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Background: The association between ultrafiltration rate (UFR) and mortality may be affected by the muscle mass or volume status in hemodialysis (HD) patients. However, there is an absence of data regarding this association. Methods: We performed an observational study on patients (≥18 years old) who had been on HD for at least 3 months. A body composition monitor (BCM) was used for baseline bioimpedance analysis measurement. The primary composite outcome was defined as the time to death or the first cardiovascular event. Results: The median (interquartile range) UFR, volume excess measured by the BCM, and lean tissue index (LTI) (calculated as lean tissue mass/height2) were 11.4 (8.0–15.0) mL/h/kg, 2.4 (1.4–4.1) L, and 12.5 (10.4–14.4) kg/m2, respectively. During 284 person-years of follow-up, the primary outcome occurred in 44 of the 167 patients (26%). Higher UFR was associated with an increased outcome of death or cardiovascular event; the adjusted hazard ratio (HR) was 1.044 (95% confidence interval [CI]: 1.006–1.083). This association remained consistent even after adjusting for volume excess. However, the association between UFR and the primary outcome was modified by LTI (pinteraction = 0.027); the association was significant in patients with LTI < 12.5 kg/m2, and the HR (95% CI) was 1.050 (1.001–1.102). Conclusion: Higher UFR was associated with an increased risk of a composite outcome of death or cardiovascular event regardless of volume status in HD patients. However, muscle mass may modify the association between higher UFR and increased risk of a composite outcome.

Objective To evaluate outcomes in patients with gynaecological cancer related lymphoedema treated with liposuction. Methods A prospective analysis of 21 patients who underwent liposuction followed by compression therapy for chronic unilateral lower limb lymphoedema with up to 8 years follow up was performed. Results Duration of lymphoedema prior to liposuction ranged from 4 to 28 years (mean 15.2 years). The mean age at time of liposuction was 52 years (range 37–67). Estimated volume excess in the affected limb ranged from 1.6 to 12 l (mean 4.7 l). The mean percentage reduction was 92.6% at 6 months (range 59.4–159.9) and 88.9% (range 60.9–127.5) at 1 year. Longer term follow-up of 6 patients at 5 years post-liposuction revealed a mean percentage reduction of 113.6% (range 83.5–155.5). Conclusion Our experience of liposuction combined with compression garments has demonstrated significant and sustainable reduction in limb volume in patients with lower limb lymphoedema secondary to gynaecological malignancy.

Background Lymphedema leads to early deposition of adipose tissue. This may explain why conservative therapies such as complex decongestive therapy (CDT) and controlled compression therapy (CCT), as well as various forms of microsurgical reconstructions, cannot completely remove the excess volume in patients with a large chronic nonpitting lymphedema. Liposuction is therefore a logical and tempting treatment to reduce the adipose tissue volume excess. This article outlines the benefits of using liposuction and presents evidence to support its use. Methods The mechanism between adipose tissue depositions is described as well as the surgical technique, postoperative care, volume measurements, effects on the lymph transport, and follow-up. Results Fifteen years' follow-up shows complete reduction of the excess volume without recurrence following liposuction in patients with postmastectomy arm lymphedema. The same promising results can also be seen in patients with leg lymphedema. Conclusion Various types of treatment of lymphedema are under discussion and there has been some controversy regarding liposuction for lymphedema. Improvements in techniques, patient preparation, and patient follow-up have led to a greater and wider acceptance of liposuction as a treatment for lymphedema in patients with large chronic nonpitting extremity lymphedemas.

Several different approaches for reconstruction have been already described taking into account size and shape of the native breast, location and type of cancer, whether adjuvant radiation and/or chemotherapy is needed, patient’s demographic information, and surgeon’s preferences and experience. We report a case of reconstruction in burn patient using a breast sensitive perforator flap from the contralateral side. Thanks to the volume excess, the left side was large enough to reconstruct the affected side. A supero-medial pedicled reduction mammaplasty was performed on the left breast, and the excess inferior-part was elevated laterally and caudally off the pectoralis major. The flap was supplied by two perforators from the internal mammary vessels, and it was transposed to the right side after resection of the burned breast tissue. The right nipple-areola complex was left buried under the flap. After 2 months, the flap pedicle was deepithelialized, debulked, and passed through inframammary fold. The nipple-areola complex was released as a pedicled flap and sutured to the flap tissue approximately at the same level of the contralateral from the sternal notch. Preoperative sensitivity assessment demonstrated worst sensation of the right breast compared to the uninjured side. At 6 months, postoperatively, the patient could localize pressure and sensibility tested by the use of cotton wool and a pinprick test was quite normal. A clear improvement was observed in cutaneous pressure sensation thresholds over the time. At 12 months, she could recognize cotton wool and a pinprick. No changes were observed in the nipple-areola complex sensibility. Level of Evidence: Level V, therapeutic study.

Volume management is an integral component of the care of patients with acute kidney injury (AKI). Considerable controversy exists regarding the use of pharmacological agents for volume management. Although overt fluid overload is often seen in AKI and may prompt attention for the use of diuretics, often these agents are used in the absence of fluid retention. Over the last decade several new agents have become available for volume removal. We reviewed the literature on this topic and addressed four key questions for the appropriate utilization of these agents. These include the drug targets and mechanism of action of available agents; clinical goals and criteria for timing of intervention; adaptation of therapy for specific clinical settings and measures required for monitoring effectiveness and patient safety. This report details our current knowledge in this area, provides evidence-based clinical practice recommendations where appropriate, and formulates a research agenda to address unanswered questions. (Int J Artif Organs 2008; 31: 127–44)

Fluid removal via ultrafiltration is a primary function of hemodialysis, and inadequate volume control is associated with significant morbidity and mortality among chronic dialysis patients. Treatment-to-treatment fluid removal goals are typically calculated on the basis of interdialytic weight gain and prescribed target weight. The clinical effect of frequent missed target weights is unclear. This study was designed to evaluate the associations of postdialysis weights above and below the prescribed target weight (separately) and outcomes.Data were taken from a national cohort of 10,785 prevalent, thrice-weekly, in-center hemodialysis patients dialyzing from 2005 to 2008 (median time at risk, 2.1 [25th percentile, 75th percentile] years) at a single dialysis organization. Patients were characterized as having an above target weight miss if their postdialysis weight was2 kg above target weight in at least 30% of baseline treatments (14.6% of cohort), or they were characterized as control otherwise. Below target weight miss characterization was analogous for patients with postdialysis weight2 kg below target weight (6.6% of cohort). Coprimary endpoints were all-cause and cardiovascular mortality.Above target weight miss in at least 30% of treatments (versus not) was associated with greater all-cause mortality (adjusted hazard ratio, 1.28; 95% confidence interval, 1.15 to 1.43); and below target weight miss in at least 30% of treatments (versus not) was associated with greater all-cause mortality (adjusted hazard ratio, 1.22; 95% confidence interval, 1.05 to 1.40). Both above and below target weight misses were also significantly associated with greater cardiovascular mortality. Secondary analyses demonstrated dose-response relationships between target weight misses and mortality. Results from sensitivity analyses considering the difference in postdialysis and target weights as a proportion of body weight were analogous to the primary results.Postdialysis weights2 kg above and below target weight are associated with higher all-cause and cardiovascular mortality. Consistent target weight achievement is a viable target for improving fluid management.

Estimates of body water, fat-free mass, and body fat in patients on peritoneal dialysis by anthropometric formulas. Background Anthropometric formulas that are used to estimate body water in peritoneal dialysis patients can also be used to estimate fat-free mass and body fat. Evaluation of body composition by the anthropometric formulas rests on two assumptions: ( 1 ) fat contains no water, and ( 2 ) the water content of the fat-free mass is constant (72%). Methods We compared estimates of body water, fat-free mass, and body fat by anthropometric formulas to estimates employing dilution of tracer substances to measure body water and standard methods to analyze body composition in studies performed on peritoneal dialysis patients. We also analyzed the potential errors of the estimates of body composition by the formulas. Results Estimates of the average body composition provided by the anthropometric formulas agreed with estimates provided by the standard methods. However, these formulas have the potential of introducing large errors when estimating body composition in individuals differing from the average subject, either because the anthropometric formulas do not account for major determinants of body composition, such as physical exercise, nutrition, and catabolic illness, or because these formulas systematically overestimate body water in subjects who are obese or experiencing volume excess. Conclusion Anthropometric formulas currently in existence can provide only approximations of body composition and may be the sources of large errors in evaluating body composition in peritoneal dialysis patients. The potential errors include estimates of body water. These errors may alter the interpretation of urea kinetic studies in certain categories of peritoneal dialysis patients (e.g., obese subjects).

This article discusses a technique of cervicofacial rejuvenation that involves ultrasound-assisted lipectomy. This method is indicated for those patients who might be early candidates for a rhytidectomy, and/or those with an adipose volume excess in the lower facial and cervical areas. The application of ultrasonic energy stimulates skin retraction and allows for the superficial fat to be more safely accessed than can be accomplished with conventional liposuction methods. This technique, along with a retrospective analysis of the first 26 cases treated with the technique, will be presented in this article.

BACKGROUND The main objective of this study was to theoretically quantify the fluctuations of fluid volume excess for different modes of intermittent ultrafiltration schedules and to compare the prediction for the typical and asymmetric thrice-weekly schedule to clinical, physiological and biophysical markers of volume expansion in a group of stable haemodialysis patients. METHODS Overall volume excess (V(OVE)) was described as the sum of a time-independent (V(0)) and a time-dependent component (V). An exact relationship was developed to relate V to variable treatment frequency, treatment spacing and net volume accumulation rate. In a single-centre haemodialysis population, body mass profiling was combined with volume state evaluation by bioimpedance analysis, N-terminal pro-B-type natriuretic peptide (NT-pro BNP) levels, clinical signs, a volume questionnaire and blood pressure levels. RESULTS In 23 patients following the typical thrice-weekly schedule, the time-averaged volume excess (V) during the whole week (1.1 ± 0.5 L) was significantly larger than that during the midweek interval (0.9 ± 0.4 L) (P < 0.002) by a factor comparable to that of 1.21 obtained from the theoretical analysis. V(OVE) was 1.3 ± 1.7 L and significantly related to pre- (P < 0.001) and post-dialysis levels of NT-pro BNP (P < 0.001). CONCLUSION Asymmetric treatment spacing such as with the typical thrice-weekly treatment schedule leads to a significant increase in time-averaged volume excess. The theoretical analysis allows for comparison of time-averaged volume excess in treatments varying with regard to treatment frequency and regularity and could be helpful to prescribe post-treatment volume (target weight) for such variable treatment modes.

Background: The epidemiology of hypertension among hemodialysis (HD) patients is difficult to describe accurately because of difficulties in the assessment of blood pressure (BP). Methods: Using 44-hour interdialytic ambulatory BP measurements, we describe the epidemiology of hypertension in a cohort of 369 patients. To seek correlates of hypertension control, antihypertensive agents were withdrawn among patients with controlled hypertension and ambulatory BP monitoring was repeated. Results: Hypertension (defined as an average ambulatory systolic BP ≧135 mm Hg or diastolic BP ≧85 mm Hg, or the use of antihypertensive medications) was prevalent in 82% of the patients and independently associated with epoetin use, lower body mass index and fewer years on dialysis. Although 89% of the patients were being treated, hypertension was controlled adequately in only 38%. Poor control was independently associated with greater antihypertensive drug use. Inferior vena cava (IVC) diameter in expiration was associated with increased risk of poorly controlled hypertension both in cross-sectional analysis and after withdrawal of antihypertensive drugs. Conclusions: Interdialytic hypertension is highly prevalent and difficult to control among HD patients. End-expiration IVC diameter is associated with poor control of hypertension in cross-sectional analyses as well as after washout of antihypertensive drugs. Among HD patients, an attractive target for improving hypertension control appears to be the reduction of extracellular fluid volume.

Background One of the option for reconstruction of segmental mandibular defect is the vascularized free fibular flap. However, difference in height between mandible and fibula causes aesthetic and functional problems. But lack of a flap wide enough to completely fill the mandibular defect is an important disadvantage for us(1). The double barrel fibula flap has been useed to eliminate this disadvantage, but this flap is too large(2-4). A piece of non-vascularized residual fibula have used as graft in addition to vascularized fibula flap(5). We designed one and a half barrel vascularized free fibular flap to overcome the disadvantages of both techniques. Methods Eight centimeter length mandibular body segment was excised because of giant cell reparative granuloma diagnosis. Vascularized fibular flap was harvested and shaped as follows. A small piece of bone (segment B) was removed at the middle of the flap to fold the flap (Figure 1). The distal half of the flap had been splitted longitidunally, and the bone segment away from the perforator vessels (segment D) were removed. And then two remaining fibula segments were folded, and placed in parallel to each other in the defect (Figure 2). Results The flap has survived. Radiography revealed bone healing between the fibula and mandible. Conclusions One and a half barrel technique may be a good solution for incompatibility of the sizes of the segmental mandibular defect and the vascularized fibula flap. This technique eliminates volume insufficiency of the classical technique, and volume excess of the double-barrel technique. One and a half vascularized fbula flap perfect fit for mandibular defect. Figure 1. Schematic drawing of the flap (arrow is showing the direction of the folding) Figure 2. The final view of the flap in the defect. References 1. Chang YM, Tsai CY, Wei FC. One-stage, double-barrel fibula osteoseptocutaneous flap and immediate dental implants for functional and aesthetic reconstruction of segmental mandibular defects. Plast Reconstr Surg. 2008;122(1):143-5. 2. Jones NF, Swartz WM, Mears DC, Jupiter JB, Grossman A. The "double barrel" free vascularized fibular bone graft. Plast Reconstr Surg. 1988;81(3):378-85. 3. Horiuchi K, Hattori A, Inada I, et al. Mandibular reconstruction using the double barrel fibular graft. Microsurgery. 1995;16(7):450-4. 4. Bahr W, Stoll P, Wachter R. Use of the "double barrel" free vascularized fibula in mandibular reconstruction. J Oral Maxillofac Surg. 1998;56(1):38-44. 5. Lee JH, Kim MJ, Choi WS, et al. Concomitant reconstruction of mandibular basal and alveolar bone with a free fibular flap. Int J Oral Maxillofac Surg. 2004;33(2):150-6. Disclosure/Financial Support None of the authors has a financial interest in any of the products.