Effects of nonsteroidal antiinflammatory drugs on renal function in patients with renal insufficiency and in cirrhotics

We have assessed the effects of acute and chronic administration of etodolac, ketoprofen, and indomethacin on renal function in patients with mild to moderate chronic renal insufficiency (CRI). We studied 18 normal volunteers and 24 patients with CRI due to hypertension and/or diabetes mellitus with creatinine clearances between 19 and 83 mL/min/1.73 m2. Clearance studies were performed with the first dose of nonsteroidal antiinflammatory drug (NSAID) to compare acute effects of the agent with a no-drug control. Subjects then received the NSAID for three to five days and, on the last day of study, underwent another clearance study to assess the effects of a single dose of NSAID superimposed on chronic dosing. With each dose of each NSAID, inulin and paraaminohippurate (PAH) clearances and fractional excretion of NA+ decreased. However, the baseline control collections after chronic dosing did not differ from the no-drug control periods. Hence, the decline in renal function with each dose is transient, and no overall adverse effect on renal function occurred with chronic dosing. In five patients with cirrhosis, we assessed the renal sparing effects of sulindac. After equilibration on a fixed sodium intake, they received a 200-mg dose of sulindac. In one patient, no adverse effect occurred; the remaining patients suffered declines in creatinine clearance of 29%, 87%, 37%, and 37%, respectively. This effect was transient and returned to control values six to eight hours after sulindac administration. At the time of maximal depression of renal function, serum concentrations of sulindac sulfide were comparable to those in subjects with normal hepatic function.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of acute and chronic dosing of NSAIDs in patients with renal insufficiency

Administration of nonsteroidal anti-inflammatory drugs (NSAIDs) to patients with chronically impaired renal function has been reported to cause abrupt and sustained reductions in renal plasma flow (RPF), glomerular filtration rate (GFR), and solute and water excretion in association with decreased renal prostanoid production. However, the time course of these acute effects and whether they are sustained during chronic exposure to the NSAIDs are unknown. Accordingly, using standard clearance and balance techniques, we investigated the effects of acute (zero to four hours) and chronic (five days) oral administration of two different NSAIDs on renal function in patients with stable, mild to moderate chronic renal insufficiency (CRI) and in normal subjects. In patients, acute oral administration of ketoprofen (K) and indomethacin (I) resulted in significant decreases in GFR (K: from 36 +/- 3 to 20 +/- 4 ml/min, P = 0.001; I: from 37 +/- 6 to 30 +/- 7 ml/min, P = 0.032; in RPF (K: from 194 +/- 21 to 146 +/- 21 ml/min, P = 0.002; I: from 222 +/- 33 to 147 +/- 18 ml/min, P = 0.016); and in urinary PGE2 excretion (K: from 0.60 +/- 0.25 to 0.08 +/- 0.02 ng/min, P = 0.05; I: from 0.34 +/- 0.06 to 0.18 +/- 0.06 ng/min, P = 0.042). Fractional excretion of sodium chloride and fractional free water clearance (CH2O/CIn) also decreased significantly after both agents. In normal subjects, GFR and RPF were not significantly decreased after acute dosing, whereas urinary PGE2 and fractional excretions of NaCl and free water decreased significantly.(ABSTRACT TRUNCATED AT 250 WORDS)

Response to furosemide in chronic renal insufficiency: rationale for limited doses

Patients with renal insufficiency often undergo therapy with large doses of loop diuretics. We tested the hypotheses that remaining nephrons respond normally to amounts of diuretic reaching them, and that more limited doses than are commonly used are sufficient to reach effective portions of the dose-response curve. In eight patients with creatinine clearance less than 20 ml/min/1.73 m2, the amount of diuretic causing half-maximal response was identical to that in normal subjects, but the maximal response expressed as fractional excretion of sodium was increased approximately 60%. The upper plateau of the dose-response curve was attained with single intravenous doses of furosemide, 120 to 160 mg. In conclusion, remnant nephrons appear to demonstrate an exaggerated response to furosemide. Because maximal response was attained with single intravenous doses of furosemide of 120 to 160 mg, there appears to be no need to administer larger single doses in such patients.

Vancomycin elimination in patients with burn injury

Patients with burns clinically appear to require considerably larger doses of vancomycin than normal to attain therapeutic serum concentrations. It has been presumed that this phenomenon is a result of increased renal elimination of this drug consequent to increased glomerular filtration rates in such patients, as has been documented with aminoglycoside antibiotics. We measured the serum clearance of vancomycin in 10 patients with burns and found this parameter to correlate closely with creatinine clearance (serum clearance = 12.5 + 0.695 creatinine clearance; r = 0.932; P less than 0.001). The slope of this relationship was similar to that reported by other investigators in patients not suffering from thermal injury. We conclude that at all levels of renal function, patients with burns clear vancomycin in a manner similar to that of other patients. Consequently, renal function can be used to select a dosing regimen for vancomycin in such patients.

Ciliary dynein conformational changes as evidenced by the extrinsic fluorescent probe 8-anilino-1-naphthalenesulfonate

The binding of 8-anilino-1-naphthalenesulfonate (ANS) to ciliary dynein ATPase leads to a marked increase in the dye's fluorescence intensity, accompanied by a blue shift in the observed fluorescence emission maximum. We found that dynein has 37 +/- 3 ANS binding sites and that experimentally applied ANS concentrations failed to alter enzyme activity. The fluorescence properties of the enzyme-dye complex were used to learn more about the binding characteristics of dynein substrates and effectors and to probe for possible conformational changes of the enzyme. The fluorescence of the dynein-ANS complex is increased by a number of substrates, including ATP, GTP, and UTP. The transfer of excitation energy from dynein chromophores to adsorbed ANS was also investigated. Our findings indicate that dynein appears to undergo a localized conformational change in its interaction with ATP. Native dynein was also found to be conformationally different from heat-activated or NEM-modified enzyme as evidenced by the emission and excitation spectra of the various enzyme-ANS complexes.

Effect of etodolac in patients with moderate renal impairment compared with normal subjects

Twenty subjects (10 with normal renal function and 10 with moderate renal insufficiency) participated in an 8-day study to assess the effects of acute and chronic etodolac dosing on renal function. Subjects and patients were hospitalized and followed a controlled diet (150 mEq sodium, 60 to 80 mEq potassium) during the study. A 3-day drug-free period was followed by 4 days of etodolac, 200 mg b.i.d. Sodium balance and body weight remained unchanged in both groups. Modest reductions in renal function as measured by clearances of inulin and p-aminohippurate occurred acutely only in the patients with renal impairment. Chronic therapy resulted in no decrements in daily creatinine clearance. In an average effective anti-inflammatory dose, etodolac did not produce a sustained effect on renal function in either normal subjects or patients with moderate renal insufficiency.

Transplantation of HLA-haploidentical T-cell-depleted marrow for leukemia: addition of cytosine arabinoside to the pretransplant conditioning prevents rejection

A total of 41 patients with hematologic malignancies (other than acute leukemia in relapse) received allogeneic bone marrow transplants at the University of Wisconsin from 1 April 1980 through 31 March 1984. In an effort to minimize graft-versus-host disease, marrow was depleted of T-lymphocytes in vitro with monoclonal anti-T-cell antibody and complement prior to infusion for seven of 19 recipients of marrow from HLA-identical, MLC-nonreactive siblings, and for all 22 recipients of marrow from MLC-reactive HLA-haploidentical donors. The recipients of HLA-identical T-depleted marrow all showed excellent engraftment following standard pre-BMT conditioning with cyclophosphamide and total body irradiation. In contrast, five of five recipients of T-depleted haploidentical marrow failed to engraft following this same conditioning regimen. The addition of cytosine arabinoside to the pretransplant conditioning appeared to correct this problem, allowing engraftment in 14 of 17 subsequent patients. These clinical results, coupled with prior in vitro data, demonstrate the need to adequately suppress residual host-versus-graft immunity in order to prevent the rejection of T-cell-depleted HLA-haploidentical bone marrow.

Continuous release of diazepam: electrophysiological, biochemical and behavioral consequences

Neuronal GABAergic sensitivity was assessed using electrophysiological, biochemical and behavioral techniques following the continuous release and maintenance of relatively constant brain levels of diazepam for greater than or equal to 21 days. Our studies indicate that long-term exposure to diazepam results in: (1) a decrease in iontophoretic sensitivity to GABA in the dorsal raphe nucleus, (2) an increase in the affinity of the GABA recognition site in brain tissue and (3) an increase in susceptibility to bicuculline-induced seizures in the intact animal. Since the decrease in GABAergic responsiveness was observed in the presence of measurable levels of diazepam, it was concluded that this subsensitivity phenomenon is associated with tolerance and not with withdrawal effects of the benzodiazepines.

Mechanisms of the synergistic combination of metolazone and bumetanide

We assessed the effects of metolazone and of bumetanide alone and in combination in normal volunteers when both sodium replete and when sodium deprived. In both conditions a supra-additive natriuretic (P less than .025) and chloruretic (P less than .05) effect of the combination was observed, the magnitude of which was somewhat greater in the sodium-deprived state. Neither phosphate excretion nor an index of delivery to the diluting segment was supra-additive, indicating that the synergistic effect most likely did not emanate from the proximal tubule. In contrast, in the sodium-deprived subjects, free water clearance relative to the delivery term was diminished 72 +/- 2% with the combination compared to 64 +/- 2% for the two diuretics individually (P = .003). These data indicate that the supra-additive response is due to a synergistic effect of the combination at the diluting segment.

American cancer society Phase I trial of naturally produced beta-interferon

Naturally produced beta-interferon was evaluated following i.m. and i.v. administration to 18 patients with advanced cancer. Fever (mean +/- S.E. = 38.1 degrees +/- 1.7 degrees), enhancement of natural killer cell cytotoxicity, and depression of the white blood cell count occurred following a single i.m. injection in the absence of detectable serum antiviral activity. Fever, rigors, and fatigue were dose-limiting toxicities following daily i.v. administration of 10 million units. Tachyphylaxis, as reported following repetitive administration of alpha-interferons, did not occur. Side effects, depression of the white blood cell count, and enhancement of natural killer cell cytotoxicity were similar when beta-interferon was administered daily as a 10-min bolus or as a 6-hr infusion. However, while natural killer cell cytotoxicity increased progressively over 10 days of bolus injections, it was maximal after the initial 6-hr infusion of beta-interferon. Administration of 10 million units of beta-interferon divided equally between a 10-min bolus injection and a 3-hr infusion was well tolerated and resulted in high initial peak and lower sustained serum interferon levels. Based on pharmacokinetic criteria, this schedule of administration can be recommended for further study in Phase II trials. However, in light of the biological activity of beta-interferon following i.m. administration, the level of beta-interferon in the serum may have limited value as a predictor of antitumor response, toxicity, or biological response modification.

Relationship of vitamin A (retinol) status to lung disease in the preterm infant

Plasma concentrations of retinol and retinol-binding protein were measured at birth in 91 preterm infants. In 64% of these babies retinol values were less than 20 micrograms/dl, suggestive of vitamin A deficiency. Forty-seven of these infants were observed with sequential measurements of retinol and retinol binding protein through 21 days of age. In babies with respiratory distress syndrome retinol values were similar to those in babies without respiratory distress syndrome. The retinol binding protein levels were lower on the third day of life in babies with respiratory distress syndrome. Babies who developed bronchopulmonary dysplasia had lower concentrations of retinol at birth (P less than 0.05) and on day 21 (P less than 0.05) than did babies who did not develop bronchopulmonary dysplasia, despite receiving recommended intakes of vitamin A. Many preterm infants are deficient in vitamin A at birth, and failure to correct this deficiency may contribute to the development of chronic lung disease.

HLA-A, B and DR in Caucasians with transitional cell carcinoma of the bladder

When HLA-A, B and DR antigens in Caucasian patients with transitional cell carcinoma of the urinary bladder were compared with controls, no significant alterations in antigen frequencies were found.

Painful gynecomastia following cytotoxic therapy for testis cancer: a potentially favorable prognostic sign?

Ninety-six patients who received cytotoxic chemotherapy for germ cell neoplasms of the testis were studied. Painful gynecomastia developed in eight patients (8%) between 6 and 24 weeks after the initiation of cytotoxic therapy (mean 18 wk). Serum content of the beta subunit of human chorionic gonadotropin was normal in each patient when gynecomastia developed. Gynecomastia occurred following cytotoxic therapy for advanced disease in seven patients, and one patient was receiving adjunctive drug therapy for stage I disease. Six of the seven patients with advanced disease were in complete remission when gynecomastia developed; survival was superior in patients who developed treatment-related gynecomastia compared to those patients who did not (p less than 0.05). Gynecomastia may occur in adult males after cytotoxic therapy for testis cancer; such gynecomastia does not necessarily indicate recurrent malignancy and may be a favorable prognostic sign.

Construct validity of the marital communication inventory

The Marital Communication Inventory (MCI) is an extremely popular self-report measure of marital communication that has been used in over 65 dissertations and empirical articles since 1970, including several recent clinical reports that used the MCI as a principal outcome measure. However, contrary to its treatment in the clinical literature as a unidimensional, valid measure of treatment outcome, the MCI appears to be a multidimensional instrument, whose primary dimension may not be a specific style or method of communication. Using a canonical correlation analysis of data from over 200 midwestern wives, we compared MCI subscales with subscales from an abbreviated version of the Barrett-Lennard Relationship Inventory (RI). Results supported the hypothesis that the primary dimension of the MCI is more closely associated with positive regard than with the more specific communication dimensions of either empathy or congruence as measured by the RI. Future clinical research in the improvement of marital communication should use the MCI in a much more careful way in order to provide the most valid outcome data.

A reinvestigation of dynein ATPase kinetics and the inhibitory action of vanadate

The kinetic properties of sea urchin flagellar dynein ATPase have been reinvestigated using a continuous assay which regenerates ATP and contains P1,P5-di(adenosine-5')pentaphosphate, a potent adenylate kinase inhibitor. Earlier studies (Shimizu, T. (1981) Biochemistry 20, 4347-4354) revealed complex, highly cooperative kinetics with respect to MgATP2- concentration in the absence of this inhibitor. With Ap5A, the kinetics are characteristic of classical Michaelis-Menten enzymes. Isolated 21 S and 14S enzyme forms were also examined, and their kinetic parameters are presented Vanadate inhibition patterns in the presence of P1,P5-di(adenosine-5')pentaphosphate lose their nonlinear character, and we observe linear noncompetitive inhibition of the "mixed" type.

History and current status of infant formulas

Formulas that approximate the composition of human milk are widely used as the sole source of nutrients for infants during the first months of life. Such formulas contain milk, soy, or meal proteins, or protein hydrolysates together with those forms of fat carbohydrate, vitamins, and minerals shown to be bioavailable to the infant. Legislation concerning nutrient composition and quality assurance of products labeled as infant formulas has been enacted by Congress. Governmental and industrial standards also help to assure microbiological safety and stability. Problems of nutrient composition and adverse reactions have occurred during the evolution and development of infant formulas. Problems concerning nutrient deficiency are now almost unknown, but adverse reactions of individuals to specific formula ingredients continue. Accurate information on composition and related nutritional properties of infant formulas is essential for their effective use and for the avoidance of undesirable complications.

Familial ovarian cancer. How rare is it?

This paper reports an apparently hereditary ovarian carcinoma in the authors' family. A grandmother, her daughter and five granddaughters have been affected. Three of the granddaughters were sisters. The mode of transmission appears to be autosomal dominant, with males capable of being carriers. Present methods of record-keeping make it difficult to link affected females in a family. Further studies are required to find the true incidence of familial ovarian cancer.

Immunosuppression in a murine B cell leukemia (BCL1): role of an adherent cell in the suppression of primary in vitro antibody responses

The ability of lymph node cells from mice bearing the BCL1 tumor to respond in vitro to mitogens, allogeneic cells, and both TI and TD antigens was investigated. The lymph nodes of such mice are not invaded with tumor cells and contain normal numbers of T and B cells. Nevertheless, at the peak of tumor burden in the spleen and blood (approximately 8 to 12 wk after injection with tumor cells), the lymph node cells from the tumor-bearing mice display markedly decreased responsiveness both to allogeneic cells and to antigens. In addition, small numbers of lymph node cells from the tumor-bearing mice suppress primary antibody responses of normal lymph node cells. This nonspecific suppression of antibody responses is mediated by a G-10 Sephadex adherent, non-T, non-B cell present in the nodes of the tumor-bearing mice. Since the BCL1 tumor model is in many respects similar to the prolymphocytic type of human chronic lymphocytic leukemia, the present results may be helpful in elucidating the mechanisms underlying the in vivo immunosuppression associated with lymphocytic neoplasms in humans.

Immunosuppression in a murine B cell leukemia (BCL1): role of an adherent cell in the suppression of primary in vitro antibody responses

The ability of lymph node cells from mice bearing the BCL1 tumor to respond in vitro to mitogens, allogeneic cells, and both TI and TD antigens was investigated. The lymph nodes of such mice are not invaded with tumor cells and contain normal numbers of T and B cells. Nevertheless, at the peak of tumor burden in the spleen and blood (approximately 8 to 12 wk after injection with tumor cells), the lymph node cells from the tumor-bearing mice display markedly decreased responsiveness both to allogeneic cells and to antigens. In addition, small numbers of lymph node cells from the tumor-bearing mice suppress primary antibody responses of normal lymph node cells. This nonspecific suppression of antibody responses is mediated by a G-10 Sephadex adherent, non-T, non-B cell present in the nodes of the tumor-bearing mice. Since the BCL1 tumor model is in many respects similar to the prolymphocytic type of human chronic lymphocytic leukemia, the present results may be helpful in elucidating the mechanisms underlying the in vivo immunosuppression associated with lymphocytic neoplasms in humans.

Clinical studies of a fast homoarginine-sensitive alkaline phosphatase in patients with cancer

The activity of an isoenzyme of alkaline phosphatase (FHAP) was measured in serum samples obtained from 1692 individual subjects. The median FHAP concentration in patients with untreated or recurrent cancer (2.73 IU/liter) was two-fold higher than in hospitalized control patients with illnesses other than cancer (1.17 IU/liter) and three-fold higher than in healthy control subjects (0.93 IU/liter). Among patients with either breast or colorectal cancer who were clinically disease free following their initial therapy, the median FHAP concentration (1.54 IU/liter) was intermediate between the median FHAP concentration in patients with untreated or recurrent cancer and that of healthy control subjects. In order to illustrate the potential clinical application of FHAP as a diagnostic cancer marker, we have selected a serum FHAP concentration of 2.22 IU/liter as a reference value above which only 3% of healthy control subjects would have a "positive" test. Utilizing this reference value, 58% of the patients in the present study with untreated or recurrent cancer would have a positive FHAP test, whereas only 11%, of hospitalized patients with illnesses other than cancer would have a positive test. These data suggest that FHAP may be equivalent to the carcinoembryonic antigen as a diagnostic cancer marker.

HLA frequencies in a Mexican American population

HLA-A and -B antigens were determined for 300 unrelated Mexican-Americans and 300 unrelated Caucasians from San Antonio by the microlymphocytotoxicity technique, using lymphocytes isolated from freshly drawn peripheral blood. Haplotype frequencies for the Mexican American population were obtained directly, based on family studies, as well as estimated from phenotype data. The results revealed clear differences in the distribution of HLA antigens between Mexican American and Caucasian populations. The predominant HLA specificities in Mexican Americans were A2 and Bw35, while the most frequently observed haplotypes were A2-Bw35, A2-B12 and A2Bw40. Despite the distinct differences in HLA antigen distribution between Mexican American and Caucasian populations, genetic distance values, calculated from the HLA frequencies, were surprisingly low.