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Obesity is increasing to unprecedented levels, including in the end-stage kidney disease population, where upwards of 60% of kidney transplant patients are overweight or obese. Obesity poses additional challenges to the care of the dialysis patient, including difficulties in creating vascular access and inserting Tenckhoff catheters, higher rates of catheter malfunction and peritonitis, the need for longer and/or more frequent dialysis (or peritoneal dialysis [PD] exchanges) to achieve adequate clearance, increased metabolic complications particularly with PD, and obesity is a barrier to kidney transplantation. In this article, we review special considerations in performing PD, hemodialysis and transplant in the obese patient, as well as the evidence behind medical and surgical management of obesity in dialysis patients.

The CD44 gene encodes several protein isoforms due to alternative splicing and post translational modifications. Given that CD44 variant isoform 9 (CD44v9) is expressed within Spasmolytic Polypeptide/TFF2-Expressing Metaplasia (SPEM) glands during repair, CD44v9 may be play a funcitonal role during the process of regeneration of the gastric epithelium. Here we hypothesize that CD44v9 marks a regenerative cell lineage responsive to infiltrating macrophages during regeneration of the gastric epithelium. Ulcers were induced in CD44-deficient (CD44KO) and C57BL/6 (BL6) mice by a localized application of acetic acid to the serosal surface of the stomach. Gastric organoids expressing CD44v9 were derived from mouse stomachs and transplanted at the ulcer site of CD44KO mice. Ulcers, CD44v9 expression, proliferation and histology were measured 1, 3, 5 and 7-days post-injury. Human-derived gastric organoids were generated from stomach tissue collected from elderly (>55 years) or young (14-20 years) patients. Organoids were transplanted into the stomachs of NOD scid gamma (NSG) mice at the site of injury. Gastric injury was induced in NRG-SGM3 (NRGS) mice harboring human-derived immune cells (hnNRGS) and the immune profile anlayzed by CyTOF. CD44v9 expression emerged within regenerating glands the ulcer margin in response to injury. While ulcers in BL6 mice healed within 7-days post-injury, CD44KO mice exhibited loss of repair and epithelial regeneration. Ulcer healing was promoted in CD44KO mice by transplanted CD55v9-expressing gastric organoids. NSG mice exhibited loss of CD44v9 expression and gastric repair. Transplantation of human-derived gastric organoids from young, but not aged stomachs promoted repair in NSG mouse stomachs in response to injury. Finally, compared to NRGS mice, huNRGS animals exhibited reduced ulcer sizes, an infiltration of human CD162+ macrophages and an emergence of CD44v9 expression in SPEM. Thus, during repair of the gastic epithelium CD44v9 emerges within a regenerative cell lineage that coincides with macrophage inflitration within the injured mucosa. Copyright © 2017 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Background Published results addressing the treatment of colorectal liver metastases (CRLM) with radiofrequency ablation (RFA) vary widely with local recurrence rates of 2–40% and 5-year survival of 14–55%. The goal of this study was to analyze our 10-year experience with laparoscopic RFA. Methods From January 2000 to July 2010, 130 patients underwent laparoscopic RFA for CRLM. Kaplan–Meier analysis was used to assess survival. Univariate and multivariate analysis were performed to identify factors associated with survival and recurrence. Results In this cohort, median survival was 40.4 months with 5-year survival of 28.8%. Overall, 9.2% of patients had a local recurrence (3.6% for tumors 3 cm or less). On univariate analysis, factors associated with decreased survival were BMI (P = 0.045), rectal primary (P = 0.005), and increased tumor size (P = 0.002). On multivariate analysis, increased tumor size (HR 1.29 [95% CI: 1.04–1.59]; P = 0.020) and bilobar disease (HR 2.06 [95% CI: 1.02–4.15]; P = 0.044) were associated with decreased survival. On univariate analysis, only BMI was found to be associated with disease recurrence (P = 0.025). Conclusions Our data demonstrate that laparoscopic RFA can achieve a median survival of 40.4 months with a low local recurrence rate. Patients with tumors 3 cm or less have a decreased risk of local recurrence. J. Surg. Oncol. 2013;107:324–328. © 2012 Wiley Periodicals, Inc.

Background Severe obesity has been shown to limit access to renal transplantation in patients with end stage renal disease (ESRD). Laparoscopic sleeve gastrectomy (LSG) has been performed in the ESRD population to assist in achieving waitlist and transplant eligibility. Little is known about how LSG impacts the bioequivalence tacrolimus products and immunosuppression pharmacokinetics. Methods This was a prospective, open-label, single-dose, crossover, two-period pharmacokinetic (PK) study. The purpose of this study was to assess single-dose PK of immediate-release tacrolimus (IR-TAC), extended-release tacrolimus (ER-TAC), and mycophenolic acid (MPA) in adult ESRD patients post-LSG. Results Twenty-three subjects were included in the 24-hour PK assessments. The ratio of geometric means between ER-TAC and IR-TAC was 103.5% (90% CI 89.6 – 119.6%) for AUC0-24 and 92.5% (90% CI 80.4 – 106.4%) for Cmax. PK parameters were similar between ER-TAC and IR-TAC, except for Cmin (p=0.004) and Cmax (p=0.04). MPA AUC0-24 was similar when given with either ER-TAC or IR-TAC (p=0.32). Patients expressing CYP3A5*1 genotypes had lower tacrolimus AUC0-24 values versus those with CYP3A5*3/*3 (IR-TAC p