。
Bradykinin is an inflammatory mediator. It is a peptide that causes blood vessels to dilate (enlarge), and therefore causes blood pressure to fall.
https://www.bmj.com/content/363/bmj.k4209
英國一個99萬人觀察型研究，要探討ACEI和ARB相比，是不是有較高肺癌機會？
收入了自1995至2015年服用以上降血壓藥的患者，平均追蹤6.4年，發現使用ACEI和ARB相比肺癌的機會增加：(incidence rate 1.6 v 1.2 per 1000 person years; hazard ratio 1.14, 95% confidence interval 1.01 to 1.29)。
使用ACEI時間愈久，肺癌危險機會愈高，用藥5年後開始有差異 (hazard ratio 1.22, 1.06 to 1.40) ，用藥到了第10年差異最大(1.31, 1.08 to 1.59)。
作者提出假說：可能是ACEI導致會降血壓的bradykinin累積， 刺激了肺細胞癌化。
Bradykinin
 | |||||
 | |||||
Bradykinin is an inflammatory mediator. It is a peptide that causes blood vessels to dilate (enlarge), and therefore causes blood pressure to fall.
2018年10月17日 星期三
洗腎患者無肝炎但是得了肝癌
一位常年茹素，心情開朗的腎友葉OO，平日抽血無肝指數異常，一日因為腹部不適，到醫院做了腹部超音波和切片檢查，結果是少見的惡性腫瘤
S5-8: 6.1 cm angiosarcoma, bilateral liver lobe
這消息真是晴天霹靂！樂觀的腎友和腫瘤科醫師、外科醫師討論後，因為這腫瘤惡性率高、存活率低，開刀或是化療的效果差，腎友決定不要治療，患者4個月後在安寧病房過世。
-----------
呼應之前胃腸科醫師說的：不是沒有肝炎，就不會得肝癌，隨時注意自己的狀況和及時就醫檢查是必要的！
------------
內科學誌 2011：22：423-430
原發性肝臟血管肉瘤 – 中部某醫學中心十年的經驗
彰 化 基 督 教 醫 院 胃 腸 肝 膽 科 病 理 科
摘 要
原發性肝臟血管肉瘤是相當罕見的肝臟惡性腫瘤，只占肝臟惡性腫瘤的1%左右。本研 究分析從民國90年1月到民國99年12月，在彰化基督教醫院診斷罹患此癌症的10位個案。 本研究發現，罹患此腫瘤的病人多以老年人和男性居多，右上腹痛和貧血是最常見的表現。 雖然肝外轉移的情況不常見，但是多數病人發現時，腫瘤已經廣泛的侵襲肝臟組織，而使得 此疾病的預後極差。影像學表現是決定病人預後重要的工具，若是在電腦斷層上看到腫瘤已 經侵犯肝臟兩葉或是有腹水，病人多存活不到3個月。即使腫瘤一開始只侵犯肝臟單葉而接 受開刀治療，術後肝內轉移仍舊很快發生，形成臨床治療上重大和困難的挑戰。
------------
借用wikipedia圖：https://en.wikipedia.org/wiki/Angiosarcoma#/media/File:Epithelioid_angiosarcoma_-_high_mag.jpg
By Nephron - Own work, CC BY-SA 3.0, Link
S5-8: 6.1 cm angiosarcoma, bilateral liver lobe
這消息真是晴天霹靂！樂觀的腎友和腫瘤科醫師、外科醫師討論後，因為這腫瘤惡性率高、存活率低，開刀或是化療的效果差，腎友決定不要治療，患者4個月後在安寧病房過世。
-----------
呼應之前胃腸科醫師說的：不是沒有肝炎，就不會得肝癌，隨時注意自己的狀況和及時就醫檢查是必要的！
------------
內科學誌 2011：22：423-430
原發性肝臟血管肉瘤 – 中部某醫學中心十年的經驗
彰 化 基 督 教 醫 院 胃 腸 肝 膽 科 病 理 科
摘 要
原發性肝臟血管肉瘤是相當罕見的肝臟惡性腫瘤，只占肝臟惡性腫瘤的1%左右。本研 究分析從民國90年1月到民國99年12月，在彰化基督教醫院診斷罹患此癌症的10位個案。 本研究發現，罹患此腫瘤的病人多以老年人和男性居多，右上腹痛和貧血是最常見的表現。 雖然肝外轉移的情況不常見，但是多數病人發現時，腫瘤已經廣泛的侵襲肝臟組織，而使得 此疾病的預後極差。影像學表現是決定病人預後重要的工具，若是在電腦斷層上看到腫瘤已 經侵犯肝臟兩葉或是有腹水，病人多存活不到3個月。即使腫瘤一開始只侵犯肝臟單葉而接 受開刀治療，術後肝內轉移仍舊很快發生，形成臨床治療上重大和困難的挑戰。
------------
借用wikipedia圖：https://en.wikipedia.org/wiki/Angiosarcoma#/media/File:Epithelioid_angiosarcoma_-_high_mag.jpg
By Nephron - Own work, CC BY-SA 3.0, Link
洗腎患者做含碘顯影劑檢查應注意事項
在我當住院醫師時，慢性腎臟病或是已經規則透析患者做了有顯影劑的電腦斷層檢查一定要求要接著排洗腎一次。然而目前的證據顯示，除非使用了大量的顯影劑或是心臟功能很差，並不一定要立即排洗腎，醫療操作上和以往已然不同。
目前高雄長庚心臟科使用的是：low osmolarity non-ionic contrast。
---------------------------------------
ACR Manual on Contrast Media
Version 10.3，2018
ACR Committee on Drugs and Contrast Media
Page 40
Renal Dialysis Patients and the Use of Iodinated Contrast Medium Patients with anuric end-stage chronic kidney disease who do not have a functioning transplant can receive intravascular iodinated contrast medium without risk of further renal damage because their kidneys are no longer functioning. However, there is a theoretical risk of converting an oliguric patient on dialysis to an anuric patient on dialysis by exposing him or her to intravascular iodinated contrast medium. This remains speculative, as there are no conclusive outcomes data in this setting.
Patients receiving dialysis are also at theoretical risk from the osmotic load imposed by intravascular iodinated contrast medium because they cannot readily clear the excess intravascular volume. This osmotic load can theoretically result in pulmonary edema and anasarca, an issue that may have been more significant in the past when high-osmolality IV contrast media were utilized. Complications were not observed in one study of patients on dialysis who received intravascular nonionic iodinated contrast medium [91], though the number of patients in that study was small. In patients at risk for fluid overload, low osmolality or isoosmolality contrast media should be employed with dosing as low as necessary to achieve a diagnostic result.
Most low-osmolality iodinated contrast media are not protein-bound, have relatively low molecular weights, and are readily cleared by dialysis. Unless an unusually large volume of contrast medium is administered, or there is substantial underlying cardiac dysfunction, there is no need for urgent dialysis after intravascular iodinated contrast medium administration [91].
目前高雄長庚心臟科使用的是：low osmolarity non-ionic contrast。
---------------------------------------
ACR Manual on Contrast Media
Version 10.3，2018
ACR Committee on Drugs and Contrast Media
Page 40
Renal Dialysis Patients and the Use of Iodinated Contrast Medium Patients with anuric end-stage chronic kidney disease who do not have a functioning transplant can receive intravascular iodinated contrast medium without risk of further renal damage because their kidneys are no longer functioning. However, there is a theoretical risk of converting an oliguric patient on dialysis to an anuric patient on dialysis by exposing him or her to intravascular iodinated contrast medium. This remains speculative, as there are no conclusive outcomes data in this setting.
Patients receiving dialysis are also at theoretical risk from the osmotic load imposed by intravascular iodinated contrast medium because they cannot readily clear the excess intravascular volume. This osmotic load can theoretically result in pulmonary edema and anasarca, an issue that may have been more significant in the past when high-osmolality IV contrast media were utilized. Complications were not observed in one study of patients on dialysis who received intravascular nonionic iodinated contrast medium [91], though the number of patients in that study was small. In patients at risk for fluid overload, low osmolality or isoosmolality contrast media should be employed with dosing as low as necessary to achieve a diagnostic result.
Most low-osmolality iodinated contrast media are not protein-bound, have relatively low molecular weights, and are readily cleared by dialysis. Unless an unusually large volume of contrast medium is administered, or there is substantial underlying cardiac dysfunction, there is no need for urgent dialysis after intravascular iodinated contrast medium administration [91].
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