Understanding the reasons for provincial discordance in cancer drug funding-a survey of policymakers

Background

Cancer drug-funding decisions between provinces shows discordance. The pan-Canadian Oncology Drug Review (pcodr) was implemented in 2011 partly to address uneven drug coverage and lack of transparency in the various provincial cancer drug review processes in Canada. We evaluated the underlying reasons for ongoing provincial discordance since the implementation of pcodr.

Methods

Participation in an online survey was solicited from participating provincial ministries of health (mohs) and cancer agencies (cas). The 4-question survey (with both multiple-choice and free-text responses) was administered between 4 March 2015 and 1 April 2015, inclusive. Anonymity was ensured. Descriptive statistics were used to evaluate responses.

Results

Data were available from 9 provinces (all Canadian provinces except Quebec), with a response rate of 100%. The 12 responses received each came from a senior policymaker with more than 5 years' experience in cancer drug funding decision-making (5 from mohs, 7 from cas). Responses for 3 provinces came from both a moh representative and a ca representative. The most common reason for funding a drug not recommended by pcodr was political pressure (64%). The most common reason not to fund a drug recommended by pcodr was budget constraints (91%). The most common reason for a province to fund a drug before completion of the pcodr review was also political pressure (57%).

Conclusions

Political pressure and budgetary constraints continue to affect equity of access to cancer drugs for patients throughout Canada.

Salt-losing nephropathy in mice with a null mutation of the Clcnk2 gene

AIM

The basolateral chloride channel ClC-Kb facilitates Cl reabsorption in the distal nephron of the human kidney. Functional mutations in CLCNKB are associated with Bartter's syndrome type 3, a hereditary salt-losing nephropathy. To address the function of ClC-K2 in vivo, we generated ClC-K2-deficient mice.

METHODS

ClC-K2-deficient mice were generated using TALEN technology.

RESULTS

ClC-K2-deficient mice were viable and born in a Mendelian ratio. ClC-K2-/- mice showed no gross anatomical abnormalities, but they were growth retarded. The 24-h urine volume was increased in ClC-K2-/- mice (4.4 ± 0.6 compared with 0.9 ± 0.2 mL per 24 h in wild-type littermates; P = 0.001). Accordingly, ambient urine osmolarity was markedly reduced (590 ± 39 vs. 2216 ± 132 mosmol L^-1 in wild types; P < 0.0001). During water restriction (24 h), urinary osmolarity increased to 1633 ± 153 and 3769 ± 129 mosmol L^-1 in ClC-K2-/- and wild-type mice (n = 12; P < 0.0001), accompanied by a loss of body weight of 12 ± 0.4 and 8 ± 0.2% respectively (P < 0.0001). ClC-K2-/- mice showed an increased renal sodium excretion and compromised salt conservation during a salt-restricted diet. The salt-losing phenotype of ClC-K2-/- mice was associated with a reduced plasma volume, hypotension, a slightly reduced glomerular filtration rate, an increased renal prostaglandin E2 generation and a massively stimulated renin-angiotensin system. Clckb-/- mice showed a reduced sensitivity to furosemide and were completely resistant to thiazides.

CONCLUSION

Loss of ClC-K2 compromises TAL function and abolishes salt reabsorption in the distal convoluted tubule. Our data suggest that ClC-K2 is crucial for renal salt reabsorption and concentrating ability. ClC-K2-deficient mice in most aspects mimic patients with Bartter's syndrome type 3.

Management of hypothermia for perinatal asphyxia in Austria - a survey of current practice standards

BACKGROUND

Therapeutic hypothermia (HT) has been shown to reduce the risk of death or disability and increase the rate of survival free of -disability at 18-24 months of age in hypoxic-ischemic encephalopathy (HIE).

OBJECTIVES

The aim of this study was to take a national survey which (a) evaluated the practice of therapeutic HT for perinatal asphyxia in Austria, (b) evaluated the current clinical management of neonatal HIE and (c) evaluated the need for a national perinatal asphyxia and HT registry.

METHODS

In January 2013, a questionnaire was sent out to the clinical heads of all neonatal level-II and level-III units in Austria.

RESULTS

We received replies from all 30 level II and level III units in Austria (response rate 100%). 19 units (63%) answered that they applied HT, 11 units (37%) said they transferred patients for cooling to other units, 3 of those 11 units (27%) said they applied cooling during transport. 25 units (83%) felt the necessity to establish a national registry.

CONCLUSION

The results of this survey show that there is already a high implementation of therapeutic HT in Austria, but there remains a need for information, awareness and training. Problem areas tend to be in the transport of asphyxiated neonates, brain monitoring during cooling and follow-up of affected patients. We believe, that the establishment of national guidelines and a national register could increase awareness for the importance of therapeutic HT in neonatal HIE, thus improve the Austrian management of those infants.

Type of delivery onset has a significant impact on post-natal mortality in preterm infants of less than 30 weeks' gestation

AIM

Type of delivery onset is not currently evaluated for its predictive impact. This study explored whether the type of preterm delivery onset was an antenatal predictor for post-natal mortality in preterm infants <30 weeks' gestation and should be included in antenatal counselling.

METHODS

This retrospective cohort study included 1117 preterm infants <30 weeks' gestation born between 1999 and 2008 in a tertiary perinatal referral centre. Study patients were classified into spontaneous or iatrogenic preterm deliveries. Spontaneous deliveries included deliveries after preterm premature rupture of membranes (PPROM) and preterm labour. The study outcome was infant mortality before discharge from hospital.

RESULTS

We included 499 patients born after PPROM (44.7%) and 247 born after preterm labour (22.1%). Iatrogenic preterm birth was noted in 282 patients (25.2%) and 89 patients fulfilled both criteria for spontaneous and iatrogenic preterm delivery (8.0%). Babies born after iatrogenic preterm delivery in gestational weeks 25-29 had significantly higher mortality rates. Logistic regression revealed that type of preterm delivery onset was an independent antenatal predictor for post-natal mortality.

CONCLUSION

Type of preterm delivery onset had a significant impact on post-natal mortality in preterm infants <30 weeks' gestation, with a higher mortality rate after iatrogenic preterm delivery.

An assessment of the perceived benefits and challenges of participating in a practice-based research network

BACKGROUND

A survey was conducted to describe the benefits of and challenges to practitioner participation in the Practitioners Engaged in Applied Research and Learning (PEARL) Network, a dental practice-based research network (PBRN). The results were compared with results from medical PBRNs across different tiers of participation (based on practitioner-investigators previous involvement with PEARL research protocols).

METHODS

A 39-item web-based survey addressed the benefits of PBRN participation on three levels: individual/practitioner, practice (office), and community/professional. Participants were also asked to rate challenges to participation.

RESULTS

A total of 153 of 216 PEARL practitioner-investigators participated, a response rate of 71%. The majority (70%) was male, with a median of 23 years in private practice. 'Means to stay informed of new developments in my profession' was considered a 'very important' benefit for nearly three-quarters of the sample (71%). 'Opportunity to improve clinical procedures' was considered as 'very important' by 73% of respondents. In terms of benefits related to the community and profession, 65% of respondents reported 'means to directly contribute to the evidence base of dental practice' as being 'very important'. 'Disruption in practice routine/clinical practice' was considered the most important challenge to participation.

CONCLUSIONS

The benefits of and challenges to participation identified did not differ across tiers of participation and were similar to benefits identified by participants in medical PBRNs. The results of this study will help facilitate the design of future PBRN protocols to encourage greater participation by the profession. Results suggest that practitioners with similar interests could be recruited to collaborative studies between medicine and dentistry.

Diamondlike Carbon Materials as Low-k Dielectrics for Multilevel Interconnects in Ulsi

A variety of diamondlike carbon (DLC) materials were investigated for their potential applications as low-k dielectrics for the back end of the line (BEOL) interconnect structures in ULSI circuits. Hydrogenated DLC and fluorine containing DLC (FDLC) were studied as a low-k interlevel and intralevel dielectrics (ILD), while silicon containing DLC (SiDLC) was studied as a potential low-k etch stop material between adjacent DLC based ILD layers, which can be patterned by oxygen-based plasma etching

It was found that the dielectric constant (k) of the DLC films can be varied between >3.3 and 2.7 by changing the deposition conditions. The thermal stability of these DLC films was found to be correlated to the values of the dielectric constant, decreasing with decreasing k. While DLC films having dielectric constants k>3.3 appeared to be stable to anneals of 4 hours at 400 °C in He, a film having a dielectric constant of 2.7 was not, losing more than half of its thickness upon exposure to the same anneal. The stresses in the DLC films were found to decrease with decreasing dielectric constant, from 700 MPa to about 250 MPa. FDLC films characterized by a dielectric constant of about 2.8 were found to have similar thermal stability as DLC films with k >3.3. The thermally stable FDLC films have internal stresses <300 MPa and are thus promising candidates as a low-k ILD.

For the range of Si contents examined (0-9% C replacement by Si), SiDLC films with a Si content of around 5% appear to provide an effective etch-stop for oxygen RIE of DLC or FDLC films, while retaining desirable electrical characteristics. These films showed a steady state DLC/SiDLC etch rate ratio of about 17, and a dielectric constant only about 30% higher than the 3.3 of DLC.

Integration Issues for Diamond Like Carbon in a Copper Damascene Process Flow

Hydrogenated “diamondlike” carbon (DLC) is a potential candidate as a low k material for the back end interconnect (BEOL) dielectric for VLSI chips. The DLC material is an attractive dielectric due to its isotropic properties and the ability to deposit the films by CVD techniques, such as PECVD or HDP systems. Under suitable preparation conditions such materials can reach dielectric constant values below 2.8, even as low as 2.4. While the as-deposited films are not stable to exposure to subsequent processing temperatures of about 400 C, it appears that they can be stabilized, in terms of dimensional stability and material loss, by an initial anneal.

The integration of DLC films in the BEOL structure further requires good adhesion with the materials in contact with the DLC dielectric, such as silicon nitride or silicon oxide, and liner metallurgy. As the potential application of the DLC films will be in Cu based damascene structures the behavior of the films under CMP conditions is also important.

The talk will discuss the evaluation of DLC films and of integration issues such as adhesion under processing conditions, patterning, CMP behavior. Blanket and patterned structures built with DLC films will be presented.

Low Dielectric Constant Sicoh Films As Potential Candidates for Interconnect Dielectrics

The quest to improve the high performance in ULSI circuits, is driving the search for new materials with low dielectric constants (k=2.5–3.0) for the back end of the line (BEOL) interconnect structures. Novel SiCOH films comprising Si, C, O and H, have been deposited by a PECVD deposition technique. The films have been characterized as-deposited and after anneals of up to 8 hours at 400°C. The atomic composition of the films has been determined by RBS and FRES analysis and their optical properties have been determined by FTIR and index of refraction measurements. The mechanical properties have been determined by measurements of stress and of crack development velocity in water. Metal insulator silicon structures have been used to test the electrical properties of the SiCOH films. After an initial stabilization anneal, the SiCOH films are thermally stable up to 400°C have low tensile stresses (<50 MPa), an extremely low crack propagation velocity, and a hydrophobic behavior. According to the deposition conditions the films have dielectric constants in the range of 2.8 to 3.5. These film properties, combined with an easy-to-integrate deposition process indicate that the material has a strong potential as an interconnect dielectric.

100-GHz transistors from wafer-scale epitaxial graphene

The high carrier mobility of graphene has been exploited in field-effect transistors that operate at high frequencies. Transistors were fabricated on epitaxial graphene synthesized on the silicon face of a silicon carbide wafer, achieving a cutoff frequency of 100 gigahertz for a gate length of 240 nanometers. The high-frequency performance of these epitaxial graphene transistors exceeds that of state-of-the-art silicon transistors of the same gate length.

Life Expectancy of Women with Lupus Nephritis Now Approaches That of the General Population

Immunosuppressive treatment has changed the prognosis of Lupus nephritis over time, but improvement in prognosis is difficult to analyze in different historical periods, and should be better demonstrated in comparison with life expectancy of sex-and age-matched people. Long-term patient and renal survival of 90 patients diagnosed with Lupus nephritis at our center from 1968 to 2001 with a follow-up time of 14±8 years was retrospectively evaluated. Patient and kidney survival significantly increased over time. Multivariate analyses show that risks of patient and renal death decreased by 8% at each year of follow-up, and increased by more than 5 time in patients aged > 30 years at diagnosis. As only 14 patients were men, relative survival as compared to that of the sex- and age-matched general population of the Piedmont Region was calculated for the 76 women. Improvement in the survival of the cohort of women was seen at any time of follow-up: in particular, it was sharply lower in the first period (relative survival at 5,10 and 15 years = 0.784, 0.665, and 0.620, respectively) and increased in the second (relative survival at 5,10 and 15 years = 0.939, 0.921, and 0.850, respectively) nearly approaching that expected for the general population, i.e. 0.993, 0.983 and 0.967, respectively. Taken together, our data allow us to draw the conclusion that life expectancy in women with Lupus nephritis has improved over time, paralleling an improved awareness of the disease and a significant increase in steroid pulse therapy as induction/remission phase. Improvement in survival is for the first time demonstrated to cover the gap with life expectancy of the general population for women with Lupus nephritis.

Genetic differentiation and natural hybridization between the Sardinian endemic Maniola nurag and the European Maniola jurtina

The Mediterranean island of Sardinia is known for its multitude of unique genetic lineages. We view one of them in a larger phylogeographic context. The endemic Sardinian Meadow Brown butterfly, Maniola nurag, is restricted to the mountainous areas of the island, whereas its widespread close relative, Maniola jurtina, also occurs on the coast. At intermediate altitudes the species' distributions overlap. There, a number of individuals exhibit phenotypic characteristics intermediate between the two species. We examined patterns of intra- and interpopulation variation in 10 M. nurag populations from Sardinia and 16 M. jurtina populations from Sardinia and continental Europe, as well as 17 intermediate individuals, sampled in 1999-2002, by means of allozyme markers, combining it with a morphometric analysis based on 18 wing-characters of 52 males. At the 15 loci studied (aldolase, aat-1, aat-2, g6pdh, gpd, idh-1, idh-2, mdh-1, mdh-2, mpi, me, leu-ala, pgi, pgm, and 6pgdh), 76 different alleles were detected, 63 of which were shared by M. nurag and M. jurtina. None of the loci was found to be alternatively fixed between the two species. In that respect, this study testifies to the difficulties that may arise when trying to identify hybrids from genotypic data. Levels of genetic variation in island populations (M. jurtina: H(O) = 0.137-0.189; M. nurag: H(O) = 0.141-0.270) were comparable to those of mainland M. jurtina (H(O) = 0.141-0.236). A Bayesian admixture analysis supported the hypothesis of mixed (hybrid) ancestry of individuals occurring at intermediate altitudes. Similarly, neighbour-joining and unweighted pair-group method with arithmetic averaging (UPGMA) analyses, as well as morphometrics hinted at the existence of a Maniola-hybrid zone in Sardinia at intermediate altitudes. We discuss the results in the light of the phylogeography of other Sardinian taxa with the aim to reach a general understanding of the biogeographic history of this island's endemic species.

Extrahepatic immunological manifestations of hepatitis C virus in dialysis patients

BACKGROUND

Hepatitis C virus (HCV) infection may be associated with various extrahepatic immunological disorders. Uremic patients on chronic regular dialytic treatment (RDT) frequently develop immunological abnormalities. The aim of this study was to evaluate the probability that HCV infection creates an increased risk for extrahepatic immunological abnormalities in chronic RDT patients.

SUBJECTS AND METHODS

In a series of one hundred sixteen chronic RDT patients, HCV status was determined by anti-HCV antibodies, polymerase chain reaction (PCR) RNA and viral genotyping. After excluding four anti-HCV negative/PCRRNA positive patients, a comparison was made between 51 anti-HCV negative/PCR-RNA negative and 61 anti-HCV positive patients, this latter group including seventeen PCR-RNA negative, fifteen genotype 1, thirteen genotype 2, three genotype 3, four genotype 4, four undeterminable genotype and five mixed genotypes. The following investigations were performed: cryoglobulinemia (presence, titer and, when possible, identification), monoclonal gammopathy, antineutrophil cytoplasm antibodies, antidouble stranded DNA antibodies, circulating immunocomplexes and immunoglobulin levels.

RESULTS

Cryoglobulinemia was found in 77% of anti-HCV positive versus 29% of anti-HCV negative patients, and cryocrit > 1% in 50% versus 9.8% respectively, p=<0.01. Also cryoglobulin concentration was higher (logarithmic transformation: 4.38 +/- 0.94 vs 3.11 +/- 1.06, p =< 0.001) in anti-HCV positive versus negative patients. Multivariate logistic regression analysis showed a significantly increased odds ratio (12.0, confidence interval 3.0 to 48.3) for having high levels of cryoglobulins (cryocrit >1%) after adjusting for age and dialytic age. The prevalence of this abnormality did not differ significantly among patients infected with different genotypes, but a tendency towards a lower frequency was observed in the anti-HCV positive/PCR negative subgroup. Cryoglobulins were identified as type I (2 anti-HCV positive case), type II (2 anti-HCV positive and 1 anti-HCV negative case) and type 3 (1 anti-HCV negative case). The frequency of monoclonal gammopathy was not significantly different between anti-HCV positive and anti-HCV negative patients (6.5% versus 2%) as well as that of the other parameters evaluated except for IgG concentration which was higher in the anti-HCV positive group (1,685 +/-605 versus 1349 +/- 352 mg/dl, p 0.006). Five events, potentially linked to HCV infection, occurred in our anti-HCV positive patients: 2 cases of porphyria cutanea, 1 case of unexplained peripheral neuropathy, 1 cutaneous leukocytoclastic vasculitis, 1 death for non-Hodgkin's lymphoma. In one anti-HCV positive patient treated with interferon-alpha, the presence of cryoglobulins, monoclonal gammopathy and high IgG levels strictly paralleled that of viremia, disappearing during the recovery phase under treatment and reappearing shortly after stopping treatment.

CONCLUSIONS

HCV infection provides a significantly increased risk for developing extrahepatic immunological abnormalities also in chronic RDT patients. It is possible that the clinical relevance of this event might be scant because of the low level of these abnormalities, but an awareness of its possibility should to be taken into account.

Mechanisms regulating target gene selection by the homeodomain-containing protein Fushi tarazu

Homeodomain proteins are DNA-binding transcription factors that control major developmental patterning events. Although DNA binding is mediated by the homeodomain, interactions with other transcription factors play an unusually important role in the selection and regulation of target genes. A major question in the field is whether these cofactor interactions select target genes by modulating DNA binding site specificity (selective binding model), transcriptional activity (activity regulation model) or both. A related issue is whether the number of target genes bound and regulated is a small or large percentage of genes in the genome. In this study, we have addressed these issues using a chimeric protein that contains the strong activation domain of the viral VP16 protein fused to the Drosophila homeodomain-containing protein Fushi tarazu (Ftz). We find that genes previously thought not to be direct targets of Ftz remain unaffected by FtzVP16. Addition of the VP16 activation domain to Ftz does, however, allow it to regulate previously identified target genes at times and in regions that Ftz alone cannot. It also changes Ftz into an activator of two genes that it normally represses. Taken together, the results suggest that Ftz binds and regulates a relatively limited number of target genes, and that cofactors affect target gene specificity primarily by controlling binding site selection. Activity regulation then fine-tunes the temporal and spatial domains of promoter responses, the magnitude of these responses, and whether they are positive or negative.

Limited value of zinc protoporphyrin as a marker of iron status in chronic hemodialysis patients

BACKGROUND

In an attempt to find new parameters able to evaluate the actual iron availability by bone marrow cells, zinc protoporphyrin (ZnPP), a metabolic intermediate generated in the red blood cell by the incorporation of zinc instead of iron, has been proposed. ZnPP is a good marker of iron-deficiency anemia in non-uremic people, as red blood cell ZnPP concentration rises specifically (except for lead intoxication) in this condition. Existing data on ZnPP as a marker of iron deficiency in uremic patients comes mainly from cross sectional studies on chronic hemodialysis and has produced conflicting results.

SUBJECTS AND METHODS

Therefore, we prospectively studied 42 HID patients, 28-88 years old, 13-346 months of dialysis age, beginning from a period of maximal iron deficiency, due to the lack of parenteral iron compounds (T0) up to the end of more than one year of follow-up with continuous parenteral iron supplementation (T4). ZnPP, hemoglobin, transferrin saturation and ferritin were serially determined before and after six weeks (T1), four months (T2), seven months (T3) and 14 months (T4) of parenteral iron supplementation at a maintenance dose of 0.5-1 mg/kg/week.

RESULTS

In comparison with baseline values (95+/-37 micromol/mol heme) there were no significant changes in ZnPP levels at T1 and T2 despite a continuous increase in both transferrin saturation and ferritin values, while ZnPP significantly decreased at T4 (63+/-37 micromol/mol heme, p<0.001). There was no correlation between ZnPP and both transferrin saturation and ferritin at any time during the study, the same was true for ZnPP and zinc and lead serum concentration, fibrinogen and reactive C protein levels at T1 and T4, respectively. At T4, only 2/10 patients who still showed ZnPP levels >80 micromol/mol heme had absolute or functional iron deficiency, when the percentage of hypochromic red cells were measured.

CONCLUSION

We conclude that ZnPP untimely parallels a change in iron balance in only a proportion of uremic people, in as much as confounding factors, such as chronic inflammation and uremia in itself may obscure its relationship with iron status. Therefore, ZnPP cannot be assumed to be a first-line diagnostic marker of iron balance in uremic patients.

Catastrophic antiphospholipid syndromes in systemic lupus erythematosus

The objective of this study was to look for the occurrence of catastrophic antiphospholipid syndromes (APS) and to try to detect discriminating factors for predicting a worse prognosis, related to Lupus anticoagulant (LA) and antiphospholipid antibodies (aPL), in systemic lupus erythematosus (SLE) with main renal involvement. Regression, recursive partition and logistic regression analyses were applied to our 80 SLE patients prospectively followed up since 1980. Immunologic and other laboratory parameters including beta 2-glycoprotein 1 dependence, resistance to activated protein C caused by a substitution on the coagulation factor V gene, induction of monocyte procoagulant activity. Regression studies demonstrated an overall worse prognosis in term of both thrombosis and death for the group of LA/aPL positive patients (33/80). However, recursive partition analysis was able to isolate a small high risk-subgroup (8/33) characterized by persistent LA/aPL antibodies positive result, widespread signs of noninflammatory vasculopathy (skin, brain, kidney) and renal pathology mimicking that of thrombotic microangiopathy or arteriolosclerosis, also in the absence of classic SLE-nephritis. Only in this subset, three catastrophic APS were recorded, while, in traditional SLE nephritis, even persistent LA/aPL positive results (sometimes after one previous thrombosis) did not seem to imply a particularly severe prognosis. All serologic criteria employed are unable to identify high-risk patients. We conclude that catastrophic APS is a rare event in renal SLE. Before more predictive serologic markers become available, a simple algorithm, dealing with clinical data and renal histologic patterns, may help physicians to identify putatively high risk-LA/aPL antibodies in SLE patients with main renal involvement. This ominous subset does not belong to the group of classic SLE-nephritis.

Guidelines for looking at the antiphospholipid antibodies in systemic lupus erythematosus

Lupus anticoagulant (LA), anticardiolipin (aCL), and/or antiphospholipid (aPL) antibodies are the hallmarks of the antiphospholipid syndrome, characterized by widespread thrombosis. The syndrome has been described as primary or secondary when aCL/aPL are the only classes of detectable autoantibodies or occur in the context of systemic lupus erythematosus (SLE) or SLE-like disease. However, since LA/aCL/aPL have been extensively looked for, it has become evident that they may also be detected in the absence of any clinical correlation with thrombosis. In particular, among SLE patients, these antibodies mean a high risk of thrombosis only in a small subset, sharing clinical features with primary antiphospholipid syndrome. As laboratory examination is still unable to distinguish between high-risk and non-high-risk antiphospholipid antibodies, it is crucial to have some reasonable criteria able to guide the day-to-day clinical practice. We attempt to trace the following guidelines: (1) distinguish between transient and persistent LA/aCL/aPL results; (2) do not forget the LA phenomenon in the era of aCL/aPL; (3) maintain a strict communication with the laboratory; (4) exclude other causes of primary coagulation abnormalities; (5) look at the time of appearance of LA/aCL/aPL with respect to thrombosis; (6) analyze any possible laboratory clue putatively useful to distinguish between 'rouge' and 'non-rouge' LA/aCL/aPL; (7) look for signs of widespread noninflammatory vasculopathy; (8) do not engage a war to the knife against LA/aCL/aPL by immunosuppressive therapies.

Is pregnancy-related acute renal failure a disappearing clinical entity?

The actual disappearance of pregnancy-related acute renal failure (PR-ARF) is a common "feeling" for nephrologists. The aim of this study was to exactly quantify this event by evaluating epidemiology and the extent of renal damage in PR-ARF. From 1958 to 1994, 84 cases of PR-ARF were observed (5.8% of total number of ARF needing dialysis). In four successive periods (1956-67, 1968-77, 1978-87, 1988-94), the incidence of PR-ARF fell from 43% to 0.5% with respect to the total number of ARF, and from 1/3000 to 1/18,000 with respect to the total number of pregnancies. Maternal mortality in the past was high (31%), but no cases of death in the last period were seen. Irreversible renal damage was recorded in 11.1% of PR-ARF, and, in particular, in 18.7% of cases of preeclampsia-eclampsia (PE-E). The worst maternal and renal prognosis occurred in PE-E that was complicated by abruptio placentae (AP). Neither disseminated intravascular coagulation (DIC), microangiopathic hemolytic anemia, nor prostacyclin imbalance were significantly related to the severity of renal damage. Heparin therapy did not modify DIC evolution and renal outcome and was aggravated by severe hemorragic complications. Support therapy with plasma infusion, antithrombin III, and antiplatelet agents seems to be helpful. In conclusion, PR-ARF has become a rare occurrence and, in our experience, no cases of death or irreversible renal damage were observed in the last 7 years. The most important reasons for this favorable evolution seem to be an improved medical care and more effective measures of careful prevention, mainly regarding tempestive delivery.