Persistent transactivation of EGFR and ErbB2/HER2 by protease-activated receptor-1 promotes breast carcinoma cell invasion

Hyperactivation of ErbB signaling is implicated in metastatic breast cancer. However, the mechanisms that cause dysregulated ErbB signaling and promote breast carcinoma cell invasion remain poorly understood. One pathway leading to ErbB activation that remains unexplored in breast carcinoma cell invasion involves transactivation by G-protein-coupled receptors (GPCRs). Protease-activated receptor-1 (PAR1), a GPCR activated by extracellular proteases, is overexpressed in invasive breast cancer. PAR1 is also proposed to function in breast cancer invasion and metastasis, but how PAR1 contributes to these processes is not known. In this study, we report that proteolytic activation of PAR1 by thrombin induces persistent transactivation of EGFR and ErbB2/HER2 in invasive breast carcinoma, but not in normal mammary epithelial cells. PAR1-stimulated EGFR and ErbB2 transactivation leads to prolonged extracellular signal-regulated kinase-1 and -2 signaling and promotes breast carcinoma cell invasion. We also show that PAR1 signaling through Galpha(i/o) and metalloprotease activity is critical for ErbB transactivation and cellular invasion. Finally, we demonstrate that PAR1 expression in invasive breast carcinoma is essential for tumor growth in vivo assessed by mammary fat pad xenografts. These studies reveal a critical role for PAR1, a receptor activated by tumor-generated proteases, in hyperactivation of ErbB signaling that promotes breast carcinoma cell invasion.

Age-dependent effects of treadmill exercise during a period of inactivity

The objective of this study was to investigate the effect of a treadmill exercise protocol to prevent muscle weakness, atrophy and alterations in calcium regulation in adult, old and very old rats. Adult (7-12 months), old (29-30 months) and very old (34-36 months) F344BNF(1) rats were randomly assigned to weight bearing (WB), weight bearing exercise (WBX), non-weight bearing (NWB) and non-weight bearing exercise (NWBX) groups. The WB group was considered the sedentary-control animals. NWB rats were hindlimb unweighted for 14 days. WBX and NWBX groups were exercised on a treadmill for approximately 15 min four times daily. The contractile properties [diameter, peak active force (P(0)), specific tension (P(0)/CSA)] of single myosin heavy chain type II fibers and Ca regulation [Ca(2+) dependent ATPase activity] were determined. Fiber diameter reduced by 24% in the very old rats with NWB. P(0) and P(0)/CSA declined in the young adult and very old rats with NWB. NWBX attenuated these changes in the young and very old rats. Ca(2+) dependent ATPase activity increased with treadmill exercise during non-weight bearing in the young animals. In conclusion, the treadmill exercise is beneficial in attenuating the non-weight bearing-induced changes in the individual MHC type II muscle fibers of the gastrocnemius muscle.

Topical amiloride ointment accelerates healing of mechanical skin ulcers in albino rabbits and patients

The present investigation was undertaken to explore the ulcer-healing property of 1% amiloride ointment on mechanically produced skin ulcers in albino rabbits and at donor site of patients requiring split skin graft. Four skin ulcers measuring 2 X 2 cm(2) (two on either side of the midline) were made 2 cm apart on the pre-shaved back of each anesthetized rabbit up to the depth of subcutaneous tissue. Ulcers on one side of the midline were treated with sterile soft paraffin and served as control, whereas those on the other side were treated with amiloride ointment. Each ulcer was observed for its size, slough formation, and any sign of irritation on alternate days, until healing was complete. Healing of ulcers was significantly (p<0.001) accelerated with amiloride ointment in terms of days required for complete healing, ulcer size, and area under the size-time curve. In each patient, the anterior thigh was used as donor site. Grafts were harvested from midline using Watson's modification of Humby's knife. Each site was divided into proximal and distal halves and was covered with either soft paraffin tulle serving as control or 1% amiloride tulle as test site and then dressed conventionally. Healing was evaluated visually on 10th postoperative day. Healing was significantly accelerated by amiloride tulle in terms of days required for complete healing (p<0.01), better quality of skin regenerated, leading to ease of removal of dressing with less of patient's discomfort, and hence more acceptability (p<0.01). No irritation or suppression of immunity was noticeable. Thus, topical amiloride may prove to be an inexpensive and better ulcer-healing agent with no apparent side effect. Inhibition of urokinase-type plasminogen activator and modulation of field strengths by amiloride seem to be responsible for this effect.

Mine Blast Injuries - Our Experience

BACKGROUND

The sudden increase in incidence and magnitude of mine blast injuries prompted us to highlight the problem and its management.

METHODS

The cases of mine blast injuries occurring during mining and demining in a particular geographical area were analysed. Total 27 cases of mine blast injuries occurred during mining or demining operations in a period of 13 months.

RESULTS

Various body regions were involved in the mine blast injuries but the main brunt was borne by feet and legs followed by multiple body regions due to splinters. 14 patients underwent below knee (BK) amputation while 4 patients required through knee (TK) amputations. The effect of blast was so severe that most of the cases required 2 to 5 times wound debridements. The initial aggressive debridement / open stump amputation saved the limb and life of all patients.

CONCLUSION

A mine blast causes extensive injuries and psychological trauma. Management is needed urgently, surgery is difficult, and amputation is often inevitable. Maximum lives and limbs can be saved with aggressive debridement, repeated inspections and dressings under anaesthesia and definitive closure at optimum time.

Transcriptional networks and cellular senescence in human mammary fibroblasts

Senescence, the molecular program that limits the finite proliferative potential of a cell, acts as an important barrier to protect the body from cancer. Techniques for measuring transcriptome changes and for modulating their expression suggest that it may be possible to dissect the transcriptional networks underlying complex cellular processes. HMF3A cells are conditionally immortalized human mammary fibroblasts that can be induced to undergo coordinated senescence. Here, we used these cells in conjunction with microarrays, RNA interference, and in silico promoter analysis to promote the dissection of the transcriptional networks responsible for regulating cellular senescence. We first identified changes in the transcriptome when HMF3A cells undergo senescence and then compared them with those observed upon replicative senescence in primary human mammary fibroblasts. In addition to DUSP1 and known p53 and E2F targets, a number of genes such as PHLDA1, NR4A3, and a novel splice variant of STAC were implicated in senescence. Their role in senescence was then analyzed by RNA silencing followed by microarray analysis. In silico promoter analysis of all differential genes predicted that nuclear factor-kappaB and C/EBP transcription factors are activated upon senescence, and we confirmed this by electrophoretic mobility shift assay. The results suggest a putative signaling network for cellular senescence.

Maternal and fetal outcome in valvular heart disease

OBJECTIVES

To compare the pregnancy outcomes of women having valvular heart disease with the pregnancy outcomes of healthy women.

METHODS

A retrospective comparison of the maternal and fetal pregnancy outcomes of 312 women with valvular heart disease and 321 healthy women cared for at a tertiary care hospital during the same period. Statistical analysis was done using the chi(2)-test, with significance fixed at 0.05.

RESULTS

Women with valvular heart disease had a significantly higher incidence of surgical interventions during pregnancy than women in the control group [13.4% (balloon mitral valvotomy) vs. 0.6% (ovarian cystectomy)], congestive heart failure (5.1% vs. 0%, P<0.001), and mortality [0.64% (two women) vs. 0%]. Perinatal outcome was also more adverse in the valvular heart disease group than in the control group, with increased preterm delivery rate (48.3% vs. 20.5%), reduced birth weight (2434+/-599 g vs. 2653+/-542 g; P<0.001), and a higher incidence of APGAR scores less than 8 (8.3% vs. 4%; P<0.01). There was also a higher rate of instrumental delivery (9.9% vs. 3.4%). However, the rate of cesarean deliveries was similar in the two groups.

CONCLUSIONS

Pregnancy in women with valvular heart disease is associated with significantly higher maternal morbidity and adverse fetal outcomes and requires a team approach for optimal management.

Chiari I malformation related syringomyelia: radionuclide cisternography as a predictor of outcome

BACKGROUND

This prospective study, conducted in patients with Chiari I malformation (C I) related syringomyelia who underwent posterior decompression and duroplasty, utilizes radionuclide cisternography in order to study the cerebrospinal fluid (CSF) dynamics at the foramen magnum and to predict the clinical outcome following surgery.

METHODS

17 consecutive patients of C I with syringomyelia (but without hydrocephalus or fixed atlanto-axial dislocation), underwent a detailed neurological examination and were assigned a clinical disability score based on the modified Klekamp and Samii score. A radionuclide cisternography (using Tc99m-DTPA) was performed via the lumbar route and the ascent of the tracer was followed utilizing a gamma camera immediately after injection and then sequentially after 1, 2, 4, 6 and 24 hours. After posterior decompression and duroplasty, the modified Klekamp and Samii score was repeated at follow-up visits (range: 3 months to one year) along with radionuclide cisternography at 3 months, and MR imaging at 6 months.

FINDINGS

Three patterns of tracer flow were observed: a). rapid flow (n=7); b). supratentorial subarachnoid delay (n=7); and, c). foramen magnum block (n=3). The patients having foramen magnum block had the poorest clinical scores on admission. At follow up, there was an improvement in the clinical scores so that the mean scores in all three categories reached nearly the same level. Following posterior decompression, the radionuclide cisternography performed in 10 patients showed a rapid flow of the tracer without any obstruction. The syrinx resolved in 4 of the 11 patients in whom an MRI was done.

INTERPRETATION

The patients with C I with syringomyelia may often have a free flow of tracer across the FM. Posterior decompression and duroplasty provides maximum clinical relief in patients with a demonstrable foramen magnum block on radionuclide cisternography while those with a normal flow have less relief. The symptomatology related to brain-stem compression immediately responds to the surgical procedure but the syrinx-induced signs and symptoms of spinal cord dysfunction persist.

Mitral valve surgery and maternal and fetal outcome in valvular heart disease

OBJECTIVES

To compare maternal and fetal outcomes in patients with non-operated valvular heart disease and patients who had surgery before or during pregnancy.

METHODS

The 308 women with valvular heart disease who delivered in this hospital in the last 8 years were divided into three groups. The 218 (70.7%) women in group 1 had no surgical intervention; the 42 (13.6%) women in group 2 underwent balloon mitral valvotomy during pregnancy; and the 48 (15.5%) women in group 3 had surgical intervention before pregnancy (35 had balloon mitral valvotomy, eight had mitral valve replacement, and five had mitral valve repair). Maternal and fetal outcomes were compared for these three groups.

RESULTS

The antenatal events differed significantly: 175 (80.3%), 40 (94.2%), and 46 (95.8%) patients in groups 1, 2 and 3, respectively, had uneventful pregnancies. In group 1, 14 (6.4%) patients had congestive heart failure (P>0.05) and 24 (11%) patients had cardiac arrhythmias, which was statistically significant. The rate of preterm deliveries did not differ significantly among the three groups. The groups did not differ in mean birth weight, mode of delivery, low birth weight, Apgar scores less than 8, stillbirths, neonatal death, or congenital anomalies.

CONCLUSIONS

Mitral valve surgery before or during pregnancy did not significantly improve maternal and fetal outcomes but decreased adverse events such as congestive heart failure and cardiac arrhythmias. It should be therefore performed only in selected cases.

Discharge from triage: modelling the potential in different types of emergency department

OBJECTIVE

To assess the potential for patients to be assessed and discharged directly from triage in an emergency department (ED).

METHODS

Modelling was undertaken by collection of retrospective electronic data from four different EDs. Serial removal of groups was undertaken using data from coding systems related to patients details of admission/treatment/investigations and procedure undertaken. The final group left were analysed for ambulance usage, prior primary care consultation, and age group.

RESULTS

29.4% patients were discharged after clinical assessment but without any specific treatment or investigation. It was seen that of the patients who can be considered for discharge from triage, 15.5% were brought to the ED by ambulance, 3.5% were patients who had already consulted primary care, and 11% were children.

CONCLUSIONS

This study suggests that a large percentage of patients seen in EDs may not require the extra facilities of that department. There is potential for a large number to be discharged within a few minutes of arrival if appropriate assessment skills are available at first contact. This may require more senior assessment than is currently used. This study has not assessed safety of such a system or the times of day when it is best deployed.

Evaluation of Cases of Secondary Infertility by Hysterosalpingography and Hysteroscopy

Hysterosalpingography (HSG) and hysteroscopy, two investigative modalities were performed on a group of 50 patients of secondary infertility and the results analysed. In this study, the infertile women were evaluated with HSG followed by hysteroscopy to evaluate the causes of secondary infertility and attempt a correlation between these investigative modalities. The complete agreement between HSG and hysteroscopy was established in 43 (86%) cases. HSG showed a false positive rate of 23% and false negative rate of 6%. The sensitivity of HSG was 77% and specificity 93% in diagnosing uterine conditions. The conditions missed were likely due to the overfilling of the uterus. HSG showed a good correlation with hysteroscopy and being a safe and simple procedure, it should be the preliminary Investigation in infertile patients. Thus, the two investigative modalities were found to be complementary to each other rather than being mutually exclusive.

A comparative evaluation of therapeutic effects of once a day dose of losartan potassium versus enalapril maleate in mild to moderate essential hypertension

Hypertension is a major public health problem both in the developing and developed countries of the world and if untreated, can lead to various fatal complications like cerebral stroke, encephalopathy, ischaemic heart disease (IHD), renal failure and sudden cardiac death, etc. In the present study, a comparative evaluation was made between angiotensin-II receptor antagonists like losartan potassium (50 mg daily) and angiotensin converting enzyme (ACE) inhibitors like enalapril maleate (5 mg daily) in 100 patients (50 males and 50 females having 25-50 years of age) of mild to moderate essential hypertension with diastolic blood pressure (DBP) 90-109 mmHg. Both the drugs were tried as monotherapy for their clinical efficacy, safety, tolerability and adverse effect profile in this open trial. Losartan potassium lowered the DBP to <90 mmHg in 62% of the patients at the end of 8 weeks compared to 40% in the enalapril group. Percentage of side effects with losartan was 20 and 50 with enalapril. It is concluded that both the drugs are effective antihypertensive agents and cause significant and comparable fall in systolic blood pressure (SBP) and DBP in patients of mild to moderate essential hypertension. But losartan potassium has been found to be more effective with fewer side effects when compared to enalapril maleate.

Spontaneous bladder rupture secondary to posterior urethral valves in a neonate

Bladder rupture is a rare cause of ascites in neonates. A review of literature revealed about 32 cases including both iatrogenic and spontaneous rupture. This case report describes a successfully treated case of spontaneous rupture of bladder with ascites in a neonate with posterior urethral valves.

Novel Sp family-like transcription factors are present in adult insect cells and are involved in transcription from the polyhedrin gene initiator promoter

We earlier documented the involvement of a cellular factor, polyhedrin (polh) promoter-binding protein, in transcription from the Autographa californica nuclear polyhedrosis virus polh gene promoter. Sequences upstream of the polh promoter were found to influence polh promoter-driven transcription. Analysis of one such region, which could partially compensate for the mutated polh promoter and also activate transcription from the wild-type promoter, revealed a sequence (AcSp) containing a CACCC motif and a loose GC box resembling the binding motifs of the transcription factor Sp1. AcSp and the consensus Sp1 sequence (cSp) specifically bound factor(s) in HeLa and Spodoptera frugiperda (Sf9) insect cell nuclear extracts to generate identical binding patterns, indicating the similar nature of the factor(s) interacting with these sequences. The AcSp and cSp oligonucleotides enhanced in vivo expression of a polh promoter-driven luciferase gene. In vivo mopping of these factor(s) significantly reduced transcription from the polh promoter. Recombinant viruses carrying deletions in the upstream AcSp sequence confirmed the requirement of these factor(s) in polh promoter-driven transcription in the viral context. We demonstrate for the first time DNA-protein interactions involving novel members of the Sp family of proteins in adult insect cells and their involvement in transcription from the polh promoter.

Ovarian dysgenesis with balanced autosomal translocation

Autosomal translocations are rare in the patients with ovarian dysgenesis. An 18-year-old female who presented with primary amenorrhoea had hypergonadotropic hypogonadism and streak ovaries with hypoplastic uterus. Karyotype analysis revealed a balanced autosomal translocation involving chromosomes 1 and 11. The probable role of autosomal translocations in ovarian dysgenesis has been discussed.

Acute ventricular rate control in atrial fibrillation: IV combination of diltiazem and digoxin vs. IV diltiazem alone

OBJECTIVE

To analyze the efficacy of an IV combination of diltiazem and digoxin vs IV diltiazem alone for acute ventricular rate control in patients with atrial fibrillation.

DESIGN

Prospective, randomized, open-label study.

PATIENTS AND METHODS

Fifty-two patients with atrial fibrillation and uncontrolled ventricular rates were randomized to receive either an IV combination of diltiazem and digoxin or IV diltiazem alone and were observed for 12 h. The successful rate control was defined as a ventricular rate < 100 beats per minute (bpm) persisting for 1 h or conversion to sinus rhythm. The loss of rate control was defined as an increase in the ventricular rate to > 100 bpm persistently for > 30 min or rebound to atrial fibrillation.

RESULTS

In both treatment arms (n = 26 each), all patients achieved successful and comparable ventricular rate control at 12 h. The mean (+/- SD) time taken to achieve successful rate control was shorter in the combination arm (15 +/- 16 vs. 22 +/- 22 min). Six patients in the combination arm and 11 in the diltiazem-alone arm experienced episodes of loss of rate control. This loss in the combination arm was less than that in the diltiazem-alone arm (14 vs 39 episodes; p = 0.05). The loss of rate control per patient in the combination arm was also less than that in the diltiazem-alone arm (2.0 +/- 1.0 vs. 3.5 +/- 1.9 episodes per patient; p = 0.04).

CONCLUSIONS

This study demonstrates that in patients with atrial fibrillation who have a rapid ventricular response, the IV combination of diltiazem and digoxin results in a more efficacious ventricular rate control with fewer fluctuations than that achieved by therapy with IV diltiazem alone.

Intracellular osteopontin is an integral component of the CD44-ERM complex involved in cell migration

Osteopontin (OPN) is a secreted glycoprotein with mineral- and cell-binding properties that can regulate cell activities through integrin receptors. Previously, we identified an intracellular form of osteopontin with a perimembranous distribution in migrating fetal fibroblasts (Zohar et al., J Cell Physiol 170:88-98, 1997). Since OPN and CD44 expression are increased in migrating cells, we analyzed the relationship of these proteins with immunofluorescence and confocal microscopy. A distinct co-localization of perimembranous OPN and cell-surface CD44 was observed in fetal fibroblasts, periodontal ligament cells, activated macrophages, and metastatic breast cancer cells. The co-localization of OPN and CD44 was prominent at the leading edge of migrating fibroblasts, where OPN also co-localized with the ezrin/radixin/moesin (ERM) protein ezrin, as well as in cell processes and at attachment sites of hyaluronan-coated beads. The subcortical location of OPN in these cells was verified by cell-surface biotinylation experiments in which biotinylated CD44 and non-biotinylated OPN were isolated from complexes formed with hyaluronan-coated beads and identified with immunoblotting. That perimembranous OPN represents secreted protein internalized by endocytosis or phagocytosis appeared to be unlikely since exogenous OPN that was added to cell cultures could not be detected inside the cells. A physical association with OPN, CD44, and ERM, but not with vinculin or alpha-actin, was indicated by immunoadsorption and immunoblotting of cell proteins in complexes extracted from hyaluronan-coated beads. The functional significance of OPN in this complex was demonstrated using OPN-/- and CD-/- mouse fibroblasts which displayed impaired migration and a reduced attachment to hyaluronan-coated beads. These studies indicate that OPN exists as an integral component of a hyaluronan-CD44-ERM attachment complex that is involved in the migration of embryonic fibroblasts, activated macrophages, and metastatic cells.

Biochemical and functional characterization of intercellular adhesion and gap junctions in fibroblasts

Despite their significance in wound healing, little is known about the molecular determinants of cell-to-cell adhesion and gap junctional communication in fibroblasts. We characterized intercellular adherens junctions and gap junctions in human gingival fibroblasts (HGFs) using a novel model. Calcein-labeled donor cells in suspension were added onto an established, Texas red dextran (10 kDa)-labeled acceptor cell monolayer. Cell-to-cell adhesion required Ca(2+) and was >30-fold stronger than cell-to-fibronectin adhesion at 15 min. Electron micrographs showed rapid formation of adherens junction-like structures at approximately 15 min that matured by approximately 2-3 h; distinct gap junctional complexes were evident by approximately 3 h. Immunoblotting showed that HGF expressed beta-catenin and that cadherins and connexin43 were recruited to the Triton-insoluble cytoskeletal fraction in confluent cultures. Confocal microscopy localized the same molecules to intercellular contacts of acceptor and donor cells. There was extensive calcein dye transfer in a cohort of Texas red dextran-labeled cells, but this was almost completely abolished by the gap junction inhibitor beta-glycyrrhetinic acid and the connexin43 mimetic peptide GAP 27. This donor-acceptor cell model allows large numbers (>10(5)) of cells to form synchronous cell-to-cell contacts, thereby enabling the simultaneous functional and molecular studies of adherens junctions and gap junctions.

Intracellular osteopontin is an integral component of the CD44-ERM complex involved in cell migration

Osteopontin (OPN) is a secreted glycoprotein with mineral- and cell-binding properties that can regulate cell activities through integrin receptors. Previously, we identified an intracellular form of osteopontin with a perimembranous distribution in migrating fetal fibroblasts (Zohar et al., J Cell Physiol 170:88-98, 1997). Since OPN and CD44 expression are increased in migrating cells, we analyzed the relationship of these proteins with immunofluorescence and confocal microscopy. A distinct co-localization of perimembranous OPN and cell-surface CD44 was observed in fetal fibroblasts, periodontal ligament cells, activated macrophages, and metastatic breast cancer cells. The co-localization of OPN and CD44 was prominent at the leading edge of migrating fibroblasts, where OPN also co-localized with the ezrin/radixin/moesin (ERM) protein ezrin, as well as in cell processes and at attachment sites of hyaluronan-coated beads. The subcortical location of OPN in these cells was verified by cell-surface biotinylation experiments in which biotinylated CD44 and non-biotinylated OPN were isolated from complexes formed with hyaluronan-coated beads and identified with immunoblotting. That perimembranous OPN represents secreted protein internalized by endocytosis or phagocytosis appeared to be unlikely since exogenous OPN that was added to cell cultures could not be detected inside the cells. A physical association with OPN, CD44, and ERM, but not with vinculin or alpha-actin, was indicated by immunoadsorption and immunoblotting of cell proteins in complexes extracted from hyaluronan-coated beads. The functional significance of OPN in this complex was demonstrated using OPN-/- and CD-/- mouse fibroblasts which displayed impaired migration and a reduced attachment to hyaluronan-coated beads. These studies indicate that OPN exists as an integral component of a hyaluronan-CD44-ERM attachment complex that is involved in the migration of embryonic fibroblasts, activated macrophages, and metastatic cells.

Etiology, prognosis, and outcome of post-operative acute renal failure

A Multivariate analysis was done in all patients who developed post operative ARF, during the period 1990-1995 to determine the etiological spectrum and to identify various variables affecting the outcome. Of 140 patients (110 operated at SGPGI and 30 operated outside) 116 underwent elective surgery. The different types of surgery leading to ARF were urosurgery (3.5%), open heart surgery (32.9%), gastrosurgery (16.4%), pancreatic surgery (9.3%), obstetrical surgery (3.6%) and others (2.8%). The incidence of ARF in SGPGI patients was highest in pancreatic surgery group (8.2%) followed by open heart surgery (3%). The different etiological factors responsible for ARF were perioperative hypotension (67.1%), sepsis (63.6%) and exposure to nephrotoxic drugs (29.3%). Sixty-four patients (45.7%) required dialysis. The overall mortality was 45%. The mortality was highest in patients who underwent open heart surgery (89.1%) followed by pancreatic surgery (84.6%). The factors associated with high mortality, other than the type of surgery, were preoperative hypotension (p < 0.05), oliguria (p < 0.01), need for dialysis (p < 0.05) and multiorgan failure (p < 0.001). AM following emergency surgery had poor outcome, though not statistically significant. Perioperative sepsis (p < 0.05) and preoperative use of aminoglycoside (p < 0.05) were significantly higher in patients operated outside SGPGI. This was associated with higher incidence of ARF. Thus we conclude that presence of multiorgan failure, oligoanuria, preoperative hypotension and need far dialysis are poor prognostic markers in ARF following surgery.

Level of renal function at the initiation of dialysis in the U.S. end-stage renal disease population

Level of renal function at the initiation of dialysis in the U.S. end-stage renal disease population.

BACKGROUND

More than 285,000 individuals in the United States suffer from end-stage renal disease (ESRD) and are treated predominantly by dialysis. Despite the high cost and poor outcomes of dialysis treatment for ESRD, there are few data about the level of renal function at the onset of ESRD and no established medical criteria for the initiation of dialysis.

METHODS

We report the level of serum creatinine and glomerular filtration rate (GFR) in 90,897 patients who began dialysis in the U. S. between April 1995 through September 1997. Data were obtained from the U.S. Renal Data System. GFR was predicted by an equation developed from the Modification of Diet in Renal Disease Study.

RESULTS

The mean (SD) serum creatinine was 8.5 (3.8) mg/dl. The mean (SD) predicted GFR was 7.1 (3.1) ml/min/1.73 m2, with a range from 1 to 42 ml/min/1.73 m2. The proportion of patients with predicted GFR of > 10, 5 to 10, and <5 ml/min/1.73 m2 was 14, 63, and 23%, respectively. The mean predicted GFR was significantly lower among younger patients, women, African Americans, patients with a higher body weight, patients with ESRD because of diseases other than diabetes, uninsured patients, patients who were employed, homemakers or students, and patients selecting hemodialysis.

CONCLUSIONS

There is wide variation in renal function at the initiation of dialysis in the U.S. ESRD population, and a substantial fraction of patients start dialysis at very low levels of predicted GFR. Further analyses are needed to examine the factors associated with late initiation of dialysis and its impact on the cost and outcomes of ESRD.

Acute renal failure in an intensive care unit in India--prognostic factors and outcome

We prospectively analyzed 70 consecutive patients who developed acute renal failure (ARF) in the intensive care unit (ICU) during a six year period to define prognostic factors and outcome. Age, sex, preexisting chronic diseases, systemic infections, number of organs failing during the disease course, need and mode of renal replacement therapy (RRT), and length of stay in ICU were recorded. Analysis of factors in survivors (n=7, Gp A) and nonsurvivors (n=63, Gp B) was done by univariate and multivariate analysis. The mean age of patients was 28.6 years. Forty nine (70%) patients developed ARF following surgery, whereas 21 (30%) developed ARF in a medical setting. Cardiovascular surgery (39) and pancreatic surgery (7) were important causes in the surgical group, whereas in the medical group acute pancreatitis (11) was the main causative factor. One patient had ARF only, while in the rest, other organs were also involved. In more than 80% of these patients, organ failure and sepsis were present before the onset of ARF. Fifty two (74.3%) patients required dialytic support. The overall mortality was 90%. Number of organs failing, (1.5 +/-9 in Gp A vs 3.6 +/- 8 in Gp B), presence of systemic infection (1 in Gp A vs 55 in Gp B), prolonged stay in ICU (3.7 +/- 1.1 days in Gp A vs 8.0 +/- 5.4 in Gp B) and need for RRT (2 in Gp A vs 50 in Gp B) correlated with the mortality. Using multiple logistic regression analysis, only multiple organ failure (3 or more) correlated with the mortality. We conclude that multiple organ failure is a poor prognostic factor in patients with ARF in the setting of the ICU.