The effect of weight loss after bariatric surgery on albuminuria.

BACKGROUND: Bariatric surgery achieves long-term weight loss in obese adults with improvement of diabetes and hypertension. Little is known about the effect of this weight loss on renal parameters. METHODS: We performed a retrospective study of 94 obese adults who had Roux-en-Y gastric bypass surgery with a mean 12-month follow-up. Baseline (preoperative) mean age was 49 years, 76% were female, 37 had blood pressure (BP) >or= 140/90 mmHg and 32 had Type 2 diabetes. 73 patients had normoalbuminuria (urine albumin creatinine ratio (ACR) <30 mg/g) while 21 had microalbuminuria (ACR 30<300 mg/g). RESULTS: At follow-up (postoperative), we observed a decrease in mean body weight (133.6 to 97.9 kg, p<0.0001), mean hemoglobin A1c (6.3 to 5.6%, p<0.0001) and mean systolic blood pressure (132.7 to 114.0 mmHg, p<0.0001). There was a significant reduction in ACR (median with interquartile range) from 9.5 (5-28) to 5.5 (3-10) mg/g, p < 0.0001. Fewer patients had microalbuminuria (22.2 to 6.2%, p=0.004) after surgery. Subgroup analysis revealed that significant decrease in ACR was present in the 32 patients with diabetes (16.5 (5-67) to 6.0 (4-11) mg/g, p=0.001) and in the 37 patients with metabolic syndrome (8.0 (5-16) to 6.0 (3-13) mg/g, p=0.012), while 25 patients with obesity alone had a lower ACR (6.5 (4-13) to 4.5 (3-8) mg/g, p=0.270). Multiple linear regression analysis showed change in hemoglobin A1c (p=0.011) and baseline level of ACR (p<0.0001) to be significantly associated with change in ACR. CONCLUSION: We conclude that obese adults have a reduction in albuminuria after surgical weight loss, most importantly in patients with diabetes or metabolic syndrome.

Progression of superficial venous thrombosis to deep vein thrombosis.

PURPOSE: We have evaluated the progression of isolated superficial venous thrombosis to deep vein thrombosis in patients with no initial deep venous involvement. METHODS: Patients with thrombosis isolated to the superficial veins with no evidence of deep venous involvement by duplex ultrasound examination were evaluated by follow-up duplex ultrasonography to determine the incidence of disease progression into the deep veins of the lower extremities. Initial and follow-up duplex scans evaluated the femoropopliteal and deep calf veins in their entirety; follow-up studies were done at an average of 6.3 days, ranging from 2 to 10 days. RESULTS: From January 1992 to January 1996, 263 patients were identified with isolated superficial venous thrombosis. Thirty (11%) patients had documented progression to deep venous involvement. The most common site of deep vein involvement was progression of disease from the greater saphenous vein in the thigh into the common femoral vein (21 patients, 70%), with 18 of these extensions noted to be nonocclusive and 12 having a free-floating component. Three patients had extended above-knee saphenous vein thrombi through thigh perforators to occlude the femoral vein in the thigh, three patients had extended below-knee saphenous disease into the popliteal vein, and three patients had extended below-knee thrombi into the tibioperoneal veins with calf perforators. At the time of the follow-up examination all 30 patients were being treated without anticoagulation. CONCLUSIONS: Proximal saphenous vein thrombosis should be treated with anticoagulation or at least followed by serial duplex ultrasound evaluation so that definitive therapy may be initiated, if progression is noted. More distal superficial venous thrombosis should be carefully followed clinically and repeat duplex ultrasound scans performed, if progression is noted or patient symptoms worsen.

The use of intravascular ultrasound in the management of thoracic outlet syndrome.

We have reviewed our early experience with intravascular ultrasound in the management of thoracic outlet syndrome. Eight patients presenting with symptoms of venous obstruction secondary to thoracic outlet syndrome have been evaluated by duplex ultrasound, contrast venography, and intravascular ultrasound (IVUS). IVUS was performed at the same time as venography, using the brachial venous access site. In all eight patients IVUS and venography were in agreement. IVUS was able to identify the etiology of the stenoses. Four of the six patients with abnormal IVUS studies have had surgery, and IVUS was used intraoperatively during three of these cases. Based on the demonstration of release of extrinsic compression by real time imaging, it was possible to limit the necessary dissection to two first rib resections alone and one resection of just the insertion of the pectoralis minor muscle. Three of the four patients have had complete resolution of their symptoms postoperatively. Currently, the average follow-up time is 13 months. One patient who was a current procedure has had a minor relapse at 6 months. There have been no complications. These results have shown that IVUS is a safe technique and is as accurate as venography in identifying the sites and degree of narrowing. IVUS provides additional data as well regarding the etiology of the underlying process. The intraoperative use of IVUS has proved helpful in decision-making to minimize the dissection necessary to release extrinsic venous compression. The operative results compare favorably with those found in the literature.