Cognitive decline related to chronic kidney disease as an exclusion factor from kidney transplantation: results from an international survey

Background and hypothesis

There seems to be a lack of consensus on the necessity and the modality of psychological and specifically cognitive assessment of candidates for kidney transplantation. Both points are often delegated to individual hospitals/centres, whereas international guidelines are inconsistent. We think it is essential to investigate professionals' opinions to advance towards a consistent clinical practice.

Methods

This paper presents the results of an international survey among clinical professionals, mainly nephrologists from the CONNECT (Cognitive decline in Nephro-Neurology: European Cooperative Target) network and beyond (i.e. from personal contacts of CONNECT members). The survey investigated their opinions about the question of whether cognitive decline in patients with chronic kidney disease may affect their eligibility for kidney transplantation.

Results

Our results show that most clinicians working with patients affected by chronic kidney disease think that cognitive decline may challenge their eligibility for transplantation despite data that suggest that, in some patients, cognitive problems improve after kidney transplantation.

Conclusion

We conclude that three needs emerge as particularly pressing: defining agreed-on standards for a multifaceted and multifactorial assessment (i.e. including both clinical/medical and psychosocial factors) of candidates with chronic kidney disease to kidney transplantation; further investigating empirically the causal connection between chronic kidney disease and cognition; and further investigating empirically the possible partial reversibility of cognitive decline after kidney transplantation.

Chemotherapy induced cardiotoxicity: on the way to personalized risk stratification based on genetic variants

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): 1.Flanders Research Foundation- FWO (doctoral research grant) 2.UZA Foundation-Wolvenbos Grant 2019

Background

Anthracycline chemotherapy is a cornerstone in the treatment of several malignancies. However, it causes substantial toxicity, of which cardiotoxicity is the most frequent and most severe (1). Ideally, patients at risk for cardiotoxicity are identified prior to treatment, however, traditional patient- and treatment-related factors fail to fully predict the individual risk at the moment. Improved risk stratification for ANT-induced cardiotoxicity could possibly be reached by taking genetic risk factors into account.

Purpose

We assessed the prevalence of variants in genes encoding for cardiac proteins in the development of anthracycline-induced cardiotoxicity.

Methods

Patients presenting with early (< 1y) or late (> 1y) anthracycline-induced cardiotoxicity between 1995 and 2020 were included. Cardiotoxicity was defined as a decline in left ventricular ejection fraction (LVEF) to <50% and a ≥10% reduction from baseline by echocardiography. Genetic analysis was offered using a haloplex gene panel composed of 59 known cardiomyopathy-related genes. Variants were classified according to ACMG guidelines(2). Both variants of unknown significance (VUS, class 3) and likely pathogenic/pathogenic variants (class 4 and 5) were taken into account. Frequency of genetic variants was compared to a matched positive control cohort of patients with dilated cardiomyopathy (DCM).

Results

Forty-two patients that had developed cardiotoxicity (mean age at time of diagnosis 54yrs) fulfilled the inclusion criteria and agreed to genetic testing. The majority of patients had been treated for lymphoma (52.4%) or breast cancer (38.1%). Total equivalent dose of anthracyclines averaged 285.5 mg/m² doxorubicin. Patients showed an average reduction in LVEF of 27.1% (+- 10.1). In 18 patients (42.9 %), a variant could be identified; 15 patients carried a variant of unknown significance (VUS) and 3 carried a likely pathogenic variant. In total 29 variants different variants were identified in 18 distinct individuals. Genetic yield was independent of anthracycline-dose and the presence of other cardiovascular risk factors. The genetic yield in cardiotoxicity patients did not differ significantly from this in DCM-controls (18/42 VUS, 5/42 (likely) pathogenic variants, p = 0.19).

After initiation of standard heart failure therapy, 6 (33.3%) of variant carriers showed incomplete recovery of cardiac function, compared to only 3 (12.5%) of patients who did not carry a variant (p=0.103).

Conclusion

Prevalence of genetic variants in anthracycline-induced cardiotoxicity is similar to that in isolated dilated cardiomyopathy. This finding supports a second-hit mechanism in which anthracycline chemotherapy, uncovers a genetically determined cardiomyopathy. As such, genetic variants in cardiomyopathy genes could improve individualized risk stratification prior to anthracycline chemotherapy and can assist in personalized prevention of this feared side effect of chemotherapy.

MO899: The Clinical frailty Scale is Useful for ICU Triage in Dialysis Patients With COVID-19–An Eracoda Analysis

BACKGROUND AND AIMS

during the COVID-19 pandemic, several guidelines have recommended the use of the Clinical Frailty Scale (CFS) for triage of critically ill patients with COVID-19 in case of shortage in ICU resources. However, no data on using CFS assessment for ICU triage for dialysis patients is yet available. This study evaluates whether CFS is associated with mortality rates in a cohort of hospitalized dialysis patients with COVID-19.

METHOD

the analyses are based on data of the European Renal Association COVID-19 Database (ERACODA). Dialysis patients who presented with COVID-19 between 1 February 2020 and 30 April 2021 and with complete information on CFS and vital status at 3 months were included. Study outcomes were hospital and ICU admission rates and hospital and ICU mortality at 3 months after hospital admission. Cox regression analyses were performed to assess the association of CFS category (≤5 versus ≥ 6) and study outcomes in line with Dutch ICU triage guidelines for COVID-19. Furthermore, additional subgroup analyses were performed to assess the association between CFS and 3-month mortality by age category (<65, 65–75 and >75 years).

RESULTS

among a total of 2206 dialysis patients (mean age = 67.2 (14.1) years, male sex = 61%), 1694 (77%) had CFS ≤ 5 and 514 (23%) had CFS ≥ 6. Hospitalization rate was comparable in patients with CFS ≤ 5 and in patients with CFS ≥ 6 (67 and 71%, respectively), whereas the rate of ICU admission was higher in patients with CFS ≤ 5 than in patients with CFS ≥ 6 (16 versus 9%, p = 0.001). Among 1501 hospitalized patients, 3-month mortality was 26% of patients with CFS ≤ 5 and 59% in patients with CFS ≥ 6 (P < 0.001). Multivariate analysis with adjustment for patient demographics, smoking status and BMI revealed that CFS ≥ 6 was associated with hospital mortality [aHR 2.27 (1.88–2.74) versus CFS ≤ 5; P < 0.001) with a significant interaction for age (P = 0.029). aHR was 4.00 (2.56–6.37; CFS ≥ 6 versus CFS ≤ 5; P < 0.001) in patients < 65 years, aHR was 1.87 (1.33–2.64; CFS ≥ 6 versus CFS ≤ 5; P < 0.001) in patients 65–75 years and aHR was 2.12 (1.64–2.75; CFS ≥ 6 versus CFS ≤ 5; P < 0.001) in patients >75 years. Among 219 ICU admitted patients, 3-month mortality was 60% of the patients with CFS ≤ 5 and 91% in the patients with CFS ≥ 6, respectively. Multivariate analysis with adjustment for patient demographics, smoking status and BMI revealed that CFS ≥ 6 was associated with ICU mortality [aHR 1.80 (1.17–2.77); CFS ≥ 6 versus CFS ≤ 5; P = 0.002].

CONCLUSION

more frail dialysis patients with CFS ≥ 6 who are hospitalized for COVID-19 were less often admitted to the ICU, but in case they were admitted to the ICU they have a very high mortality of 91% in this cohort study. In fit to mildly frail dialysis, patients who were admitted to the ICU, mortality rates are lower. The association between frailty and hospital mortality is interacted by age with the strongest association in patients younger than 65 years. These findings suggest that CFS may be a useful complementary triage tool for ICU admission of dialysis patients during the ongoing COVID-19 pandemic.

[Glomerular hematuria: an atypical presentation of anti-glomerular basement membrane nephritis]

BACKGROUND

Urologic diseases can cause hematuria, but dysmorphic erythrocytes directs to a glomerular disease. The latter might occur isolated or in the presence of systemic complaints, proteinuria or kidney failure. These factors determine the differential diagnosis that ranges from an innocent IgA nephropathy to a fatal anti-glomerular basement membrane (GBM) nephritis.

CASE

A 30-year old patient attended the outpatient clinic because of glomerular hematuria and normal kidney function with working diagnosis IgA nephropathy. Three months later he presented to the emergency department with a severe acute kidney injury duo to an anti-GBM nephritis. In retrospect, the anti-GBM titer was already high during the outpatient clinic phase, but due to the preserved kidney function, anti-GBM nephritis was not added to the differential diagnosis.

CONCLUSION

Glomerular hematuria with a preserved kidney function could in a rare instance be caused by a subclinical anti-GBM nephritis. Follow-up of the kidney function and comprehensive laboratory testing - or even a kidney biopsy - could potentially lead to an early diagnosis of anti-GBM nephritis.

Long-Term Transplantation Outcomes in Patients With Primary Hyperoxaluria Type 1 Included in the European Hyperoxaluria Consortium (OxalEurope) Registry

Introduction

In primary hyperoxaluria type 1 (PH1), oxalate overproduction frequently causes kidney stones, nephrocalcinosis, and kidney failure. As PH1 is caused by a congenital liver enzyme defect, combined liver–kidney transplantation (CLKT) has been recommended in patients with kidney failure. Nevertheless, systematic analyses on long-term transplantation outcomes are scarce. The merits of a sequential over combined procedure regarding kidney graft survival remain unclear as is the place of isolated kidney transplantation (KT) for patients with vitamin B6-responsive genotypes.

Methods

We used the OxalEurope registry for retrospective analyses of patients with PH1 who underwent transplantation. Analyses of crude Kaplan–Meier survival curves and adjusted relative hazards from the Cox proportional hazards model were performed.

Results

A total of 267 patients with PH1 underwent transplantation between 1978 and 2019. Data of 244 patients (159 CLKTs, 48 isolated KTs, 37 sequential liver–KTs [SLKTs]) were eligible for comparative analyses. Comparing CLKTs with isolated KTs, adjusted mortality was similar in patients with B6-unresponsive genotypes but lower after isolated KT in patients with B6-responsive genotypes (adjusted hazard ratio 0.07, 95% CI: 0.01–0.75, P = 0.028). CLKT yielded higher adjusted event-free survival and death-censored kidney graft survival in patients with B6-unresponsive genotypes (P = 0.025, P < 0.001) but not in patients with B6-responsive genotypes (P = 0.145, P = 0.421). Outcomes for 159 combined procedures versus 37 sequential procedures were comparable. There were 12 patients who underwent pre-emptive liver transplantation (PLT) with poor outcomes.

Conclusion

The CLKT or SLKT remains the preferred transplantation modality in patients with PH1 with B6-unresponsive genotypes, but isolated KT could be an alternative approach in patients with B6-responsive genotypes.

Clinical implications of isolated troponinemia following immune checkpoint inhibitor therapy

Cardiovascular adverse events induced by immune checkpoint inhibitors (ICIs) have gained significant interest over the past decade due to their impact on short- and long-term outcomes. They were initially thought to be rare, but the increasing use of ICIs in the treatment of both advanced and early stages of various malignancies has resulted in a substantial increase in their incidence. Different guidelines have proposed screening measures for ICI-induced myocarditis by incorporating troponin measurements at baseline and during the first few weeks of treatment. However, no specific guidelines have been developed yet regarding the interpretation of an asymptomatic rise in troponins. This state-of-the art review aims to provide an overview of the clinical relevance of elevated troponins during checkpoint inhibition and recommendations on how to manage elevated troponin levels during ICI therapy.

MO879PROPOSAL OF A GERIATRIC ASSESSMENT TAILORED FOR OLDER CHRONIC KIDNEY DISEASE PATIENTS: RESULTS OF A PRAGMATIC CONSENSUS-BASED APPROACH

Background and Aims

Unidentified cognitive decline and other geriatric impairments are prevalent in older patients with advanced kidney disease. Despite guideline recommendation of geriatric evaluation, routine geriatric assessment is not common in these patients. While high burden of vascular disease and existing pre-dialysis care pathways mandate a tailored geriatric assessment, no consensus exists on which instruments are most suitable in this population to identify geriatric impairments. Therefore, the aim of this study was to propose a geriatric assessment, based on multidisciplinary consensus, for older people with advanced chronic kidney disease.

Method

A pragmatic approach was chosen to reach agreement on a suitable set of instruments to routinely identify major geriatric impairments in older patients with advanced chronic kidney disease. This approach included focus group meetings to identify criteria for the assessment, literature review to identify potential instruments, questionnaire to inventory currently used instruments, an expert consensus meeting to ensure that the selection of tests was based on input from clinical experience in nephrology and geriatrics, and pilot testing to ensure practicability. In preparation of the consensus meeting we composed a project team and an expert panel (n=33), drafted selection criteria for the selection of instruments, and assessed potential instruments for the test-set.

Results

Selection criteria related to general geriatric domains, clinical relevance, feasibility and duration of the assessment. The consensus-set contains instruments in functional, cognitive, psychological, somatic, patient preferences, nutritional status, and social domains (Figure 1). Administration of (seven) patient questionnaires and (ten) professional-administered instruments, by nurse (practitioners), takes estimated 20 and 40 minutes, respectively. Results are discussed in a multi-disciplinary meeting including at least nephrology and geriatric expertise, informing nephrology treatment decisions and follow-up interventions amongst which comprehensive geriatric assessment.

Conclusion

This first multi-disciplinary consensus on nephrology-tailored geriatric assessment intent to benefit clinical care and enhance research comparability for older patients with advanced chronic kidney disease. The proposed geriatric assessment is currently implemented in multiple hospitals and studies. Future initiatives and studies should provide insights on effectiveness, feasibility, patient’s satisfaction and, value for shared treatment decision making and outcome improvement.

FC 027COVID-19 IN PATIENTS ON KIDNEY REPLACEMENT THERAPY - CLINICAL CHARACTERISTICS AT TRIAGE ASSOCIATED WITH ADMISSION, READMISSION AND SHORT-TERM OUTCOMES

Background and Aims

Patients on kidney replacement therapy (KRT) are at high risk of developing severe COVID-19 illness and often require high intensity care and utilisation of hospital resources. During the ongoing pandemic, the optimal care pathway and triage for KRT patients presenting with varying severity of COVID-19 illness is unknown. We studied clinical factors and outcomes associated with admission, readmission and short-term outcomes.

Method

Data from the European Renal Association COVID-19 Database (ERACODA) was analysed. This database includes granular data on dialysis patients and kidney transplant recipients with COVID-19 from all over Europe. The clinical and laboratory features at first presentation of hospitalized and non-hospitalized patients and those who returned for second presentation were studied. In addition, possible predictors of outcome in those who were not hospitalized at first presentation were identified.

Results

Among 1,423 KRT patients (haemodialysis; 1017/kidney transplant; 406) with COVID-19, 25% (n=355) were not hospitalized at first presentation. Of them, only 10% (n=36), presented for a second time in the hospital. The median interval between the first and second presentation was 5 days (Interquartile interval: 2-7 days). Patients who re-presented had worsening of pulmonary symptoms, a fall in oxygen saturation (97% to 90%), and an increase in C-reactive protein (26 mg/L to 73 mg/L) between their attendances. Patients who re-presented after initial assessment were older (72 vs. 63 years) and initially more often had pulmonary symptoms and abnormalities on lung imaging compared with those who did not present for a second time. The 28-day mortality rate of patients admitted at the second presentation was similar to that of patients admitted at first presentation (26.5% vs. 29.7%, p=0. 61). Among patients who were not hospitalized at first presentation (mortality 6%), age, prior smoking, clinical frailty scale, and shortness of breath at first presentation were identified as predictors of mortality.

Conclusion

KRT patients with COVID-19 and mild pulmonary abnormalities and no signs of pulmonary insufficiency can be safely returned without hospitalization. These patients should be advised to seek immediate contact when they develop respiratory distress. Our findings provide support for a risk-stratified clinical approach to admissions of KRT patients presenting with COVID-19. The study findings may be valuable for clinical triage and optimising hospital capacity utilisation during the ongoing pandemic.

MO505IMPACT OF THE COVID-19 PANDEMIC ON SYMPTOMS OF ANXIETY AND DEPRESSION AND HEALTH-RELATED QUALITY OF LIFE IN OLDER PATIENTS WITH CHRONIC KIDNEY DISEASE

Background and Aims

Older patients with advanced chronic kidney disease (CKD) are at increased risk for a severe course of the coronavirus disease-2019 (COVID-19) and vulnerable to mental health problems. We aimed to investigate prevalence and associated patient (demographic and clinical) characteristics of mental wellbeing (health-related quality of life [HRQoL] and symptoms of depression and anxiety) before and during the COVID-19 pandemic in older patients with advanced CKD.

Method

An ongoing Dutch multicentre prospective cohort study enrols patients of ≥70 years with an eGFR <20 mL/min/1.73m² from October 2018 onward. With additional questionnaires during the pandemic (May-June 2020), disease-related concerns about COVID-19 and general anxiety symptoms were assessed cross-sectionally, and depressive symptoms, HRQoL, and emotional symptoms longitudinally.

Results

The 82 included patients had a median age of 77.5 years (inter-quartile range 73.9-82.1), 77% was male and none had tested positive for COVID-19. Cross-sectionally, 67% of the patients reported to be more anxious for COVID-19 because of their kidney disease, and 43% of the patients stated that their quality of life was reduced due to the COVID-19 pandemic (Figure 1). Higher COVID-19-related stress was associated with a lower education level (p=0.036), and patients who reported to feel more down due to COVID-19 were more often female (p=0.020). Anxiety scores were higher among females compared to males (median 4.0 [IQR 3.0-9.0] versus 2.0 [0.0-6.0], p=0.020), and weakly associated to a decline in eGFR (correlation coefficient 0.197, p=0.023).

Compared to pre-COVID-19, presence of depressive symptoms had increased (11% to 22%; p=0.022) and physical HRQoL declined (40.4±10.1 to 36.1±10.4, p<0.001). Mental HRQoL (50.3±9.6 to 50.4±9.9; p=0.913) and emotional symptoms remained similar. Males showed a greater decline in physical HRQoL (mean -5.3, SD 8.5) compared to females (mean -0.9, SD 5.7; p=0.039).

Conclusion

Our findings show that older patients with advanced CKD suffered from disease-related anxiety for COVID-19, increased depressive symptoms, and reduced physical HRQOL during the COVID-19 pandemic. The impact of the pandemic on this vulnerable patient group extends beyond increased mortality risk, and awareness of mental health problems during the pandemic is essential. More in-depth investigation on disease-related COVID-19 concerns and its implications for the CKD population is needed.

[Autonomic hyperreflexia after spinal cord injury : perioperative management]

Spinal cord injury can have widespread consequences beyond the disruption of sensory and motor functions. Injury at or above the sixth thoracic spinal cord segment frequently leads to dysregulation of the autonomic nervous system, which results in a syndrome called autonomic hyperreflexia or dysreflexia. It is a hypertensive crisis triggered by visceral or somatic stimuli below the level of the injury and caused by sympathetic spinal reflexes not modulated by regulatory centers in the brain. Patients with spinal cord injuries frequently undergo surgery for multiple reasons. Because of the potentially lethal complications of autonomic hyperreflexia, physicians, and in particular anaesthesiologists, must be aware of the underlying pathophysiological mechanisms and adequate perioperative management.

CHANGING NURSING CARE TIME AS AN EFFECT OF CHANGED CHARACTERISTICS OF THE DIALYSIS POPULATION

BACKGROUND

The population of dialysis patients is ageing. Dialysis nurses are confronted with geriatric patients with multiple comorbidities. Nurses are confronted with an increasing burden of care.

OBJECTIVES

The present study focused on the question of whether, over time, the increasing age and comorbidities of the haemodialysis population increased nursing care time. Furthermore, we studied potential changes in the predictors of the required nursing time.

DESIGN

Observational study.

PARTICIPANTS

A total of 980 dialysis patients from 12 dialysis centres were included.

MEASUREMENTS

Nurses filled out the classification tool for each patient and completed a form for reporting patient characteristics for groups of relevant haemodialysis patients at baseline and after 1 and four years. Changes in patient and dialysis characteristics were analysed, as well as the estimated nursing care time needed.

RESULTS

An increase in the nursing time needed for dialysis was largely due to decreased mobility, closing of the vascular access and a greater need for psychosocial attention and was most strongly present in incident dialysis patients. The time needed for dialysis decreased as patient participation increased and vascular access changed from catheters to fistulae. Over the four-year period, the average overall needed nursing care time per haemodialysis session did not change.

CONCLUSIONS

Our study shows that the average nursing time needed per patient did not change in the four-year observation period. However, more time is required for incident patients; thus, if a centre has high patient turnover, more nursing care time is needed.

Paper or Plastic? Exploring the Effects of Natural Enrichment on Behavioural and Neuroendocrine Responses in Long-Evans Rats

Enriched environments are beneficial to neurobiological development; specifically, rodents exposed to complex, rather than standard laboratory, environments exhibit evidence of neuroplasticity and enhanced cognitive performance. In the present study, the nature of elements placed in the complex environment was investigated. Accordingly, rats (n = 8 per group) were housed either in a natural environment characterised by stimuli such as dirt and rocks, an artificial environment characterised by plastic toys and synthetic nesting materials, a natural/artificial environment characterised by a combination of artificial and natural stimuli or a laboratory standard environment characterised by no enrichment stimuli. Following exposure to emotional and cognitive behavioural tasks, including a cricket hunting task, a novel object preference task and a forced swim task, brains were processed for glial fibrillary acidic protein (GFAP)-, neuronal nuclei (NeuN)- and brain-derived neurotrophic factor (BDNF) immunoreactivity. Baseline and stress foecal samples were collected to assess corticosterone (CORT) and dehydroepiandrosterone (DHEA). Natural environment animals exhibited shorter diving latencies and increased diving frequencies in the second forced swimming task, along with higher DHEA/CORT ratios, and higher GFAP immunoreactivity in the hippocampus. The type of environmental enrichment did not influence levels of BDNF immunoreactivity in the CA1, CA3 and dentate gyrus of the hippocampus; however, natural environment animals exhibited higher levels of NeuN immunoreactivity in the retrosplenial cortex, an area involved in spatial memory and other cognitive functions. These results suggest that, in addition to enhancing behavioural and endocrinological variables associated with resilience, exposure to natural stimuli might alter plasticity in brain areas associated with cortical processing and learning.

[PERIOPERATIVE VISUAL LOSS AFTER SPINE SURGERY: A CASE REPORT]

Perioperative visual loss is a rare but devastating complication that may follow spine surgery in the prone position. So far, the incidence, mechanisms and risk factors have not been clearly established. Most commonly, the visual loss results from an ischemic optic neuropathy. We describe the case of a 68 year-old woman who underwent a lumbar laminectomy in the prone position. Upon recovery from anesthesia, the patient complained of total left blindness. This visual loss was, slowly and only partially, recovered after 72 hours. We discuss the most common causes of postoperative visual loss, the risk factors and preventive strategy.

The role of titin and extracellular matrix remodelling in heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) is characterised by a high incidence of metabolic comorbidities that share the potential to induce both systemic and coronary microvascular inflammation and oxidative stress. These pathophysiological alterations contribute to increased passive stiffness of the myocardium and to diastolic dysfunction, both hallmarks of HFpEF. Passive myocardial stiffness depends mainly on two components: the extracellular matrix (ECM) and the cardiomyocytes. Quantitative and qualitative changes in collagen metabolism leading to myocardial fibrosis determine the ECM-based stiffness of the myocardium. Different noninvasive diagnostic tools to assess myocardial fibrosis are being developed, some of which have demonstrated to correlate with clinical status and prognosis. Cardiomyocytes mainly alter the passive stiffness through alterations in the giant myofilament titin, which serves as a spring. By modifying its phosphorylation state or by direct oxidative effects, titin determines cardiomyocyte-based passive stiffness. Probably the relative importance of cardiomyocyte-based changes is more important in the beginning of the disease, whereas ECM-based changes become more prominent in the more advanced stages. The present review focuses on these changes in ECM and cardiomyocytes in HFpEF and their potential prognostic and therapeutic implications.

The Influence of Different Beta-Blocking Drugs on the Peripheral Circulation in Raynaud's Phenomenon and in Hypertension

In a double-blind, randomized, placebo-controlled study, the authors investigated the effects of different beta-adrenoceptor blocking drugs on the peripheral circulation. A single intravenous injection of the nonselective beta-blocker propranolol (0.20 mg/kg), the beta 1-selective adrenoceptor blocker metoprolol (0.25 mg/kg), and the nonselective beta-blocker with partial agonistic activity (PAA) pindolol (0.04 mg/kg) and of placebo (saline) was given to eight patients with a primary Raynaud's phenomenon and to nine untreated patients with primary hypertension. The authors measured finger skin temperature (FST), and laser Doppler estimated finger skin blood flux (LDF) before, during, and after a standardized finger cooling test, performed 25 minutes after the administration of the drugs. In both patients groups propranolol, metoprolol, and pindolol had no significant effect on FST and LDF in the first 25 minutes after administration both in comparison to baseline value and to placebo. Also, no significant differences were found in the recoveries of FST and LDF after cold challenge between all drugs and placebo in both groups. The authors conclude that no adverse effect of any type of beta-adrenoceptor blocker in comparison to placebo could be detected after a single administration on both the baseline finger skin perfusion and the recovery after cold-induced vasoconstriction. In addition, the authors could not demonstrate a favorable effect of beta 1-selectivity or PAA in comparison to a nonselective beta-adrenoceptor blocker without PAA, in any group.

Surgical resection of a sphenoid wing meningioma in a patient with Glanzmann thrombasthenia

Glanzmann thrombasthenia (GT) is a rare autosomal recessive disorder characterized by a deficiency or functional defect of platelet glycoprotein (GP) IIb/IIIa. Physiologically, this platelet receptor mediates aggregation of activated platelets by binding the adhesive proteins, fibrinogen, von Willebrand factor (VWF) and fibronectin. This facilitates attachment and aggregation of platelets at sites of vascular injury. We reported the management of a pterional meningioma resection in a patient with Glanzmann thrombasthenia, with recombinant factor VIIa (rFVIIa - NovoSeven) as haemostatic agent. A 48-year-old woman suffering from Glanzmann thrombasthenia was scheduled for spheno-orbital meningioma en plaque surgery. Because of repeated platelet transfusions, this patient developed isoantibodies against missing GPIIbIIIa and alloantibodies against Human Leukocyte Antigen (HLA) leading to refractoriness to platelet transfusions. We observed that Novoseven offered sufficient haemostasis conditions. Therefore, we noticed a deep vein thrombosis. This imposed us to use low weight molecular heparin despite recent surgery.

Description of a new species, Bifidobacterium crudilactis sp. nov., isolated from raw milk and raw milk cheeses

A new Bifidobacterium species is described based on the study of ten Gram-positive strains with fructose-6-phosphate phosphoketolase activity. They are part of a phenotypic group comprising 141 strains isolated from raw milk and raw milk cheeses in French raw milk cheese factories. This group was separated by a numerical analysis based on API 50CH, API 32A tests and growth at 46 degrees C. A strong similarity of 16S rRNA sequences (99.8%) was shown between strain FR62/b/3(T) and Bifidobacterium psychraerophilum LMG 21775(T). However, low DNA-DNA relatedness was observed between their DNAs (31%). The new isolates are able to grow at low temperatures (all ten strains up to 5 degrees C) and strain FR62/b/3(T) grows under aerobic conditions, as does B. psychraerophilum. However, contrary to B. psychraerophilum, they do not ferment L-arabinose, D-xylose, arbutin or melezitose, but they do acidify lactose. The DNA G+C content of FR62/b/3(T) is 56.4mol%. Therefore, the name Bifidobacterium crudilactis sp. nov. is proposed, with its type strain being FR62/b/3(T) (=LMG 23609(T)=CNCM I-3342(T)).

Plasma myeloperoxidase and vitamin E levels in head injury: preliminary results related to outcome

This preliminary study was designed to assess a possible role of neutrophil activation and to determine the prognostic value of plasma myeloperoxidase (MPO) and vitamin E (Vit. E) levels in severe head injury. Plasma MPO and Vit. E levels were measured in nine severely head-injured patients (Glasgow Coma Score </=8) (ages 12-80 years) 6, 12. 18, 24, and 30 h after trauma. Patients were classified into two groups according to outcome after discharge from the ICU: group D (death; n = 5) and group S (survival; n = 4). Plasma MPO levels were increased immediately after trauma and then decreased. The MPO peak observed after 6 h was significantly higher (p < 0.05) in group D (mean +/- SEM: 1,237 +/- 122 ng/ml) than in group S (mean +/- SEM: 543 +/- 148 ng/ml). Plasma Vit. E levels were lower than normal values and decreased over time. They were always significantly lower (p < 0.05) in group D than in group S, except for the first sample. These differences cannot be explained entirely by total plasma lipid (TL) values since no statistical difference in TL concentrations was found between the two groups during the course of study. The ratio of Vit. E to TL. considered as the best index of Vit. E status, was lower in group D than in group S. and the difference reached statistical significance (p < 0.05) 12 h after trauma. In conclusion, in spite of the limited number of patients included in this study, it appears that severe head injury is associated with an increase in MPO and a decrease in Vit. E levels. These biochemical changes are of greater magnitude in group D than in group S; they suggest neutrophil activation and lipoperoxidation processes. Finally, plasma MPO and Vit. E seem to be new discriminant factors of outcome in head-injured patients.

Factors predictive of failure of Brescia-Cimino arteriovenous fistulas

OBJECTIVE

To evaluate patency rates of Brescia-Cimino fistulas and to find out which independent factors were predictors of failure.

DESIGN

Retrospective clinical study.

SETTING

University hospital, The Netherlands.

SUBJECTS

150 consecutive patients (mean age 56 years, range 17-80) who had 153 primary Brescia-Cimino fistulas created during the 5-year period January 1995-December 1999.

MAIN OUTCOME MEASURES

Patency rates calculated by the Kaplan-Meier method and the possible predictive value of 20 different variables assessed by Cox's proportional hazard model.

RESULTS

The primary patency rate was 70% at 3 months, and 7 distinct factors were significantly associated with failure of the fistula. The ones with a hazard ratio (HR) for failure greater than 2.5 were: the start of dialysis before creation of the fistula (HR 2.79, p < 0.01), moderate or poor quality of both the artery (HR 2.54, p < 0.01) and vein (HR 3.55, p < 0.001), and postoperative use of acenocoumarol instead of acetylsalicylic acid (HR 3.14. p < 0.01).

CONCLUSION

The major determinants for a successfully created Brescia-Cimino fistula were creation of the fistula before the start of dialysis, as well as good quality of both the artery and the vein. This argues for timely creation of such fistulas in patients with end-stage renal disease and for accurate preoperative examination to establish the quality of the vessels.

Creation of the "thymoheart" allograft: implantation of autologous thymus into the heart prior to procurement

BACKGROUND

A state of tolerance may be more easily achieved if fully vascularized and functional donor thymus is transferred to the recipient at the time of whole organ transplantation.

METHODS

A composite "thymoheart" allograft was created by implanting autologous thymus into a donor heart 60-90 days before organ procurement. Successful intracardiac engraftment of autologous thymus was documented by histology and by flow cytometric analysis.

RESULTS

Histology of the thymic autografts at explantation revealed viable thymus with preservation of normal thymic architecture. Cells retrieved from thymic autografts 60 days after implantation exhibited the same MHC class I and class II staining profiles by flow cytometry as cells taken from the residual native thymus.

CONCLUSION

We have created a novel composite organ that confers vascularized and functional donor thymus to heart allograft recipients at the time of transplantation without affecting cardiac function.

Disease spectrum of patients with antineutrophil cytoplasmic autoantibodies of defined specificity: distinct differences between patients with anti-proteinase 3 and anti-myeloperoxidase autoantibodies

OBJECTIVE

To compare the disease spectrum of consecutive patients with antineutrophil cytoplasmic autoantibodies directed against proteinase 3 (anti-PR3) or myeloperoxidase (anti-MPO).

DESIGN

Retrospective analysis.

SETTING

Three teaching hospitals in the Netherlands.

MAIN OUTCOME MEASURES

Clinical features at presentation, histopathological characteristics and outcome.

SUBJECTS

All consecutive patients who tested positive for anti-PR3 (n=46) or anti-MPO (n=46) over an 8-year-period.

RESULTS

At diagnosis, patients with anti-PR3 had a higher vasculitis activity index than patients with anti-MPO (P < 0.001). The mean (SD) number of affected organs in the anti-PR3 group exceeded that of the anti-MPO group (3.9 (1.4) and 2.2 (1.1), respectively; P < 0.01). The combination of renal and respiratory tract involvement was present in as many as 78.3% of patients with anti-PR3 and in only 23.9% of patients with anti-MPO (P < 0.01). Renal-limited disease exclusively occurred in patients with anti-MPO. Granulomas were found in 41.3% of anti-PR3- but in only 4.3% of anti-MPO-positive patients (P < 0.01). All anti-PR3-positive patients had Wegener's granulomatosis or microscopic polyangiitis. By contrast, diagnoses in the anti-MPO group were more diverse: idiopathic necrotizing crescentic glomerulonephritis (26.1%), microscopic polyangiitis (26.1%). Churg-Strauss syndrome (4.3%), Wegener's granulomatosis (2.2%), giant cell arteritis (2.2%), clinically suspected vasculitis (19.6%), as well as miscellaneous nonvasculitic disorders (19.6%). During follow-up, 10 anti-PR3-positive patients had 11 relapses whereas only 3 patients with anti-MPO relapsed (P=0.04).

CONCLUSION

A large divergence was seen in the disease spectrum between patients with anti-PR3 and those with anti-MPO. In particular, extra-renal disease manifestations, granuloma formation and relapses were more prominent in anti-PR3- than in anti-MPO-positive patients.

[The current status of organ transplantation: the role of xenotransplantation?]

In the last few years, transplantation was an area of intense research activity. However, there is a worldwide shortage of donor organs for clinical transplantations. Currently, interest in xenotransplantation research is growing not only because of the increased demand for organs but also because of advances in molecular biology techniques that make possible the genetic or immunological manipulations of the animal donor rather than the human recipient. The better definitions of the mechanisms responsible for xenograft rejection should facilitate appropriate therapeutic strategies for long xenograft survival.

Increase in antioxidant capacity of plasma during propofol anesthesia

We have examined the effect of total intravenous anesthesia (TIVA) using a continuous propofol infusion on the antioxidant capacity of plasma in 18 neurosurgical patients who required cerebrospinal fluid shunting. Patients were premedicated with hydroxyzine, alprazolam, and atropine. Anesthesia was induced intravenously with propofol 1.5 mg kg-1 and sufentanil 0.15-0.3 microgram kg-1. Tracheal intubation was facilitated with atracurium 0.5 mg kg-1. Anesthesia was maintained with a continuous propofol infusion at an increasing rate from 6 to 12 mg kg-1 h-1 under controlled ventilation (FiO2 = 0.4 in air). In all patients, arterial blood samples were drawn before induction of anesthesia and during surgery for measurement of blood propofol concentration and plasma antioxidant capacity, which was assessed as the ability to inhibit lipid peroxidation. Lipid peroxidation was induced in vitro by exposing a linoleic acid microemulsion to hemoglobin-generated oxoferryl radicals, and assessed by ultraweak chemiluminescence in the absence (control) and the presence of the plasma samples. The antioxidant capacity of plasma, measured by the inhibition of light emission and expressed as a percentage of control, increased significantly from 39.8 +/- 2% (mean +/- SEM) to 44.7 +/- 2.4% during anesthesia (Wilcoxon test, p < 0.001). No correlation was observed between this increased resistance to lipid peroxidation and blood propofol concentrations (Spearman test, r = 0.07, NS). We conclude that the capacity of plasma to inhibit lipid peroxidation increases in patients during TIVA maintained with a continuous propofol infusion.

Diaspirin crosslinked hemoglobin (DCLHb): absence of increased free radical generation following administration in a rabbit model of renal ischemia and reperfusion

In control rabbits, a renal ischemia of 60 min followed by 10 min of reperfusion resulted in an enhanced free radical production in cortical tissue, as assessed by a significant decrease of free glutathione (42%), protein-bound GSH (17%), and vitamin E (49%). In contrast, catalase or glutathione peroxidase activities were not affected by these experimental conditions. Free radical production in this model was also measured directly using electron spin resonance (ESR) spectroscopy associated with a PBN (alpha-phenyl N-tert-butyl-nitrone) spin trap agent in the venous blood arising from the ischemic kidney. The signal consisted of a triplet of doublets. In contrast, no signal could be detected in control blood samples taken prior to inducing ischemia. The burst of free radical production occurred in the early phase after restoration of flow in the kidneys rendered ischemic, as evidenced by a signal of weak intensity which generally appeared within the third minute after reperfusion and progressively increased to form a well-defined asymmetric signal following 10 min of reperfusion. The precise nature of free radicals trapped by the PBN agent remains, however, to be elucidated, but analysis of the coupling constants (aN = 14.5-15 G; a beta H = 2.5-3 G) and asymmetry of the central doublets suggests that the ESR signal may arise from a nitorxy-radical adduct resulting from the spin trapping by PBN of both oxygen- or carbon-centered radicals of lipid origin. As evidenced by both direct and indirect measurements, exchange of rabbit blood immediately after inducing renal ischemia with 30 ml/kg of Diaspirin Crosslinked Hemoglobin (7.5 g/dl in lactated electrolyte) or human serum albumin (7.5 g/dl in lactated electrolyte) did not exacerbate free radical production mediated by an ischemia reperfusion phenomenon, a typical situation found in a resuscitation setting.

Direct evidence of free radical production after ischaemia and reperfusion and protective effect of desferrioxamine: ESR and vitamin E studies

After surgical renal revascularisation, warm renal ischaemia due to renal artery cross-clamping contributes to postoperative renal dysfunction. After reperfusion, free radicals are thought to be a significant cause of injury. Nevertheless, indisputable proof of free radical production is scarce, partly because of their transient nature. In this study, electron paramagnetic resonance and vitamin E levels were used to demonstrate the free radical production after renal ischaemia and reperfusion. Rabbit kidneys were submitted either to 15 or 60 minutes of ischaemia followed by reperfusion. A spin trap agent (alpha-phenyl-N-tert-butyl nitrone (PBN), 20mg/ml, 1 ml/min) was infused during reperfusion directly into the left renal artery via an aortic catheter before declamping. Blood samples were selectively drawn from the left renal vein for ESR analysis (Varian spectrometer E109) of lipidic residues extracted from blood samples. The vitamin E content of the left renal cortex was determined by HPLC procedure. The right renal cortex was used as a control for the vitamin E values. In the venous effluent, ESR analysis revealed the formation of a spectrum consisting of a triplet of asymmetric doublets. This signal resulted from the spin trapping by PBN of a mixture of both oxygen- and carbon- centred lipidic radicals. The amplitude of the signal which is proportional to the amount of free radicals was significantly higher after 60 minutes ischaemia than after 15 minutes.(ABSTRACT TRUNCATED AT 250 WORDS)

Preservation of cortical microcirculation after kidney ischemia-reperfusion: value of an iron chelator

Treatment of suprarenal aneurysms and renal artery reconstructions are both responsible for normothermic ischemia of the kidney (during clamping) followed by reperfusion (declamping). During reflow through an organ undergoing ischemia the production of free radicals can be associated with cell injury and a no-reflow phenomenon characterized by perfusion defects after a period of transient hyperemia. The objectives of this study were to demonstrate the existence of this phenomenon in the kidney undergoing ischemia followed by reperfusion and to test the potential protection afforded by an iron chelator (desferrioxamine) since free radical reactions are catalyzed by iron. Adult New Zealand white rabbits were divided into the following three groups: group A, 15 minutes of ischemia plus 10 minutes of reperfusion; group B, 60 minutes of ischemia plus 10 minutes of reperfusion; and group C, 60 minutes of ischemia plus 10 minutes of reperfusion combined with infusion of desferrioxamine (50 mg/kg). Cortical microcirculation in the kidney was measured by laser Doppler flowmeter before ischemia and 1, 5, and 10 minutes after reperfusion. Vitamin E content was determined in the cortex of the left kidney after 10 minutes of reperfusion and compared with that of the right (control) kidney. After 1 minute of reperfusion the cortical microcirculatory flow was significantly increased in all three groups (reactive hyperemia). In groups A and C blood flow returned to preclamping values after 10 minutes of reperfusion; however, blood flow in group B remained significantly reduced (29.2% +/- 10.5%) after 5 minutes of reperfusion with a further reduction to 48.5% +/- 5.7% after 10 minutes. These findings were correlated with the dosage of vitamin E since the vitamin E content was greatly reduced by 46.7% +/- 7.8% in group B but did not change significantly in groups A and C. This study shows that 60 minutes of normothermic ischemia is followed by a significant reduction in cortical microcirculatory flow (no-reflow phenomenon). Infusion of an iron chelator (desferrioxamine), however, which decreases the intensity of lipid peroxidation induced by the free radicals, preserves the microcirculatory flow.

[Malformative and degenerative diseases of the cervical spine: preoperative evaluation]

Malformative or degenerative abnormalities of the cranio-cervical joint which are the most frequently encountered in neurosurgery concern the occipital bone, the atlantoaxial joint and the surrounding nervous or vascular structures. These pathologies may have an acquired or congenital origin. In the last eventuality, they are frequently associated with other malformative disorders involving the vertebral column, the thorax, the kidneys or the heart. The clinical picture is various and many systems can be affected. Therefore, preoperative assessment of patients implies a multifactorial evaluation. The anesthesiologist should refer to the following check list: examination of the neck and cervical spine, neurological status, evaluation of associated diseases, pulmonary and cardiac function tests, airways permeability and conditions of endotracheal intubation.

Evidence for free radical formation during human kidney transplantation

Fourteen patients undergoing kidney transplantation were studied for evidence of the production of free radicals as assessed by the measurement of vitamin E (an index of lipid peroxidation) and of myeloperoxidase (a marker of neutrophil activation) in the systemic blood. Early (2 min) and late revascularization (30 min) of the kidney were respectively associated with a significant decrease of 35.5 and 40% of the initial level of plasma vitamin E. This consumption paralleled to the decrease of the vitamin E/total lipids ratio, a better indicator of vitamin E status. Heparin administration preceding renal artery clamping resulted in a twofold significant increase of baseline plasma myeloperoxidase (MPO) level (523 +/- 214 ng/ml). At kidney reperfusion, MPO concentration rose again and reached a maximum value of 1,653 +/- 882 ng/ml, indicating the presence of considerable neutrophil activation. A return to the baseline value was observed after 30 min of reperfusion. A short discussion about the possible origin of this MPO increase is given. Taken together, these data strongly suggest that free radical production, leading to lipid peroxidation phenomena, can occur within the early phase of kidney revascularization. Preliminary data using electron spin resonance with the spin-trapping technique strengthen this hypothesis.

In vivo free radical production after cross-clamping and reperfusion of the renal artery in the rabbit

Postischaemic reperfusion injury is often attributed to the generation of oxygenated free radicals which may subsequently promote lipid peroxidation in cell membranes. Electron paramagnetic resonance spectroscopy in association with the spin trap molecule alpha-phenyl-N-tert-butyl-nitrone allowed direct confirmation of lipid free radical production after renal ischaemia-reperfusion in an in vivo rabbit model. A 60-min period of ischaemia followed by reperfusion caused free radical production twofold greater than after 15 min of ischaemia. Glutathione and alpha-tocopherol have been measured in renal tissue, as indirect markers of lipid peroxidation. After 15 min of ischaemia followed by 10 min of reperfusion, the mean(s.e.m.) glutathione content of the ischaemic kidney was slightly but significantly reduced by 11.9(2.5)% (P < 0.003). The content of alpha-tocopherol was unchanged. However, 10 min of reperfusion following 60 min of ischaemia led to significant decrease in mean(s.e.m.) content of both glutathione (30.4(3.7)%) (2.23(0.2) versus 3.14(0.18) mumol/g wet tissue, P < 0.001) and alpha-tocopherol (46.1(7.8)%) (0.57(0.10) versus 1.09(0.14) micrograms/g wet tissue, P < 0.001) when compared to the control kidney. Under these experimental conditions, desferrioxamine (15 mg/kg administered intravenously before inducing ischaemia), a drug known to limit free radical production, significantly limited the decrease of alpha-tocopherol to 20.8(6.4)% (0.83(0.08) versus 1.05(0.04) micrograms/g wet tissue, P < 0.05), but did not prevent glutathione consumption in the reperfused kidney.

Comparison between alprazolam and hydroxyzine for oral premedication

The safety and efficacy of alprazolam and hydroxyzine administered orally as surgical premedicants were compared in a double-blind controlled study. Sixty-five patients were given either alprazolam 1 mg or hydroxyzine 75 mg, one to two hours before surgery. Anxiety was assessed by both the patient and the anaesthetist, the patient using a visual analogue scale, the anaesthetist employing both analogue and ordinal ratings. Sedation was assessed by the anaesthetist only, using the same two methods. Amnesia was appraised with a simple memory test. Safety was assessed by recording adverse effects and measuring haemodynamic variables. Premedication with alprazolam produced a modest reduction in anxiety (28%) (P < 0.01) while hydroxyzine had no detectable effect. The comparison of the sedation level and of the memory test revealed no difference between the two premedicants. Minor side effects were only observed in the hydroxyzine group. Changes in blood pressure were more pronounced in the hydroxyzine group. This study shows that alprazolam and hydroxyzine are safe and efficient oral premedicants. However, alprazolam is preferable to hydroxyzine in terms of anxiolytic and adverse effects.

[Oxygen metabolism and toxicity in the phenomenon of ischemia-reperfusion]

One of the major cause of human disease results from the compromise of blood flow and oxygen delivery to tissues. Ischemia phenomenon is defined as blood flow that is inadequate to maintain normal tissue function. Prolonged ischemia ultimately results in irreversible changes in cell metabolism and cell death. Historically, it was felt that if ischemia results in altered cell function and injury, then reoxygenation or reperfusion leading to a restoration of a normal blood flow was expected to have a beneficial effect and promote salvage of tissue depending on the extent of ischemia. Recent studies have, however, revealed that reoxygenation leads to an oxygen metabolism resulting in the generation of active and toxic oxygen intermediates (free radicals) which play an important role in the pathophysiology of reperfusion injury.

DNA strand breaks in human leukocytes induced by chemotherapy and total body irradiation

The occurrence of DNA strand breaks and/or DNA alkali-labile sites in peripheral blood leucocytes was demonstrated ex vivo in three patients during and after bone marrow ablative chemotherapy and total body irradiation (TBI) with use of fluorometric analysis of the DNA unwinding rate in alkaline solution (FADU assay). DNA damage was apparent after cyclophosphamide administration and after TBI, related to the amount of the applied dose. In vivo repair occurred within 24 hours, although not to pretreatment values. Demethoxydaunorubicin and busulfan at the dosages used did not induce measurable DNA strand breaks. The experiences described may be developed further to study ex vivo the occurrence of DNA lesions in patients during and after anticancer treatment. Such studies may be of value in comparing the DNA damaging potential of different chemotherapeutic or radiotherapeutic regimens and as a biological assessment of DNA damage after nuclear casualties in cases where the dose is greater than 1-2 Gy and measurement can be made within due time after the ionizing exposure.

Evidence of in vivo free radical generation by spin trapping with alpha-phenyl N-tert-butyl nitrone during ischemia/reperfusion in rabbit kidneys

By using alpha-phenyl N-tert-butyl nitrone (PBN) as spin trap molecule and the electron paramagnetic resonance (EPR) technique, we obtained the first direct evidence of in vivo intervention of free radicals during an ischemia (50 minutes) reperfusion phenomenon in kidney of an intact rabbit. An EPR signal (triplet of doublets) characterized by coupling constants aN = 14.75-15 G and aH beta = 2.5-3 G was detected in blood samples. The signal was consistent with a nitroxyl-radical adduct resulting from the spin trapping by PBN of either oxygen-or carbon-centered radicals. Control experiments indicated that the EPR signal was not due to a toxic effect of the spin trap molecule.

Improved outcome prediction based on CSF extrapolated creatine kinase BB isoenzyme activity and other risk factors in severe head injury

The present study of 43 patients with severe head injury shows that outcome prediction can be markedly improved by combining an appropriate marker of the degree of initial brain damage and other risk factors. The patients were classified into three groups according to their actual outcome after 6 months: death (22 patients); persistent vegetative state or severe disability (eight patients); and moderate disability or good recovery (13 patients). By applying stepwise logistic discriminant analysis to the patients' data, five significant risk factors were selected: degree of neurological damage assessed by cerebrospinal fluid (CSF) extrapolated creatine kinase BB isoenzyme activity, Glasgow-Liège Coma Scale score, age, incidence of thoracic injury, and intracranial pressure (ICP). Extrapolated creatine kinase BB activity had the highest prognostic ability (67%). Uncontrollable elevated ICP proved to be systematically associated with death, whereas its absence was not necessarily indicative of a favorable outcome. The combination of the five variables yielded a total prognostic efficiency of 91%. The percentages of correctly predicted patients for the three outcome groups were, respectively, 100%, 50%, and 100%. Thus, half of the persistently vegetative and severely disabled patients were identified by the selected factors.