Multidrug-resistant tuberculosis patients' views of interventions to reduce treatment loss to follow-up

SETTING

Patients who initiated treatment for multidrug-resistant tuberculosis (MDR-TB) at 15 Programmatic Management of Drug-resistant Tuberculosis (PMDT) health facilities in the Philippines between July and December 2012.

OBJECTIVES

To describe patients' views of current interventions, and suggest changes likely to reduce MDR-TB loss to follow-up.

METHODS

In-depth interviews were conducted between April and July 2014 with MDR-TB patients who were undergoing treatment, had finished treatment at the time of the interview (controls), or had been lost to follow-up (LTFU). Responses were thematically analyzed.

RESULTS

Interviews were conducted with 182 patients who were undergoing or had completed treatment and 91 LTFU patients. Views and suggestions could be thematically categorized as approaches to facilitate adherence or address barriers to adherence. The top themes were the need for transportation assistance or improvements to the current transportation assistance program, food assistance, and difficulties patients encountered related to their medications. These themes were addressed by respectively 63%, 60%, and 32% of the participants.

CONCLUSIONS

A more patient-centered approach is needed to improve MDR-TB treatment adherence. Programs should strive to provide assistance that considers patient preferences, is adequate to cover actual costs or needs, and is delivered in a timely, uninterrupted manner.

Symmetric and asymmetric left ventricular hypertrophy in patients with end-stage renal failure on long-term hemodialysis

BACKGROUND

Patients with end-stage renal disease on regular hemodialysis have an increased prevalence of left ventricular (LV) hypertrophy that is associated with morbidity and mortality. Asymmetric septal hypertrophy and impairment of LV outflow can occur in these patients and may contribute to adverse outcomes. More insight into the prevalence, extent, geometry, and promoting factors of LV hypertrophy is important.

METHODS

An unselected group of 62 patients (31 women), aged 55 +/- 14 years, on maintenance hemodialysis was investigated by Doppler echocardiography. Eight patients with valvular heart disease were excluded from further analysis. We assessed prevalence of LV hypertrophy and asymmetric septal hypertrophy, as well as parameters of LV geometry and LV filling and outflow dynamics.

RESULTS

Prevalence of LV hypertrophy was 65%. Patients were analyzed according to LV mass and geometry. Mean LV mass index was normal (105 +/- 17 g/m2) in Group 1 without LV hypertrophy (n = 19); it was markedly elevated in Group 2 (symmetric hypertrophy, n = 22) and Group 3 (asymmetric hypertrophy with systolic anterior movement of mitral valve, n = 7), and highest (191 +/- 54 g/m2) in Group 4 (asymmetric hypertrophy without systolic anterior movement of mitral valve, n = 6, p < 0.001). Age, body mass index, and duration of hypertension were associated with LV hypertrophy and asymmetric septal hypertrophy (p = 0.01). Group 3 with systolic anterior motion of mitral valve had the smallest end-diastolic LV diameters (p = 0.02); increased heart rates, and increased ejection velocities in the LV outflow tract (p = 0.03, and p = 0.005, respectively, vs. Groups 1, 2, and 4) which pointed to an impairment of LV outflow.

CONCLUSIONS

Symmetric LV hypertrophy and asymmetric septal hypertrophy are frequent in patients on maintenance hemodialysis. Predictors for LV hypertrophy were age and body mass index, and, particularly for asymmetric septal hypertrophy, age and hypertension duration. Volume withdrawal during hemodialysis may lead to symptomatic hypotension due to dynamic obstruction in some patients with severe asymmetric septal hypertrophy.

The influence of hypoalbuminemia on maximal flow rates and transmembrane pressure during plasmapheresis--an in vitro study

BACKGROUND

Plasmapheresis has been used for the treatment of acute liver failure (ALF). In these patients, hypoalbuminemia is often observed. Since albumin improves the disaggregability of erythrocytes, hypoalbuminemia might deteriorate rheology and thus influence the overall performance of plasmapheresis.

METHODS

Hypoalbuminemia was mimicked by using porcine blood because of its physiologically low albumin/globulin ratio (AGR). Filters (n = 16) were integrated in a closed extracorporeal in vitro system. In the control group (n = 8), native porcine blood (AGR 0.8) was used. In the study group (n = 8), we used porcine blood supplemented with human albumin to obtain the human AGR value of 1.2. Two different heparinization protocols were compared in each group (2.5 IU/ml: n = 4 with albumin and n = 4 without albumin versus 5 IU/ml: n = 4 with and n = 4 without albumin).

RESULTS

In both heparinization protocols the higher AGR led to lower transmembrane pressure (TMP) levels compared to the lower AGR. The reduced TMPs enabled higher blood flow and filtration rates.

CONCLUSION

Maintenance of a physiological AGR in ALF patients might improve the performance of plasmapheresis and--as opposed to raised heparinization--contribute to a safer application.

Assessment of renal function in renal transplant patients using cystatin C. A comparison to other renal function markers and estimates

To date, little evidence is available to define the role of cystatin C in patients with renal transplants. Thus, to assess, whether cystatin C (CysC) provides better information on renal function than other markers, CysC, creatinine clearance (CrCl), serum creatinine (SCr), beta2-microglobulin (beta2-M), and 125I-Iothalamate clearance were determined in 30 patients. Correlation and ROC curves were obtained and characteristics like sensitivity and specificity were calculated. Further, to evaluate the usefulness of these markers for monitoring, intraindividual coefficients of variation for CysC and SCr measurements were compared in 85 renal transplant patients. CysC correlated best with GFR, whereas SCr, CrCl and beta2-M all had lower correlation coefficients. CysC was superior to SCr, even when renal function equations of were used. The diagnostic accuracy of CysC was significantly better than SCr. but did not differ significantly from CrCl and beta2-M. Together, our data show that in patients with renal transplants, CysC has a similar diagnostic value as CrCl. However, it is superior to determinations of SCr. The intraindividual variation of CysC is significantly greater than that of SCr. This might be due to better ability of CysC to reflect temporary changes especially in mildly impaired GFR, most critical for early detection of rejection and other function impairment. In conclusion, CysC allows for easy and accurate assessment of renal function (GFR) in steady state renal transplant patients and is clearly superior to the commonly used serum creatinine.

Folic acid supplementation rarely improves erythropoietin response

Pronai et al. [1995] published an article in <i>Nephron</i> which claimed that folic acid supplementation improves erythropoietin (EPO) response. The authors studied 13 patients who were resistant to EPO given at a dosage of 75 U/kg (per week or per dose?). Eight patients responded with a fall in mean corpuscular volume (MCV) and a rise in hematocrit when they were given folic acid.

Rapid and accurate assessment of glomerular filtration rate in patients with renal transplants using serum cystatin C

BACKGROUND

Assessment of renal function in patients with renal transplants is of great importance. Various studies have reported cystatin C as an easily and rapidly assessable marker that can be used for accurate information on renal function impairment. To date, no study is available to define the role of cystatin C in patients with renal transplants.

METHODS

Thirty steady-state patients (50% male/50% female) with status post-kidney transplantation were studied. To assess renal function, cystatin C, creatinine clearance, serum creatinine, beta2-microglobulin (beta2M), and [125I]iothalamate clearance were determined. Correlations and non-parametric ROC curves for accuracy, using a cut-off glomerular filtration rate (GFR) of 60 ml/min, were obtained for the different markers allowing for calculations of positive predictive values (PPV), positive likelihood ratios (PLR), specificity and sensitivity, respectively. Further, to evaluate the usefulness of these markers for monitoring, intraindividual coefficients of variation (CVs) for cystatin C and creatinine measurements were compared in 85 renal transplant patients. Measurements consisted of at least six pairs of results, which were obtained at different time points during routine follow-up.

RESULTS

Cystatin C correlated best with GFR (r=0.83), whereas serum creatinine (r=0.67), creatinine clearance (r=0.57) and beta2M (r=0.58) all had lower correlation coefficients. The diagnostic accuracy of cystatin C was significantly better than serum creatinine (P=0.025), but did not differ significantly from creatinine clearance (P=0.76) and beta2M (P=0.43). At a cut-off of 1.64 mg/l, cystatin C has a PPV of 93%, PLR of 6.4, specificity 89% and sensitivity 70%, respectively. For beta2M, PPV 83%, PLR 1.7, specificity 67% and sensitivity 75% was seen at a cut-off of 3.57 mg/l. Accordingly, at a cut-off of 125 micromol/l for serum creatinine, a PPV 76%, PLR 1.4, specificity 44% and sensitivity 80% was revealed. Finally, at a cut-off of 66 ml/min/1.73 m2 for creatinine clearance, the following characteristics were found: PPV 94%, PLR 7.7, specificity 89% and sensitivity 85%. The intraindividual variation of creatinine was significantly lower than that of cystatin C (P<0.001). With increasing concentrations, their ratios of CV tended towards a value of 1, demonstrating identical variability at low GFR.

CONCLUSION

Together, our data show that in patients with renal transplants, cystatin C, in terms of PPV and PLR, has a similar diagnostic value as creatinine clearance. However, it is superior to serum determinations of creatinine and beta2M. The intraindividual variation of cystatin C is greater than that of creatinine. This might be due to the better ability of cystatin C to reflect temporary changes especially in mildly impaired GFR, most critical for early detection of rejection and other function impairment. Thus, cystatin C allows for rapid and accurate assessment of renal function (GFR) in renal transplants and is clearly superior to the commonly used serum creatinine.

[Febrile convulsions: assessment of current status]

Febrile seizures are the most frequent neurologic disorders during childhood. The pathogenesis is not clear even today. Viral infections of the upper airways, exanthema subitum, acute otitis media, infection of the urinary tract and febrile reactions after vaccination are the most frequent precipitating factors. Predictors in identifying children with very high risk of recurrence are young age at onset, family history of febrile seizures in a first-degree relative, a history of recurrent febrile seizures and a lower degree of fever at the onset of febrile seizures. A family history of epilepsy, neurodevelopmental abnormalities and a lower degree of fever at the onset of febrile convulsion are predictors of later epilepsy in children who have febrile seizures. The prognosis of febrile seizures is very good. In the acute situation, rectal diazepam should be given in the event of prolonged febrile seizures (> 3 minutes) only. Intermittent diazepam therapy and long-term antiepileptics are not recommended. The best prophylactic treatment is education and reassurance for parents and children.

Surgical treatment of "steal syndrome" induced by arteriovenous grafts for hemodialysis

OBJECTIVE

A rare but serious complication of angioaccess surgery for hemodialysis is the so called steal syndrome presenting as ischemia distal to an arteriovenous fistula. The main problem of various surgical techniques to correct steal is subsequent thrombosis of the fistula or persistence of distal ischemia.

INTERVENTIONS

This paper describes an unknown technique for correction of ischemic steal consisting of ligation of the artery just distal to the take-off of the fistula and arterial bypass from the artery proximal to the take-off of the fistula to the artery distal to ligation.

PATIENTS

Six patients with chronic renal insufficiency (3 male, 3 female) with patent upper arm cephalic fistulas presented with severe hand ischemia.

RESULTS

Symptoms improved in all 6 patients immediately after operation. Successful hemodialysis could be maintained using the original fistula.

CONCLUSIONS

The described technique is maybe the procedure of choice for the correction of fistula induced ischemic steal.

Plasma potassium in patients with terminal renal failure during and after haemodialysis; relationship with dialytic potassium removal and total body potassium

BACKGROUND

Chronic haemodialysis (HD) patients may present with severe predialysis hyperkalaemia which is improved by dialytic treatment. However, factors influencing the behaviour of postdialysis plasma potassium (plasma K) are not well known.

METHODS

In this prospective study 14 patients (7 female, 7 male) on chronic HD were investigated during a standardized 4-h HD with a 2 m2 high-flux dialyser and up to 6 h postdialysis. Dialytic potassium removal was measured by dialysate collection. Total body potassium (TBK) was measured by whole-body counting of 40K.

RESULTS

Plasma K declined from 5.65 to 3.62 mmol/l on HD. In spite of a total dialytic removal of 107 mmol of potassium plasma K rose to 5.01 mmol/16 h postdialysis. TBK, as adjusted for age, was 38.2 and 49.0 mmol/kg BW in female and male patients respectively, i.e. in the normal range. Of a total potassium removal of 107 mmol on HD only 42% originated from the extracellular space. Dialytic potassium removal was best correlated with removal of intracellular potassium but also with extracellular potassium content and with the product of plasma K x TBK. The 6-h postdialysis plasma K was correlated with the predialysis value but not with TBK or dialytic potassium removal.

CONCLUSION

A rather high dialytic removal of potassium (which is correlated with plasma K x TBK) does not necessarily prevent a rapid postdialysis rebound of plasma K. Therefore patients with marked hyperkalaemia should be monitored closely postdialysis. TBK can be normal in haemodialysis patients who are well nourished.

[Chronic hepatitis B infection and liver failure following kidney transplantation]

Chronic liver diseases, especially due to chronic hepatitis B virus infection, are among the leading causes of late mortality in renal transplant recipients. We report on 4 HBsAg-positive patients observed over a period of 8 years, who were free of symptomatic liver disease for 7-19 years after renal transplantation and died within a few days of acute hepatic failure. The cases presented document the prognostic relevance of chronic hepatitis B virus infection in renal transplant recipients and illustrate that an asymptomatic HBsAg carrier state can evolve within a very short time to fatal liver disease.

Dexamethasone therapy for bacterial meningitis in children. Swiss Meningitis Study Group

Routine use of steroids as adjunctive treatment of bacterial meningitis remains controversial. We have carried out a prospective, placebo-controlled, double-blind study of dexamethasone in 115 children with acute bacterial meningitis in Switzerland. The patients were randomly assigned to receive either placebo (n = 55) or dexamethasone (n = 60) in addition to optimum antibiotic treatment (100 mg/kg daily ceftriaxone). Dexamethasone therapy (0.4 mg/kg) was started 10 min before the first dose of ceftriaxone and given every 12 h for 2 days. Baseline demographic, clinical, and laboratory features of the two groups were similar. After 24 h treatment meningeal inflammation as shown by cerebrospinal fluid (CSF) glucose concentration was significantly less with dexamethasone than with placebo (mean increase in glucose 63 [76] vs 40 [75]%, p = 0.008). However, other indices of inflammation showed similar changes in both groups. Addition of dexamethasone did not affect the rate at which CSF became sterile. Both groups showed prompt clinical responses and similar frequencies of complications (15 vs 12%). Monitoring for possible adverse effects of dexamethasone revealed no abnormalities. At follow-up examinations 3, 9, and 15 months after hospital discharge, 9 (16%) of 55 placebo recipients and 3 (5%) of 60 dexamethasone recipients had one or more neurological or audiological sequelae (p = 0.066); the relative risk of sequelae was 3.27 (95% CI 0.93-11.47). Our results and those of similarly designed studies lead us to believe that adjunctive dexamethasone therapy improves outcome from bacterial meningitis in infants and children. We recommend its use, preferably in the dose regimen used in this study.

Immune-mediated type A gastritis and glomerulonephritis

The first two cases reported in the literature of patients with immune-mediated type A gastritis with microcarcinoids (as part of a polyglandular syndrome type II in one) in combination with chronic glomerulonephritis are presented. Immune-mediated type A gastritis appears to be another immunologic disorder that can be associated with chronic glomerulonephritis.

Aortic and mitral valve disease in patients with end stage renal failure on long-term haemodialysis

OBJECTIVE

To identify valvar heart disease in patients with chronic uraemia by conventional and colour coded Doppler echocardiography.

DESIGN

Case series of an unselected group of 62 patients with end stage renal failure.

SETTING

Centre for haemodialysis in a referral hospital in Switzerland.

PATIENTS

62 patients on chronic haemodialysis.

MAIN OUTCOME MEASURES

Frequency of structural and functional valve abnormalities and their relation to clinical findings.

RESULTS

Structural changes were seen in 40 (64%) of 62 patients after 50 months (range 3-178 months) on haemodialysis. The mitral annulus and aortic cusps were thickened in 25 (40%) and in 34 (55%) patients respectively. Aortic stenosis was present in eight (mean (SD) age 60.5 (8.5) years), with a maximal instantaneous pressure gradient of 41 (14) mm Hg. Aortic regurgitation was seen in eight, mitral regurgitation in seven, and mitral stenosis in three patients. Patients with aortic stenosis had been on haemodialysis for significantly longer than the remaining patients (101 (43) v 46 (43) months, p = 0.01) and had significantly higher concentrations of serum alkaline phosphatase (176 (89) v 117 (47) IU/l, p less than 0.01) and of parathyroid hormone (54 (66) v 19 (29) ng/ml, p less than 0.02).

CONCLUSIONS

Patients on long-term haemodialysis had an increased frequency of haemodynamically relevant changes in the aortic and mitral valves. The degenerative valve disease may be related in part to the duration of haemodialysis and to alterations in calcium metabolism as indicated by increased plasma concentrations of alkaline phosphatase and parathyroid hormone.

Effect of prolonged bicarbonate administration on plasma potassium in terminal renal failure

In hemodialysis patients with hyperkalemia, i.v. sodium bicarbonate has recently been found to be ineffective in lowering plasma potassium within one hour. In the present study the effect of a prolonged bicarbonate infusion on plasma potassium was investigated. Twelve patients with terminal renal failure who were on hemodialysis were infused i.v. with 8.4% sodium bicarbonate (4 mmol/min) for one hour and with 1.4% (0.5 mmol/min) for five hours (total amount 390 mmol). Plasma bicarbonate rose from 17.5 at baseline to 28.4 and 29.6 mmol/liter, and blood pH from 7.32 to 7.46 and 7.48 at one and six hours, respectively. Plasma potassium did not change significantly after one and two hours (6.04 at baseline, 5.91 and 5.77 mmol/liter, respectively). Only at four and six hours did a moderate decline to 5.44 (P less than 0.05) and to 5.30 (P less than 0.01) occur, of which approximately half was calculated to be due to ECF volume expansion. However, no change or a very moderate decrease was observed in three patients even after six hours (+0.19, -0.32, -0.33 mmol/liter). Five patients with higher baseline plasma potassium (6.15 to 8.15 mmol/liter) behaved like seven with lower levels (5.25 to 5.87 mmol/liter). Tented T-waves in the ECG of seven patients disappeared after one hour only in one patient. Plasma aldosterone, norepinephrine and epinephrine were normal to elevated before and tended to fall during i.v. bicarbonate. Plasma dopamine and insulin were in the normal range.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracranial lipomas

Intracranial lipomas are very rare tumors, mostly being localized in the midline and often asymptomatic. We report on three children with intracranial lipomas (one with extension to the cervical spinal cord) diagnosed by CT and/or MR. All three had different symptoms and neurological signs. We summarize the case reports in the literature since the CT-era.

Influence of long-term amelioration of anemia and blood pressure control on left ventricular hypertrophy in hemodialyzed patients

The course of left ventricular hypertrophy was investigated in anemic hemodialysis patients treated with recombinant human erythropoietin (r-huEPO). 12 patients, aged 60.8 +/- 9.9 years (mean +/- SD) were treated for 18.8 +/- 2.7 months. Left ventricular size was estimated by echocardiography performed before treatment and at least 12 months after relieving anemia. Patients had signs of left ventricular and/or asymmetric septal hypertrophy when compared with a nonanemic and normotensive control group matched for sex and age. At baseline, hemoglobin (Hb) was 8.6 +/- 0.7 g/dl; interventricular septum thickness (IVST) was 1.75 +/- 0.34 cm, left ventricular posterior wall thickness (LVPWT) 1.32 +/- 0.19 cm, left ventricular muscle mass index (LVMI) 222.7 +/- 41 g/m2 and blood pressure (BP) 146.4 +/- 10/81.6 +/- 6 mm Hg. Hb rose to 11.4 +/- 1.2 g/dl (p less than 0.001); IVST and LVMI decreased to 1.42 +/- 0.35 cm (p less than 0.02) and 155.4 +/- 25.1 g/m2 (p less than 0.001); LVPWT and BP remained unchanged (1.30 +/- 0.26 cm and 146.8 +/- 16.9/81.2 +/- 7.8 mm Hg) at the end of the study. During the observation period, two groups of 5 and 7 patients differed from each other. The group of 5 patients had higher BP values (158.9 +/- 9.8/86.5 +/- 5.3 vs. 140.0 +/- 9.5/79.2 +/- 6.8 mm Hg, p less than 0.01), and the period with Hb values above 10 g/dl was shorter (14.5 +/- 2.4 vs. 17.8 +/- 2.4 months, p less than 0.05). These 5 patients failed to show a significant decrease in IVST and LVMI.(ABSTRACT TRUNCATED AT 250 WORDS)

[The treatment of anemia of hemodialysis patients using recombinant human erythropoietin: comparison between intravenous and subcutaneous administration]

Recombinant human erythropoietin (r-huEPO) is now an established therapy for anemia of hemodialysis patients. However, questions remain concerning the optimal maintenance dose as well as the route and frequency of administration. This prospective study was designed to determine whether subcutaneous r-huEPO at a reduced dosage was as effective as intravenous r-huEPO in maintaining constant hemoglobin levels. It involved 12 patients on hemodialysis, previously treated with intravenous r-huEPO for 11.8 +/- 7 months (mean +/- SD). For 3 months hemoglobin was kept at a stable level of 10-13 g/dl with individually titrated intravenous r-huEPO administered thrice weekly after each hemodialysis. Patients were then switched to subcutaneous r-huEPO. Initially, approximately 50% of the previous weekly dose was given as twice weekly subcutaneous injections. During the following 3 months the r-huEPO dosage was adapted to maintain the target hemoglobin level. 3 patients did not complete the second period due to acute intercurrent complications not related to therapy. 9/12 patients completed the study. The hemoglobin concentration was kept at a constant level of (mean +/- SD) 10.5 +/- 1.1, 10.6 +/- 0.9 and 11.1 +/- 0.6 g/dl with 233 +/- 110, 246 +/- 118 and 233 +/- 116 U/kg/week of intravenous r-huEPO for the first 3 months. In the second period hemoglobin was kept at 11.5 +/- 1.2, 11.3 +/- 1.4 and 11.1 +/- 0.9 g/dl with 119 +/- 61, 118 +/- 60 and 137 +/- 78 U/kg/week of subcutaneous r-huEPO. 2 patients required an increase in the r-huEPO dose during the third month of the second period.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of anemia in hemodialysis patients using recombinant human erythropoietin: advantages and disadvantages]

18 anemic patients undergoing maintenance hemodialysis were treated with recombinant human erythropoietin (EPO) 1-3 times per week for 10.7 +/- 3 months. 4 patients underwent renal transplantation whereas 14 patients could be followed up during 12 months of EPO treatment. Hemoglobin concentration rose (from 7.0 +/- 0.7 to 11.0 +/- 1.1 g/dl, p less than 0.001) with an EPO maintenance dose of 298 units/kg/week. Blood transfusions were totally eliminated. 12 patients without iron overload required iron supplements. In the course of an infectious episode and notwithstanding an increase in EPO dosage, 2 patients exhibited a fall in hemoglobin which rose again after successful treatment of the infection. The few complications observed in connection with the rise in hemoglobin were: 1. deterioration of arterial hypertension in 7/18 with hypertensive encephalopathy in 3 patients, 2. thrombotic occlusion of the vascular hemodialysis access (a-v fistula) in 3/18, 3. periarticular inflammation with calcified deposits due to an elevated calcium-phosphorus product of 6.8 mmol/l in 4/18, 4. occurrence of hyperkalemia (6.9 +/- 0.3 mmol/l) in 7/18. These complications were more frequent during the first 3 months. They were corrected with close monitoring, drug therapy for hypertension, and intensification of dialysis and of treatment with phosphate binding substances, with the result that no differences were found in 14 patients before and after 12 months of treatment with EPO (blood pressure 133 +/- 25/77 +/- 9 vs 139 +/- 26/79 +/- 13 mm Hg [ns], potassium 5.4 +/- 0.4 vs 5.6 +/- 1.0 mmol/l [ns] and calcium-phosphorus product 4.3 +/- 1.0 vs 4.6 +/- 1.3 [ns]).(ABSTRACT TRUNCATED AT 250 WORDS)

Human recombinant erythropoietin treatment in transfusion dependent anemic patients on maintenance hemodialysis

Six anemic hemodialysis patients dependent on regular blood transfusions and with massive iron overload were treated with recombinant human erythropoietin (r-huEPO). The effect on absolute reticulocyte count, hemoglobin and serum ferritin was studied during a twenty-week period. Red-cell volume and red-cell life span were measured with 51Cr-tagged erythrocytes at baseline and after twenty weeks of r-huEPO. Absolute reticulocyte counts and hemoglobin concentration rose markedly (from 55.6 +/- 31.2 to a maximum of 174.9 +/- 31.0 x 10(9)/l at 4 weeks and from 6.8 +/- 0.3 to a maximum of 11.2 +/- 1.3 g/dl at 12 weeks, respectively, p less than 0.001) without any further need for transfusions. Red-cell volumes increased concomitantly (from 58 +/- 4 to 81 +/- 11% of normal, p less than 0.005), in spite of a persistent shortening of red-cell life span (45 +/- 18 and 47 +/- 4 days before and after r-huEPO). Markedly elevated serum ferritin concentrations indicating iron overload decreased slowly from 3,550 +/- 1,615 to 2,721 +/- 1,506 micrograms/l (p less than 0.05). It is concluded that r-huEPO is very effective in treating the anemia of patients maintained on hemodialysis. The favorable effects on hemoglobin and red-cell volumes occur in spite of persistent hemolysis and lead to a slow reduction of iron overload.

[Pathogenesis of anemia due to kidney disease]

Several factors contribute to the pathogenesis of anemia due to renal failure. Hypoproliferation of red cell progenitors may be caused partially by an inhibitory effect of some 'uremic toxins' whose existence certainly is very controversial. Iron deficiency due to gastrointestinal and dialysis-related blood losses and occasionally aluminum intoxication may interfere with the maturation of the erythron. Moderate hemolysis with shortening of red cell survival to some 50% of normal may be an additional factor. The main cause of anemia is, however, inadequate production of erythropoietin by the diseased kidney. This latter factor has now become amenable to treatment.

Effectiveness of single versus double volume exchange transfusion in newborn infants with AB0 hemolytic disease

The effectiveness of early single volume exchange transfusion (ET; 80 ml/kg) was compared with that of early double volume exchange transfusion (160 ml/kg) for treatment of hemolytic disease of the newborn caused by AB0 incompatibility. Twenty full-term infants with AB0 hemolytic disease were randomized into the two treatment groups. The groups were comparable for gestational age, body weight, hemoglobin values, reticulocyte count, maximum serum bilirubin levels, rate of rise of serum bilirubin before ET, antibody titer, and age at time of ET (all p greater than 0.05). The efficacy of treatment was similar in both groups taking into account the mean bilirubin level after ET, post-ET bilirubin, duration of phototherapy following ET, and frequency of second ET (all p greater than 0.05). However, platelet count immediately after ET was lower in the double volume ET group as compared to the single volume ET group (p less than 0.01). Hemoglobin values immediately after ET were higher in the double volume ET group (p less than 0.01). At ten days of life no differences were detectable. The results of this study indicate that the effectiveness of single volume ET for treatment of full-term infants with jaundice due to AB0 incompatibility is at least comparable to that of double exchange ET. Furthermore, the lesser aggressive approach determines less complications such as a decrease of platelet count.

[Cerebrovascular incidents in 4 hemodialysis patients treated with erythropoietin]

Human recombinant erythropoietin (r-huEPO) is very effective in the treatment of anemia of hemodialyzed patients. We describe 4 patients who developed symptoms of central nervous dysfunction during r-huEPO therapy. Three exhibited typical hypertensive encephalopathy, whereas signs of cerebral ischemia were found in the fourth. The increase in blood viscosity with r-huEPO treatment, leading to a rise in peripheral vascular resistance and blood pressure especially in previously hypertensive patients, may be of importance in the pathogenesis of these cerebrovascular incidents; preexistent arteriosclerosis is an possible additional risk factor.

Effect of various therapeutic approaches on plasma potassium and major regulating factors in terminal renal failure

PURPOSE

The development of life-threatening hyperkalemia poses a risk for patients with chronic preterminal renal failure. Various therapeutic options have been suggested for hyperkalemic emergencies in these patients; to date, however, no study has evaluated the relative efficacies of these measures in the presence of renal failure. Our goal was to examine the acute effects of a variety of therapeutic approaches, as well as those of hemodialysis, on plasma potassium levels in a hemodialysis population.

PATIENTS AND METHODS

Ten patients with terminal renal failure undergoing maintenance hemodialysis were enrolled in the study. Blood gas parameters and plasma sodium, potassium, glucose, osmolality, renin, aldosterone, epinephrine, norepinephrine, dopamine, and insulin were measured before, during, and after 60-minute infusions of bicarbonate, epinephrine, and insulin in glucose, and before, during, and after performance of regular hemodialysis for one hour.

RESULTS

Hypertonic as well as isotonic intravenous bicarbonate (2 to 4 mmol/minute) induced a marked rise in plasma bicarbonate and pH, but failed to lower the plasma potassium level (5.66 versus 5.83 mmol/liter before and after). Epinephrine, 0.05 microgram/kg/minute administered intravenously, decreased plasma potassium only slightly from 5.57 to 5.25 mmol/liter, and five patients showed no decline. On the other hand, insulin in glucose, 5 mU/kg/minute intravenously, effectively lowered plasma potassium levels from 5.62 to 4.70 mmol/liter, and hemodialysis induced the most rapid decline from 5.63 to 4.29 mmol/liter. Plasma aldosterone was elevated before treatment; it correlated with plasma potassium and dropped during intravenous bicarbonate administration or hemodialysis. Pretreatment plasma renin activity, insulin, epinephrine, norepinephrine, and dopamine levels were generally normal.

CONCLUSION

We conclude that in patients with terminal renal failure undergoing maintenance hemodialysis, intravenous bicarbonate is ineffective in lowering plasma potassium rapidly, and epinephrine is effective in only half the patients, whereas insulin in glucose is a fast and reliable form of therapy for hyperkalemic emergencies. Plasma aldosterone levels are appropriate in relationship to plasma potassium levels, and levels of other potassium-influencing hormones are generally normal.

Lethal osteogenesis imperfecta: abnormal collagen metabolism and biochemical characteristics of hypophosphatasia

We have examined collagen from a patient with the rare type IIC form of perinatally lethal osteogenesis imperfecta, in whom biochemical characteristics of hypophosphatasia were also apparent. In addition to normal alpha 1(I) and alpha 2(I) chains, there were chains overmodified along their lengths. Unexpectedly, the thermal stability of molecules containing these chains was normal. This suggests the existence of a structural mutation causing delayed triple helix formation, situated in either the alpha 1(I) or alpha 2(I) C-terminal propeptide. Since collagen synthesised by fibroblasts from each of the patient's parents was normal, the mutation was probably newly arising and dominant. In contrast to other reported cases of lethal osteogenesis imperfecta, not only was the secretion of collagen by cultured fibroblasts considerably retarded, but that of non-collagenous proteins was also severely impaired.

Long-term treatment of central precocious puberty with an intranasal LHRH analogue: control of pituitary function by urinary gonadotropins

Daily subcutaneous doses of luteinizing hormone-releasing hormone (LHRH) analogues are a well-established therapy for gonadotropin-dependent precocious puberty. Reports on intranasally administered analogues, however, are controversial. We studied the effect of intranasal D-Ser(TBU)6-LHRH(BUS) on growth rate, skeletal maturation, and urinary gonadotropins in five girls and one boy with central precocious puberty (CPP) who had been treated for 1.4-2.3 years (mean 1.9). Because of the potential antifertility effects of LHRH analogues, testicular histology was analysed in the boy. In the five children with accelerated growth, the bone age-related velocity of height gain decreased from 10.58 +/- 2.77 to 5.82 +/- 1.8 cm/year (means +/- SD, P less than 0.01), and the ratio of change in bone age to change in chronological age fell below 1. Basal luteinizing hormone (LH), and LHRH-stimulated LH and follicle stimulating-hormone, at pubertal levels before treatment, decreased significantly in all children, normalizing in four (P less than 0.04). During therapy, pituitary function was best controlled by urinary LH, which correlated with clinical data. After 13 months of therapy, testicular histology showed degenerated Sertoli cells, and absence of B- and Ap-spermatogonia and of primary spermatocytes in the boy. We conclude that: (1) Efficient long-term suppression of central precocious puberty--including accelerated growth and skeletal maturation--can be maintained by intranasal dosage of BUS. (2) Urinary LH reflects pituitary function and proves to be a reliable guide to adjustment of the LHRH-analogue dose regimen.(ABSTRACT TRUNCATED AT 250 WORDS)

Human recombinant erythropoietin in anaemic patients on maintenance haemodialysis. Secondary effects of the increase of haemoglobin

Twelve anaemic patients on haemodialysis were treated with recombinant human erythropoietin, starting with 72 IU/kg/week. The dose was doubled after 2 weeks until an increase of 2 g/dl of haemoglobin was observed. The effects on various parameters were studied during a 3-month period. Haemoglobin increased from 6.70 +/- 0.74 to 10.49 +/- 1.04 g/dl (mean +/- SD, P less than 0.001), potassium from 5.51 +/- 0.50 to 6.06 +/- 0.65 mmol/l (P less than 0.005), phosphate from 1.78 +/- 0.40 to 2.17 +/- 0.40 mmol/l (P less than 0.001) and the calcium phosphorus product from 4.3 to 5.2 (P less than 0.001). Three patients developed marked periarticular inflammation due to calcified deposits with a high calcium-phosphorus product of 6.8. An increase in arterial blood pressure was observed in three previously well-controlled hypertensive patients, one of whom developed hypertensive encephalopathy. We conclude that recombinant human erythropoietin is very effective in treating the anaemia of end-stage renal failure on haemodialysis. Regular estimations of serum potassium and phosphate are mandatory. In hypertensive individuals a further increase in blood pressure is possible.

[Diagnosis of glomerular and non-glomerular erythrocyturia using phase contrast microscopy of the urine sediment]

Recently the appearance of deformed polymorphous erythrocytes in the urinary sediment has been described as characteristic of glomerular bleeding. We studied 30 patients with histologically confirmed glomerular disorders and 25 patients with urological diseases and with hematuria. In the sediment of 10 ml urine 200 erythrocytes were counted under phase-contrast microscopy and evaluated relative to their morphology. The number of glomerular erythrocytes was expressed as a percentage. In all groups of glomerular disorders (mesangial-proliferative, membranous and membrano-proliferative glomerulonephritis, focal segmental glomerulosclerosis, glomerulonephritis of systemic disease, thinning of the glomerular basement membrane) the percentage of glomerular erythrocytes varied widely between 2 and 100%. In 7 cases less than 10% of glomerular erythrocytes were found. There was no correlation between the percentage of glomerular erythrocytes and the degree of renal insufficiency, hematuria or proteinuria. On the other hand, in patients with hematuria from the lower urinary tract, erythrocytes were uniformly non-glomerular in shape (95-100%). We conclude that 10-20% or more of glomerular erythrocytes in the urinary sediment are a good indicator of glomerular disease, whereas lower figures do not definitely rule out a glomerular origin for hematuria.

Behavior of beta 2-microglobulin in patients with chronic renal failure undergoing hemodialysis, hemodiafiltration and continuous ambulatory peritoneal dialysis (CAPD)

beta 2-microglobulin (beta 2-m) is the major component of a new form of amyloid deposit found in carpal tunnel syndrome and dialysis arthropathy of long-term hemodialysis patients. In 52 patients on maintenance hemodialysis, serum beta 2-m concentration was elevated to 37.9 +/- 1.4 (normal 1.2 +/- 0.6) mg/l. It was correlated with the time on hemodialysis (r = 0.43, p less than 0.01) and was inversely correlated with residual renal function (r = 0.87, p less than 0.001). In 20 patients on CAPD, beta 2-m likewise was increased to 31.6 +/- 2.3 mg/l; daily elimination by dialysate was only 34 mg (normal 150 mg). Hemodialysis with a cuprophane membrane caused a rise in serum beta 2-m, whereas hemodiafiltration with a polysulfone membrane performed in 5 patients over 2 1/2 months was accompanied by a decrease in serum beta 2-m from 39.5 +/- 0.7 to 29.7 +/- 1.0 mg/l predialysis (19.1 +/- 1.1 postdialysis). On the other hand, beta 2-m elimination reached only approximately 100 mg per day in spite of markedly elevated serum levels. It is concluded that serum beta 2-m is massively elevated in long-term hemodialysis and CAPD patients; contrary to routine hemodialysis with cuprophane membranes, newer more permeable membranes will permit some elimination of beta 2-m. However, based on quantitative considerations it seems difficult to obtain beta 2-m concentrations in the high normal or moderately elevated range with present day techniques.

[Glomerulonephritis in chronic bacterial infections]

Five patients with chronic bacterial infections (two with osteomyelitis, two with infected vascular prostheses, one with soft tissue abscess), but without endocarditis, developed signs of glomerulonephritis and renal failure. Histological examination in three revealed mainly proliferative glomerular alterations. The outcome of glomerulonephritis paralleled the course of infection. Recovery or marked improvement occurred in three patients in whom the infection was cured, one case with smoldering infection eventually developed endstage renal failure, and one with persistent infection died from severe complications with acute renal failure. If renal failure occurs in the setting of suppurative infection, so-called infection-associated glomerulonephritis must be considered. Prompt and effective eradication of infection has an important bearing on the course of renal function.

[Early recognition of and treatment possibilities in diabetic nephropathies]

Diabetic nephropathy due to glomerulosclerosis develops in 40% of patients with type I diabetes (in type II the incidence is only around 5%). Two mechanisms are of pathogenetic importance: hemodynamic changes with glomerular hyperfiltration leading to glomerulosclerosis and proteinuria, and biochemical alterations of the glomerular basement membrane consisting of an increase and glycosylation of collagen IV as well as a decrease in negatively charged proteoglycans and sialic acid. Diabetic nephropathy runs through several stages, the first being characterized by hyperfunction and hypertrophy. The appearance of microalbuminuria after 10-15 years of diabetes seems to be a good indicator of the later development of clinically overt nephropathy with large urinary protein losses and decreasing renal function. Successful treatment of hypertension may slow the decrease of renal function. For those patients who have reached terminal renal failure, the treatment modalities of hemodialysis, continuous ambulatory peritoneal dialysis (CAPD) and renal transplantation offer a reasonable chance of prolonging life, although the results are generally less good than in non-diabetic renal patients of the same age group. However, the ultimate goal of therapy must remain the successful prevention of the devastating late sequelae of diabetes, including diabetic nephropathy.

[Hemoglobin A1c in patients under periodic hemodialysis or continuous ambulatory peritoneal dialysis]

In 44 dialyzed patients (27 nondiabetic hemodialysis, 10 CAPD patients and 7 diabetics) hemoglobin A1c (HbA1c) concentrations were measured comparatively by column chromatography (using Bio-Rad columns) and the thiobarbituric acid (TBA) method. With column chromatography the values were significantly higher in each patient group than in healthy controls. In the diabetics, who on average showed elevated blood glucose levels, HbA1c concentrations were higher than in the other dialysis patients, although there was some overlap. On the other hand, concentrations measured in non-diabetic patients with the TBA method were only marginally higher than in controls. It is well known that column chromatography measures carbamylated hemoglobin with HbA1c, and for this reason false high concentrations are found in renal failure. The TBA method is precise and specific in this situation but unfortunately is too time-consuming for routine determinations. The simple column chromatographic method is of only limited value in the control of diabetics with renal failure; nevertheless, unequivocally elevated concentrations of greater than or equal to 7% HbA1c are a good indicator of unsatisfactory metabolic control.

[Acute rhabdomyolysis following administration of succinylcholine]

Acute rhabdomyolysis without hyperthermia, after anesthesia including succinylcholine, is described in a father and son. Rhabdomyolysis-associated acute renal failure was mild in the son but severe in the father. Known enzymatic muscular defects were excluded as cause. The clinical picture of anesthesia-associated rhabdomyolysis is discussed on the basis of these two cases and a review of the literature.

Oxygen affinity of erythrocytes and pulmonary gas exchange in patients on continuous ambulatory peritoneal dialysis

In 11 patients on continuous ambulatory peritoneal dialysis 2,3-diphosphoglycerate, oxygen (O2) affinity of red cells (P50), blood gases, ventilation, and O2 consumption were studied. Contrary to patients on maintenance hemodialysis, 2,3-diphosphoglycerate and P50 were normal in patients on continuous ambulatory peritoneal dialysis; they were correlated with each other. Arterial O2 pressure was normal; under the conditions of dialysis with 35 mmol lactate per liter dialysis fluid a slight metabolic acidosis persisted; it was combined with a moderate respiratory alkalosis. Position had no influence upon pulmonary gas exchange with the exception of the alveolo-arterial gradient which was elevated when the abdominal cavity was filled with dialysis fluid and the patients assumed the supine position. Ventilation was in the normal range, whereas O2 consumption was low, possibly due to a reduction in muscle mass in some of the patients. It is concluded that pulmonary gas exchange and erythrocyte O2 transport were normal and that O2 requirements tended to be low in this group of patients on continuous ambulatory peritoneal dialysis.