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Malho Guedes A, Punzalan S, Brown EA, Ekstrand A, Gallieni M, Rivera Gorrín M, Gudmundsdottir H, Heidempergher M, Kitsche B, Lobbedez T, Hahn Lundström U, McCarthy K, Mellotte GJ, Moranne O, Petras D, Povlsen JV, Wiesholzer M. Assisted PD throughout Europe: advantages, inequities, and solution proposals. J Nephrol 2023; 36:2549-2557. [PMID: 37856067 PMCID: PMC10703983 DOI: 10.1007/s40620-023-01765-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/13/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Peritoneal dialysis provides several benefits for patients and should be offered as first line kidney replacement therapy, particularly for fragile patients. Limitation to self-care drove assisted peritoneal dialysis to evolve from family-based care to institutional programs, with specialized care givers. Some European countries have mastered this, while others are still bound by the availability of a volunteer to become responsible for treatment. METHODS A group of leading nephrologists from 13 European countries integrated real-life application of such therapy, highlighting barriers, lessons learned and practical solutions. The objective of this work is to share and summarize several different approaches, with their intrinsic difficulties and solutions, which might helpperitoneal dialysis units to develop and offer assisted peritoneal dialysis. RESULTS Assisted peritoneal dialysis does not mean 4 continuous ambulatory peritoneal dialysis exchanges, 7 days/week, nor does it exclude cycler. Many different prescriptions might work for our patients. Tailoring PD prescription to residual kidney function, thereby maintaining small solute clearance, reduces dialysis burden and is associated with higher technique survival. Assisted peritoneal dialysis does not mean assistance will be needed permanently, it can be a transitional stage towards individual or caregiver autonomy. Private care agencies can be used to provide assistance; other options may involve implementing PD training programs for the staff of nursing homes or convalescence units. Social partners may be interested in participating in smaller initiatives or for limited time periods. CONCLUSION Assisted peritoneal dialysis is a valid technique, which should be expanded. In countries without structural models of assisted peritoneal dialysis, active involvement by the nephrologist is needed in order for it to become a reality.
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Affiliation(s)
- Anabela Malho Guedes
- Serviço de Nefrologia, Centro Hospitalar Universitário Do Algarve, Faro, Portugal.
| | - Sally Punzalan
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Edwina A Brown
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Agneta Ekstrand
- Abdomen Centre, Nephrology Helsinki University Hospital, Helsinki, Finland
| | - Maurizio Gallieni
- Department of Biomedical and Clinical Sciences, Università Di Milano, Milan, Italy
- Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, Milan, Italy
| | | | | | | | - Benno Kitsche
- Kuratorium Für Dialyse Und Nierentransplantation E.V, Cologne, Germany
- NADia-Netzwerk assistierte Dialyse, Berlin, Germany
| | | | - Ulrika Hahn Lundström
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Kate McCarthy
- Baxter Healthcare Ltd, Wallingford, Compton, Newbury, UK
| | - George J Mellotte
- Trinity Health Kidney Centre, Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - Olivier Moranne
- Department of Nephrology-Dialysis-Apheresis, CHU Caremeau Nimes, IDESP Montpellier University, Nimes, France
| | - Dimitrios Petras
- Department of Nephrology, General Hospital 'Hippokration', Athens, Greece
| | - Johan V Povlsen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Martin Wiesholzer
- Clinical Department for Internal Medicine, University Hospital St Poelten, Karl Landsteiner University of Health Sciences, St Poelten, Austria
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Bjerre A, Aase SA, Radtke M, Siva C, Gudmundsdottir H, Forsberg B, Woldseth B, Brackman D. The effects of transitioning from immediate release to extended release cysteamine therapy in Norwegian patients with nephropathic cystinosis: a retrospective study. Pediatr Nephrol 2023; 38:3671-3679. [PMID: 37219641 PMCID: PMC10514171 DOI: 10.1007/s00467-023-06005-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 04/20/2023] [Accepted: 04/20/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Nephropathic cystinosis is a rare lysosomal storage disorder in which accumulation of cystine and formation of crystals particularly impair kidney function and gradually lead to multi-organ dysfunction. Lifelong therapy with the aminothiol cysteamine can delay the development of kidney failure and the need for transplant. The purpose of our long-term study was to explore the effects of transitioning from immediate release (IR) to extended release (ER) formulation in Norwegian patients in routine clinical care. METHODS We retrospectively analysed data on efficacy and safety in 10 paediatric and adult patients. Data were obtained from up to 6 years before and 6 years after transitioning from IR- to ER-cysteamine. RESULTS Mean white blood cell (WBC) cystine levels remained comparable between the different treatment periods (1.19 versus 1.38 nmol hemicystine/mg protein) although most patients under ER-cysteamine underwent dose reductions. For the non-transplanted patients, the mean estimated glomerular filtration rate (eGFR) change/year was more pronounced during ER-treatment (- 3.39 versus - 6.80 ml/min/1.73 m2/year) possibly influenced by individual events, such as tubulointerstitial nephritis and colitis. Growth measured by Z-height score tended to develop positively. Four of seven patients reported improvement of halitosis, one reported unchanged and two reported worsened symptoms. Most adverse drug reactions (ADRs) were of mild severity. One patient developed two serious ADRs and switched back to IR-formulation. CONCLUSIONS The results from this long-term retrospective study indicate that switching from IR- to ER-cysteamine was feasible and well tolerated under routine clinical practice. ER-cysteamine allowed satisfactory disease control over the long period considered. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Anna Bjerre
- Department for Specialised Paediatrics, Oslo University Hospital, Oslo, Norway.
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Sonja Amdal Aase
- Department of Paediatric and Adolescent Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Maria Radtke
- Department of Nephrology, St Olav's University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norge
| | - Christian Siva
- Paediatric Department, Vestfold Hospital, Tønsberg, Norway
| | | | | | - Berit Woldseth
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Damien Brackman
- Children and Adolescents Clinic, Haukeland University Hospital, Bergen, Norway
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Ljungman S, Jensen JE, Paulsen D, Petersons A, Ots-Rosenberg M, Saha H, Struijk D, Wilkie M, Heimbürger O, Stegmayr B, Elung-Jensen T, Johansson AC, Rydström M, Gudmundsdottir H, Hussain-Alkhateeb L. Factors associated with time to first dialysis-associated peritonitis episode: Data from the Peritonitis Prevention Study (PEPS). Perit Dial Int 2023:8968608231161179. [PMID: 37021365 DOI: 10.1177/08968608231161179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
INTRODUCTION Peritonitis remains a potentially serious complication of peritoneal dialysis (PD) treatment. It is therefore important to identify risk factors in order to reduce the incidence of peritonitis. The aim of the present analysis was to identify factors associated with time to first peritonitis episode. METHODS Incident PD patients from 57 centres in Europe participated in the prospective randomised controlled Peritonitis Prevention Study (PEPS) from 2010 to 2015. Peritonitis-free, self-care PD patients ≥18 years were randomised to a retraining or a control group and followed for 1-36 months after PD initiation. The association of biochemical, clinical and prescription data with time to first peritonitis episode was studied. RESULTS A first peritonitis episode was experienced by 33% (223/671) of participants. Univariable Cox proportional hazard regression showed a strong association between the time-updated number of PD bags connected per 24 h (PD bags/24 h) and time to first peritonitis episode (HR 1.35; 95% confidence interval (CI) 1.17-1.57), even after inclusion of PD modalities in the same model. Multivariable Cox regression revealed that the factors independently associated with time to first peritonitis episode included age (HR 1.16 per 10 years; 95% CI 1.05-1.28), PD bags/24 h (HR 1.32; 95% CI 1.13-1.54), serum albumin <35 versus >35 g/L (HR 1.39; 95% CI 1.06-1.82) and body weight per 10 kg (HR 1.10; 95% CI 1.01-1.19). CONCLUSION This study of incident PD patients indicates that older age, greater number of PD bags connected/24 h, higher body weight and hypoalbuminaemia are independently associated with a shorter time to first peritonitis episode.
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Affiliation(s)
- Susanne Ljungman
- Department of Nephrology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jørgen E Jensen
- Department of Nephrology, Odense University Hospital, Denmark
| | - Dag Paulsen
- Department of Medicine, Innlandet Hospital HF, Lillehammer, Norway
| | - Aivars Petersons
- Department of Medicine, Nephrology Center, Paul Stradins Clinical University Hospital, Riga, Latvia
| | | | - Heikki Saha
- Department of Internal Medicine, Tampere University Hospital, Finland
| | - Dirk Struijk
- Medisch Centrum, University of Amsterdam, Netherlands
| | - Martin Wilkie
- Department of Nephrology, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, UK
| | - Olof Heimbürger
- Patient Area Endocrinology and Nephrology, Karolinska University Hospital and Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Bernd Stegmayr
- Department of Nephrology, Public Health, and Clinical Medicine, University Hospital of Umeå, Sweden
| | - Thomas Elung-Jensen
- Department of Nephrology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | | | | | | | - Laith Hussain-Alkhateeb
- Global Health Unit, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Brown EA, Ekstrand A, Gallieni M, Gorrín MR, Gudmundsdottir H, Guedes AM, Heidempergher M, Kitsche B, Lobbedez T, Lundström UH, McCarthy K, Mellotte GJ, Moranne O, Petras D, Povlsen JV, Punzalan S, Wiesholzer M. Availability of assisted peritoneal dialysis in Europe: call for increased and equal access. Nephrol Dial Transplant 2022; 37:2080-2089. [PMID: 35671088 DOI: 10.1093/ndt/gfac193] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Availability of assisted PD (asPD) increases access to dialysis at home, particularly for the increasing numbers of older and frail people with advanced kidney disease. Although asPD has been widely used in some European countries for many years, it remains unavailable or poorly utilised in others. A group of leading European nephrologists have therefore formed a group to drive increased availability of asPD in Europe and in their own countries. METHODS Members of the group filled in a proforma with the following headings: personal experience, country experience, who are the assistants, funding of asPD, barriers to growth, what is needed to grow, and their top 3 priorities. RESULTS Only 5 of the 13 countries surveyed provided publicly funded reimbursement for asPD. The use of asPD depends on overall attitudes to PD with all respondents mentioning need for nephrology team education and/or patient education and involvement in dialysis modality decision making. CONCLUSION AND CALL TO ACTION Many people with advanced kidney disease would prefer to have their dialysis at home, yet if the frail patient chooses PD most healthcare systems cannot provide their choice. AsPD should be available in all countries in Europe and for all renal centres. The top priorities to make this happen are education of renal healthcare teams about the advantages of PD, education of and discussion with patients and their families as they approach the need for dialysis, and engagement with policy makers and healthcare providers to develop and support assistance for PD.
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Affiliation(s)
- Edwina A Brown
- Imperial College Healthcare NHS Trust, Imperial College Renal and Transplant Centre, London, UK
| | - Agneta Ekstrand
- Helsinki University Hospital, Abdomen Center, Nephrology, Helsinki, Finland
| | - Maurizio Gallieni
- Department of Biomedical and Clinical Sciences, Università di Milano, Italy.,Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, Milano, Italy
| | - Maite Rivera Gorrín
- Hospital Ramón y Cajal, Servicio de Nefrología. UAH. IRyCis. Carretera de Colmenar km 9, 100 28034 Madrid, Spain
| | | | - Anabela Malho Guedes
- Serviço de Nefrologia, Centro Hospitalar Universitário do Algarve, Faro, Portugal
| | | | - Benno Kitsche
- Kuratorium für Dialyse und Nierentransplantation e.V., Cologne.,NADia - Netzwerk assistierte Dialyse, Berlin, Germany
| | - Thierry Lobbedez
- Néphrologie, CHU CAEN, Avenue de la Côte de Nacre, CAEN CEDEX 9, France
| | - Ulrika Hahn Lundström
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Kate McCarthy
- Baxter Healthcare Ltd, Wallingford, Compton, Newbury, UK
| | - George J Mellotte
- Trinity Health Kidney Centre, Tallaght University Hospital, Tallaght, Dublin NROA
| | - Olivier Moranne
- Department Nephrology-Dialysis-Apheresis, CHU Caremeau Nimes, France
| | - Dimitrios Petras
- Department of Nephrology, General Hospital 'Hippokration', Athens, Greece
| | - Johan V Povlsen
- Dept. Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Sally Punzalan
- Imperial College Healthcare NHS Trust, Imperial College Renal and Transplant Centre, London, UK
| | - Martin Wiesholzer
- Clinical Department for Internal Medicine1, University Hospital St.Poelten, Austria, Karl Landsteiner University of Health Sciences
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5
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van Eck van der Sluijs A, van Jaarsveld BC, Allen J, Altabas K, Béchade C, Bonenkamp AA, Burkhalter F, Clause AL, Corbett RW, Dekker FW, Eden G, François K, Gudmundsdottir H, Lundström UH, de Laforcade L, Lambie M, Martin H, Pajek J, Panuccio V, Ros-Ruiz S, Steubl D, Vega A, Wojtaszek E, Davies SJ, Van Biesen W, Abrahams AC. Assisted peritoneal dialysis across Europe: Practice variation and factors associated with availability. Perit Dial Int 2021; 41:533-541. [PMID: 34672219 DOI: 10.1177/08968608211049882] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In Europe, the number of elderly end-stage kidney disease patients is increasing. Few of those patients receive peritoneal dialysis (PD), as many cannot perform PD autonomously. Assisted PD programmes are available in most European countries, but the percentage of patients receiving assisted PD varies considerably. Hence, we assessed which factors are associated with the availability of an assisted PD programme at a centre level and whether the availability of this programme is associated with proportion of home dialysis patients. METHODS An online survey was sent to healthcare professionals of European nephrology units. After selecting one respondent per centre, the associations were explored by χ 2 tests and (ordinal) logistic regression. RESULTS In total, 609 respondents completed the survey. Subsequently, 288 respondents from individual centres were identified; 58% worked in a centre with an assisted PD programme. Factors associated with availability of an assisted PD programme were Western European and Scandinavian countries (OR: 5.73; 95% CI: 3.07-10.68), non-academic centres (OR: 2.01; 95% CI: 1.09-3.72) and centres with a dedicated team for education (OR: 2.87; 95% CI: 1.35-6.11). Most Eastern & Central European respondents reported that the proportion of incident and prevalent home dialysis patients was <10% (72% and 63%), while 27% of Scandinavian respondents reported a proportion of >30% for both incident and prevalent home dialysis patients. Availability of an assisted PD programme was associated with a higher incidence (cumulative OR: 1.91; 95% CI: 1.21-3.01) and prevalence (cumulative OR: 2.81; 95% CI: 1.76-4.47) of patients on home dialysis. CONCLUSIONS Assisted PD was more commonly offered among non-academic centres with a dedicated team for education across Europe, especially among Western European and Scandinavian countries where higher incidence and prevalence of home dialysis patients was reported.
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Affiliation(s)
| | - Brigit C van Jaarsveld
- Department of Nephrology, 522567Amsterdam UMC, Vrije Universiteit Amsterdam, Research institute Amsterdam Cardiovascular Sciences, the Netherlands.,Diapriva Dialysis Centre, Amsterdam, the Netherlands
| | - Jennifer Allen
- Renal and Transplant Unit, 9820Nottingham University NHS Trust, UK
| | - Karmela Altabas
- Division of Nephrology and Dialysis, Clinical Hospital Centre Sestre Milosrdnice, Zagreb, Croatia
| | - Clémence Béchade
- Service Néphrologie-Dialyse-Transplantation, Normandie University, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Anna A Bonenkamp
- Department of Nephrology, 522567Amsterdam UMC, Vrije Universiteit Amsterdam, Research institute Amsterdam Cardiovascular Sciences, the Netherlands
| | - Felix Burkhalter
- Division of Nephrology, University Clinic of Medicine, 367307Kantonsspital Baselland, Liestal, Switzerland
| | | | - Richard W Corbett
- Renal and Transplant Centre, Hammersmith Hospital, 8946Imperial College Healthcare NHS Trust, London, UK
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Centre, the Netherlands
| | - Gabriele Eden
- Medical Clinic V (Nephrology, Rheumatology, Blood Purification), Academic Teaching Hospital Braunschweig, Germany
| | - Karlien François
- Division of Nephrology and Hypertension, Vrije Universiteit Brussel, 60201Universitair Ziekenhuis Brussel, Belgium
| | | | - Ulrika Hahn Lundström
- Division of Renal Medicine, 206106Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Louis de Laforcade
- Service d'Endocrinologie-Néphrologie, 377376Centre Hospitalier Pierre Oudot, Bourgoin-Jallieu, France
| | - Mark Lambie
- Faculty of Medicine and Health Science, Keele University, Stoke on Trent, UK
| | | | - Jernej Pajek
- Department of Nephrology, University Medical Centre Ljubljana, Slovenia and Medical Faculty, University of Ljubljana, Slovenia
| | - Vincenzo Panuccio
- Nephrology, Dialysis and Renal Transplant Unit, Grande Ospedale Metropolitano 'Bianchi Melacrino Morelli', Reggio Calabria, Italy
| | - Silvia Ros-Ruiz
- Department of Nephrology, Elche University General Hospital, Alicante, Spain
| | - Dominik Steubl
- Faculty of Medicine, Klinikum rechts der Isar, Technical University Munich, Germany
| | - Almudena Vega
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ewa Wojtaszek
- Department of Nephrology, Dialysis & Internal Diseases, The Medical University of Warsaw, Poland
| | - Simon J Davies
- Faculty of Medicine and Health Science, Keele University, Stoke on Trent, UK
| | - Wim Van Biesen
- Department of Nephrology, Ghent University Hospital, Belgium
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, 8124University Medical Centre Utrecht, the Netherlands
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6
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Hahn Lundström U, Abrahams AC, Allen J, Altabas K, Béchade C, Burkhalter F, Clause AL, Corbett RW, Eden G, François K, de Laforcade L, Lambie M, Martin H, Pajek J, Panuccio V, Ros-Ruiz S, Steubl D, Vega A, Wojtaszek E, Zaloszyc A, Davies SJ, Van Biesen W, Gudmundsdottir H. Barriers and opportunities to increase PD incidence and prevalence: Lessons from a European Survey. Perit Dial Int 2021; 41:542-551. [PMID: 34409901 DOI: 10.1177/08968608211034988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION Peritoneal dialysis (PD) remains underutilised and unplanned start of dialysis further diminishes the likelihood of patients starting on PD, although outcomes are equal to haemodialysis (HD). METHODS A survey was sent to members of EuroPD and regional societies presenting a case vignette of a 48-year-old woman not previously known to the nephrology department and who arrives at the emergency department with established end-stage kidney disease (unplanned start), asking which dialysis modality would most likely be chosen at their respective centre. We assessed associations between the modality choices for this case vignette and centre characteristics and PD-related practices. RESULTS Of 575 respondents, 32.8%, 32.2% and 35.0% indicated they would start unplanned PD, unplanned HD or unplanned HD with intention to educate patient on PD later, respectively. Likelihood for unplanned start of PD was only associated with quality of structure of the pre-dialysis program. Structure of pre-dialysis education program, PD program in general, likelihood to provide education on PD to unplanned starters, good collaboration with the PD access team and taking initiatives to enhance home-based therapies increased the likelihood unplanned patients would end up on PD. CONCLUSIONS Well-structured pre-dialysis education on PD as a modality, good connections to dedicated PD catheter placement teams and additional initiatives to enhance home-based therapies are key to grow PD programs. Centres motivated to grow their PD programs seem to find solutions to do so.
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Affiliation(s)
- Ulrika Hahn Lundström
- Division of Renal Medicine, 206106Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, 8124University Medical Center Utrecht, The Netherlands
| | - Jennifer Allen
- Renal and Transplant Unit, 9820Nottingham University NHS Trust, UK
| | - Karmela Altabas
- Division of Nephrology and Dialysis, Clinical Hospital Center Sestre Milosrdnice, Zagreb, Croatia
| | - Clémence Béchade
- Service Néphrologie-Dialyse-Transplantation, Normandie University, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Felix Burkhalter
- Division of Nephrology, University Clinic of Medicine, 367307Kantonsspital Baselland, Liestal, Switzerland
| | | | - Richard W Corbett
- Renal and Transplant Centre, Hammersmith Hospital, 8946Imperial College Healthcare NHS Trust, London, UK
| | - Gabriele Eden
- Medical Clinic V: Nephrology
- Rheumatology
- Blood Purification, Academic Teaching Hospital Braunschweig, Braunschweig, Germany
| | - Karlien François
- Division of Nephrology and Hypertension, Vrije Universiteit Brussel, 60201Universitair Ziekenhuis Brussel, Brussel, Belgium
| | - Louis de Laforcade
- Service d'Endocrinologie-Néphrologie, 377376Centre Hospitalier Pierre Oudot, Bourgoin-Jallieu, France
| | - Mark Lambie
- Institute of Applied Clinical Sciences, Keele University, Stoke on Trent, UK
| | | | - Jernej Pajek
- Department of Nephrology, 37663University Medical Centre Ljubljana, Slovenia and Medical Faculty, University of Ljubljana, Slovenia
| | - Vincenzo Panuccio
- Nephrology, Dialysis and Renal Transplant Unit, Grande Ospedale Metropolitano 'Bianchi Melacrino Morelli', Reggio Calabria, Italy
| | - Silvia Ros-Ruiz
- Department of Nephrology, Elche University General Hospital, Alicante, Spain
| | - Dominik Steubl
- Department of Nephrology, Faculty of Medicine, 27190Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Almudena Vega
- Department of Nephrology, 16483Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ewa Wojtaszek
- Department of Nephrology, Dialysis and Internal Diseases, 37803The Medical University of Warsaw, Poland
| | - Ariane Zaloszyc
- Department of Pediatrics 1, 27083University Hospital of Strasbourg, Strasbourg, France
| | - Simon J Davies
- Faculty of Medicine and Health Science, Keele University, Stoke on Trent, UK
| | - Wim Van Biesen
- Department of Nephrology, 26656Ghent University Hospital, Belgium
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Ljungman S, Jensen JE, Paulsen D, Petersons A, Ots-Rosenberg M, Saha H, Struijk DG, Wilkie M, Heimbürger O, Stegmayr B, Elung-Jensen T, Johansson AC, Rydström M, Gudmundsdottir H, Petzold M. Retraining for prevention of peritonitis in peritoneal dialysis patients: A randomized controlled trial. Perit Dial Int 2020; 40:141-152. [PMID: 32063220 DOI: 10.1177/0896860819887626] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Peritonitis is more common in peritoneal dialysis (PD) patients nonadherent to the PD exchange protocol procedures than in compliant patients. We therefore investigated whether regular testing of PD knowledge with focus on infection prophylaxis could increase the time to first peritonitis (primary outcome) and reduce the peritonitis rate in new PD patients. METHODS This physician-initiated, open-label, parallel group trial took place at 57 centers in Sweden, Denmark, Norway, Finland, Estonia, Latvia, the Netherlands, and the United Kingdom from 2010 to 2015. New peritonitis-free PD patients were randomized using computer-generated numbers 1 month after the start of PD either to a control group (n = 331) treated according to center routines or to a retraining group (n = 340), which underwent testing of PD knowledge and skills at 1, 3, 6, 12, 18, 24, 30, and 36 months after PD start, followed by retraining if the goals were not achieved. RESULTS In all, 74% of the controls and 80% of the retraining patients discontinued the study. The groups did not differ significantly regarding cumulative incidence of first peritonitis adjusted for competing risks (kidney transplantation, transfer to hemodialysis and death; hazard ratio 0.84; 95% confidence interval (CI) 0.65-1.09) nor regarding peritonitis rate per patient year (relative risk 0.93; 95% CI 0.75-1.16). CONCLUSIONS In this randomized controlled trial, we were unable to demonstrate that regular, targeted testing and retraining of new PD patients increased the time to first peritonitis or reduced the rate of peritonitis, as the study comprised patients with a low risk of peritonitis, was underpowered, open to type 1 statistical error, and contamination between groups.
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Affiliation(s)
- Susanne Ljungman
- Department of Nephrology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jørgen E Jensen
- Department of Nephrology, Odense University Hospital, Denmark
| | - Dag Paulsen
- Department of Medicine, Innlandet Hospital HF, Lillehammer, Norway
| | - Aivars Petersons
- Nephrology Center, Department of Medicine, P. Stradins Clinical University Hospital, Riga, Latvia
| | - Mai Ots-Rosenberg
- Department of Internal Medicine, University Hospital of Tartu, Estonia
| | - Heikki Saha
- Department of Internal Medicine, Tampere University Hospital, Finland
| | - Dirk G Struijk
- Medisch Centrum, University of Amsterdam, the Netherlands
| | - Martin Wilkie
- Renal Unit, Department of Nephrology, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, UK
| | - Olof Heimbürger
- Patient Area Endocrinology and Nephrology, Karolinska University Hospital and Department of Clinical Science, Intervention, and Technology, Karolinska Institute, Stockholm, Sweden
| | - Bernd Stegmayr
- Department of Nephrology, Public Health, and Clinical Medicine, Umeå University, Sweden
| | - Thomas Elung-Jensen
- Department of Nephrology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | | | | | | | - Max Petzold
- Health Metrics Unit, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
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Ljungman S, Jensen J, Paulsen D, Petersons A, Rosenberg M, Saha H, Struijk D, Wilkie M, Heimburger O, Stegmayr B, Elung Jensen T, Johansson AC, Rydström M, Gudmundsdottir H, Petzold M. MO058PREVENTION OF PERITONITIS IN PATIENTS WITH PERITONEAL DIALYSIS - EFFECTS OF REGULAR, TARGETED FOLLOW-UP OF PATIENTS´ THEORETICAL KNOWLEDGE AND PRACTICAL SKILLS WITH FOCUS ON INFECTION PROPHYLAXIS (PEPS) - A RANDOMIZED, CONTROLLED TRIAL. Nephrol Dial Transplant 2017. [DOI: 10.1093/ndt/gfx124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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9
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Brekke FB, Waldum B, Amro A, Østhus TBH, Dammen T, Gudmundsdottir H, Os I. Self-perceived quality of sleep and mortality in Norwegian dialysis patients. Hemodial Int 2013; 18:87-94. [DOI: 10.1111/hdi.12066] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - Bård Waldum
- Faculty of Medicine; University of Oslo; Oslo Norway
- Department of Nephrology; Oslo University Hospital Ullevål; Oslo Norway
| | - Amin Amro
- Faculty of Medicine; University of Oslo; Oslo Norway
| | - Tone B. H. Østhus
- Department of Nephrology; Oslo University Hospital Ullevål; Oslo Norway
| | - Toril Dammen
- Faculty of Medicine; University of Oslo; Oslo Norway
| | | | - Ingrid Os
- Faculty of Medicine; University of Oslo; Oslo Norway
- Department of Nephrology; Oslo University Hospital Ullevål; Oslo Norway
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Gudmundsdottir H, Høieggen A, Stenehjem A, Waldum B, Os I. Hypertension in women: latest findings and clinical implications. Ther Adv Chronic Dis 2012; 3:137-46. [PMID: 23251774 DOI: 10.1177/2040622312438935] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Cardiovascular disease claims more women's lives than any other disease. Hypertension is an important risk factor for cardiovascular disease in women but is often underestimated and undiagnosed and there is an ongoing misperception that women are at a lower risk of cardiovascular disease than men. The attainment of clinical blood pressure goals can markedly reduce cardiovascular morbidity and mortality, yet approximately two-thirds of treated hypertensive women have uncontrolled blood pressure. Furthermore, there are special risk factors that are unique for women that needs acknowledgement in order to help prevent the great number of hypertension-related events in women. Guidelines for treatment of hypertension are similar for men and women. More studies on the interaction between gender and response to antihypertensive drugs would be of interest.
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Strand A, Gudmundsdottir H, Høieggen A, Fossum E, Bjørnerheim R, Os I, Kjeldsen SE. Increased hematocrit before blood pressure in men who develop hypertension over 20 years. ACTA ACUST UNITED AC 2012; 1:400-6. [PMID: 20409872 DOI: 10.1016/j.jash.2007.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2007] [Revised: 07/02/2007] [Accepted: 07/09/2007] [Indexed: 12/01/2022]
Abstract
We have previously demonstrated that neurohormonal activity can predict left ventricular (LV) mass in men who developed hypertension over 20 years. The aim of the study was to investigate early markers of cardiac and hemorheological changes at baseline in these men, i.e., before a rise in blood pressure. Fifty-six middle-aged men were followed for 20 years; 22 were sustained hypertensives, 17 developed hypertension, and 17 were sustained normotensives. They were compared at baseline (42 years) and follow-up (62 years). We investigated Cornell voltage product and Sokolow-Lyon voltage, hematocrit (Hct), and echocardiographic LV parameters. There was no sign of LV hypertrophy by electrocardiography (ECG) at baseline. Baseline Hct discriminated between the groups (P= .015) and correlated to diastolic blood pressure (DBP) at baseline (r = 0.37, P= .006) and follow-up (r = 0.31, P= .020). Regression analysis identified baseline Hct as an independent correlate of DBP in the cohort at baseline when they were untreated (beta = .33, P= .013, R(2) = 0.25), and of borderline significance at follow-up (beta = .26, P= .060, R(2) = 0.12) despite possible interference by antihypertensive drugs. Hct was elevated at baseline compatible with the hypothesis that pathogenic hemorheological processes could be activated at the outset and prior to cardiac changes in men who later develop hypertension.
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Affiliation(s)
- Arne Strand
- Department of Cardiology, Ullevaal University Hospital, Oslo, Norway
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12
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Krogvold L, Henrichsen T, Bjerre A, Brackman D, Dollner H, Gudmundsdottir H, Syversen G, Næss PA, Bangstad HJ. Clinical aspects of a nationwide epidemic of severe haemolytic uremic syndrome (HUS) in children. Scand J Trauma Resusc Emerg Med 2011; 19:44. [PMID: 21798000 PMCID: PMC3160365 DOI: 10.1186/1757-7241-19-44] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Accepted: 07/28/2011] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Report a nationwide epidemic of Shiga toxin-producing E. coli (STEC) O103:H25 causing hemolytic uremic syndrome (D+HUS) in children. METHODS Description of clinical presentation, complications and outcome in a nationwide outbreak. RESULTS Ten children (median age 4.3 years) developed HUS during the outbreak. One of these was presumed to be a part of the outbreak without microbiological proof. Eight of the patients were oligoanuric and in need of dialysis. Median need for dialysis was 15 days; one girl did not regain renal function and received a kidney transplant. Four patients had seizures and/or reduced consciousness. Cerebral oedema and herniation caused the death of a 4-year-old boy. Two patients developed necrosis of colon with perforation and one of them developed non-autoimmune diabetes. CONCLUSION This outbreak of STEC was characterized by a high incidence of HUS among the infected children, and many developed severe renal disease and extrarenal complications. A likely explanation is that the O103:H25 (eae and stx2-positive) strain was highly pathogen, and we suggest that this serotype should be looked for in patients with HUS caused by STEC, especially in severe forms or outbreaks.
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Affiliation(s)
- Lars Krogvold
- Department of Paediatrics, Oslo University hospital, Ulleval, 7 Oslo, Norway.
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13
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Os I, Gudmundsdottir H, Draganov B, von der Lippe E. Sterile Peritonitis Associated with Amino Acid–Containing Dialysate—a Single Center Experience in Norway. Perit Dial Int 2011; 31:103. [DOI: 10.3747/pdi.2010.00298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- I. Os
- Nephrology Oslo University Hospital Oslo, Norway
| | | | - B. Draganov
- Nephrology Oslo University Hospital Oslo, Norway
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14
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Gudmundsdottir H, Strand AH, Kjeldsen SE, Høieggen A, Os I. Serum phosphate, blood pressure, and the metabolic syndrome--20-year follow-up of middle-aged men. J Clin Hypertens (Greenwich) 2009; 10:814-21. [PMID: 19128269 DOI: 10.1111/j.1751-7176.2008.00032.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The authors investigated the relationship between serum phosphate (S-phosphate) and the metabolic syndrome in a group of middle-aged hypertensive and normotensive men during 20-year follow-up. Fifty-six men participated. Of the original 34 normotensive men, hypertension developed in 17. In the group as a whole and in those in whom hypertension developed, there was a significant negative relationship between S-phosphate at baseline and mean blood pressure (MBP) at follow-up. A significant relationship was observed between S-phosphate at baseline and components of the metabolic syndrome in the group as a whole, in individuals with hypertension, and in individuals with the lowest S-phosphate levels at follow-up. S-phosphate at baseline predicted MBP 20 years later in a group of hypertensive and normotensive men. When grouped according to the number of components of the metabolic syndrome, individuals with the lowest serum phosphate levels had the highest number of risk factors. These findings may suggest a role of low S-phosphate in the development of hypertension and the metabolic syndrome.
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Gudmundsdottir H, Strand AH, Høieggen A, Reims HM, Westheim AS, Eide IK, Kjeldsen SE, Os I. Do screening blood pressure and plasma catecholamines predict development of hypertension? Twenty-year follow-up of middle-aged men. Blood Press 2008; 17:94-103. [PMID: 18568698 DOI: 10.1080/08037050801972923] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The sympathetic nervous system is implicated in the development and maintenance of hypertension. However, the predictive impact of arterial plasma catecholamines has never been reported. We investigated arterial catecholamines and blood pressures (BPs) prospectively over 20 years in a group of well-characterized middle-aged men. METHODS Fifty-six of original 79 men were available for the follow-up. Multiple regression analysis was done with mean BP at follow-up as a dependent variable, and arterial plasma catecholamines and BP at baseline as independent variables. RESULTS Half of the originally normotensive men developed hypertension during follow-up. There were significant differences in the screening BP values measured at baseline between the new hypertensives and the sustained normotensives. Multiple regression analysis revealed arterial adrenaline at baseline as an independent predictor of mean BP at follow-up in the new hypertensives (beta = 0.646, R2 = 0.42, p = 0.007). Furthermore, arterial noradrenaline at baseline was a negative independent predictor of mean BP at follow-up in the sustained normotensives (beta = -0.578, R2 = 0.334, p = 0.020). Noradrenaline increased with age in the group as a whole (1318+/-373 vs 1534+/-505 pmol/l, p = 0.010) while adrenaline did not change. CONCLUSION Our data suggest that arterial adrenaline is involved in the development of hypertension over 20 years in middle-aged men. Men with sustained normotension may have an inherent protection against sympathetic overactivity. Furthermore, screening BP at baseline in normotensive men differentiated between those who developed hypertension and those who remained normotensive at follow-up.
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Gudmundsdottir H, Brørs O, Os I. [Metformin should not be used by patients with reduced renal function]. Tidsskr Nor Laegeforen 2008; 128:936-937. [PMID: 18431417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
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Strand AH, Gudmundsdottir H, Fossum E, Os I, Bjørnerheim R, Kjeldsen SE. Arterial Plasma Vasopressin and Aldosterone Predict Left Ventricular Mass in Men Who Develop Hypertension Over 20 Years. J Clin Hypertens (Greenwich) 2007; 9:365-71. [PMID: 17485972 PMCID: PMC8109877 DOI: 10.1111/j.1524-6175.2007.06479.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Left ventricular (LV) hypertrophy is related to blood pressure level and neurohormonal factors. The authors previously demonstrated that arterial norepinephrine levels predict LV mass in middle-aged men who developed hypertension through 20 years. The aim of this 20-year prospective study was to investigate arterial vasopressin, aldosterone, and renin as long-term predictors of LV mass. Normotensives (n=17), subjects who developed hypertension (n=17), and sustained hypertensives (n=22) were compared at baseline (42 years) and at follow-up (62 years). There were no significant differences in baseline vasopressin, aldosterone, or renin levels. The group with sustained hypertension had more LV hypertrophy (P=.025) at follow-up. Among new hypertensives, multiple regression analysis demonstrated that baseline arterial vasopressin (beta-0.53; P=.041) and aldosterone (beta-0.56;P=.032) independently explained LV mass index (R(2)=0.85; P=.035). In conclusion, baseline arterial vasopressin and aldosterone, but not renin, appear to predict LV mass in middle-aged men who developed hypertension over a 20-year period.
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Affiliation(s)
- Arne H Strand
- Department of Cardiology, Ullevaal University Hospital, Oslo, Norway.
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Strand A, Kjeldsen SE, Gudmundsdottir H, Os I, Smith G, Bjørnerheim R. Tissue Doppler imaging describes diastolic function in men prone to develop hypertension over twenty years. Eur J Echocardiogr 2007; 9:34-9. [PMID: 17448731 DOI: 10.1016/j.euje.2007.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS Hypertension is one of several risk factors of cardiovascular disease and is associated with left ventricular (LV) systolic and diastolic dysfunction. A method for reliably detecting the onset of LV dysfunction before transition to irreversible damage of the myocardium would be of crucial importance in subjects with essential hypertension. METHODS AND RESULTS Subjects with clear differences in BP level, development and duration of the hypertensive disease were examined at the age of 60 yrs: normotensives (n = 17), new hypertensives who developed hypertension over a 20 year period (n = 15) and hypertensives (n = 19). Relationships between conventional echocardiographic and tissue velocities imaging (TVI) parameters compared to LV parameters, and TVI as an estimate of LV function were explored. E'(Lat) (TVI peak early diastolic velocity) (P = 0.006) and E/E'(Lat) (P = 0.002) demonstrated differences in diastolic function between the groups. There were no significant differences regarding systolic myocardial velocities. E'(Lat) correlated to S'(Lat) (TDI peak systolic velocity) (r = 0.32, P = 0.026) and was independently predicted by S'(Lat) (R(2) = 0.24, P = 0.025) in multivariate analysis. E'(Lat) correlated negatively to LV mass index (r = -0.34, P = 0.012), also in multivariate regression analysis (R(2) = 0.12, P = 0.032). CONCLUSIONS Myocardial diastolic velocities and mitral flow to annulus velocity ratio differentiated LV function between the hypertensive and normotensive groups. The parameters probably reflect changes in relaxation, recoil and contraction and parallel changes in LV mass index.
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Affiliation(s)
- A Strand
- Department of Cardiology, Ullevaal University Hospital, Oslo, Norway.
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Strand AH, Gudmundsdottir H, Os I, Smith G, Westheim AS, Bjørnerheim R, Kjeldsen SE. Arterial plasma noradrenaline predicts left ventricular mass independently of blood pressure and body build in men who develop hypertension over 20 years. J Hypertens 2006; 24:905-13. [PMID: 16612253 DOI: 10.1097/01.hjh.0000222761.07477.7b] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Increased sympathetic activity may be an underlying mechanism in cardiovascular disease. It has been hypothesized that the degree of left ventricular (LV) hypertrophy is partly related to the blood pressure level, and partly to neurohormonal factors. The aim of this study was to investigate predictors of LV mass, including arterial plasma noradrenaline as an index of sympathetic activity, with particular emphasis on subjects who developed hypertension over a period of 20 years. METHODS In a 20-year prospective study of middle-aged men, sustained hypertensives (n = 22), new hypertensives (crossovers) (n = 17) and sustained normotensives (controls) (n = 17) were examined both at baseline and after 20 years of follow-up (at ages 42.1 +/- 0.5 and 62.3 +/- 0.6 years, respectively). Relationships between arterial plasma catecholamines, blood pressure and body mass index at baseline to left ventricular parameters by echocardiography at follow-up were investigated. RESULTS Groups were homogeneous regarding age, gender, race and body build. The group of sustained hypertensives had significantly more LV hypertrophy (P = 0.025) and diastolic dysfunction (P = 0.010). Among the crossovers, LV mass index was positively correlated to arterial plasma noradrenaline (r = 0.50, P = 0.043) and body mass index (BMI) (r = 0.51, P = 0.039) and showed a positive trend with systolic blood pressure (SBP) at baseline. Arterial plasma noradrenaline (beta = 0.47) was found to predict LV mass index after 20 years independently of BMI (beta = 0.45) and SBP (beta = 0.22) at baseline (R adjusted = 0.345, P = 0.037). Such a relationship was not found in the controls or in the sustained hypertensives, of which 16 were treated with antihypertensive drugs. CONCLUSIONS Arterial plasma noradrenaline at baseline, as an index of sympathetic activity, predicts LV mass at follow-up independently of systolic blood pressure and body build in middle-aged men who developed hypertension over a period of 20 years.
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Affiliation(s)
- Arne H Strand
- Department of Cardiology, Ullevaal University Hospital, Oslo, Norway.
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Gudmundsdottir H, Aksnes H, Heldal K, Krogh A, Froyshov S, Rudberg N, Os I. Metformin and antihypertensive therapy with drugs blocking the renin angiotensin system, a cause of concern? Clin Nephrol 2006; 66:380-5. [PMID: 17140168 DOI: 10.5414/cnp66380] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The burden of diabetes mellitus type 2 (DM2) is increasing worldwide. The combination of DM2 and hypertension (HT) is frequently encountered. Concurrent use of drugs blocking the renin angiotensin system (angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB)) and metformin have become frequent in this group of patients. That combination can become life-threatening under certain circumstances. METHOD We present 5 patients with DM2 and HT who developed severe metformin-associated lactic acidosis in a setting with acute renal failure, precipitated by dehydration and aggravated by the use of ACEI or ARB. RESULTS None of the patients had reduced renal function before the acute illness. They were admitted to the hospital in critical condition with severe metabolic acidosis (pH 6.60 6.94), high S-lactate (14 - 23 mmol/l) and S-creatinine 796 1,621 micromol/l. They were all hypothermic and 3 were hypoglycemic. All developed circulatory and respiratory collapse. They were treated with either intermittent bicarbonate hemodialysis (HD) or with continuous venovenous hemodiafiltration (CVVHDF) and bicarbonate buffering. All patients recovered without renal sequela. CONCLUSION We believe that the incidence of metformin-associated lactic acidosis in Norway may become more frequent due to increased use of metformin and drugs blocking the renin angiotensin system. The awareness of lactic acidosis as a complication to the use ofmetformin in predisposed individuals is important. General advice should be given to patients regarding reduction of dosage or withdrawal of the drugs during acute intercurrent illness with dehydration. Early diagnosis and treatment of metformin-associated lactic acidosis are crucial for the patient outcome. Hemodialysis can be life-saving and should be started without delay.
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Affiliation(s)
- H Gudmundsdottir
- Department of Nephrology, Ulleval University Hospital, Oslo, Norway.
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Abstract
Age-related arterial stiffness is more pronounced in diabetics compared to non-diabetics, which could explain the prevalence of isolated systolic hypertension (ISH, systolic blood pressure > or =140 mmHg and diastolic blood pressure <90 mmHg) being approximately twice that of the general population without diabetes. Large-scale interventional outcome trials have also shown that diabetics usually have higher pulse pressure and higher systolic blood pressure than non-diabetics. Advanced glycation end-product formation has been implicated in vascular and cardiac complications of diabetes including loss of arterial elasticity, suggesting possibilities for new therapeutic options. With increasing age, there is a shift to from diastolic to systolic blood pressure and pulse pressure as predictors of cardiovascular disease. This may affect drug treatment as different antihypertensive drugs may have differential effects on arterial stiffness that can be dissociated from their effects on blood pressure. While thiazide diuretics are associated with little or no change in arterial stiffness despite a robust antihypertensive effect, angiotensin converting enzyme inhibitors, angiotensin II receptor blockers and calcium-channel blockers have been shown to reduce arterial stiffness. However, combination therapy is nearly always necessary to obtain adequate blood pressure control in diabetics. There are no randomized controlled trials looking specifically at treatment of ISH in diabetics. Recommendations regarding treatment of ISH in diabetes mellitus type 2 are based on extrapolation from studies in non-diabetics, post-hoc analyses and prespecified subgroup analysis in large-scale studies, and metaanalysis. These analyses have clearly demonstrated that blood pressure lowering in ISH confers improved prognosis and reduced cardiovascular and renal outcomes in both diabetics and non-diabetics.
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Affiliation(s)
- Ingrid Os
- Faculty Division Ulleval, School of Medicine, University of Oslo, Oslo, Norway.
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Abstract
OBJECTIVE As hypertension is an important risk factor for renal allograft failure, we aimed to assess blood pressure control in renal transplant patients with deteriorating graft function using different methods of blood pressure measurements. METHODS Forty-nine patients with a graft survival of >1 year, and with more than a two-fold increase in urinary albumin excretion, and/or an increase in serum creatinine level >20% during the previous 12 months, were included. Office blood pressure and home BP were measured, and ambulatory blood pressures were obtained in all patients. RESULTS The mean office blood pressure (133.2+/-16.3/81.7+/-9.6 mmHg) and 24 h ambulatory blood pressure (133.1+/-12.0/79.8+/-8.3 mmHg) were similar. Home blood pressure in the morning (144.2+/-23.3/87.1+/-12.7 mmHg) and evening (143.2+/-20.6/86.4+/-10.3 mmHg) were significantly higher than ambulatory blood pressure (P<0.001 for both). Only 18% of the patients exhibited a reduction of >or=10% in systolic blood pressure during nighttime while 39% had an overt rise. Adequate blood pressure control was found in 53% of the patients using office blood pressure (<140/90 mmHg), contrasting 29% using home blood pressure (<135/85 mmHg), and 16% using mean 24-h ambulatory blood pressure (<125/80 mmHg). These findings were substantiated by the use of receiver-operating characteristic curve analysis. CONCLUSIONS Using the 24-h blood pressure as a standard, home blood pressure was superior to office blood pressure in estimating blood pressure control in renal transplant patients. Nocturnal hypertension, however, was observed frequently, adding important clinical information about blood pressure control in this high-risk population.
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Affiliation(s)
- Aud-E Stenehjem
- Department of Nephrology, Ullevål University Hospital, Oslo, Norway.
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Prøsch LK, Saelen MG, Gudmundsdottir H, Dyrbekk D, Hunderi OH, Arnesen E, Paulsen D, Skjønsberg H, Os I. Blood pressure control is hard to achieve in patients with chronic renal failure: results from a survey of renal units in Norway. ACTA ACUST UNITED AC 2005; 39:242-8. [PMID: 16127803 DOI: 10.1080/00365590510007810-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To assess the use of antihypertensive drugs and blood pressure (BP) levels in relation to current guidelines for BP control in patients with chronic renal failure (CRF). MATERIAL AND METHODS A cross-sectional survey was carried out in six renal outpatient clinics in Oslo and the surrounding area. The hospital records of all renal patients not yet in need of renal replacement therapy and with serum creatinine>or=200 micromol/l who attended consultations with nephrologists regularly (at least every third month) were reviewed. RESULTS Of the 351 patients, 97% had hypertension. the majority of patients (96%) were receiving antihypertensive therapy. The average number of antihypertensive drugs being taken was 2.7+/-1.3 (median 3), but it varied with the cause of CRF. The drugs most frequently prescribed as monotherapy were angiotensin-converting enzyme inhibitors or angiotensin II receptor antagonists, which were used by 32%; 51% of patients were using three or more antihypertensive drugs. Loop diuretics were prescribed as monotherapy in 25% of cases and in combination with two or more other drugs in 87%. Age and serum creatinine levels influenced the choice of antihypertensive therapy. The target BP of <130/80 mmHg was obtained in 13% of patients, and lack of optimal BP control was mainly due to systolic hypertension. A total of 38% of patients had a BP of <140/90 mmHg, while 58% failed to achieve a systolic BP of <140 mmHg. CONCLUSION Optimal blood pressure control is hard to achieve in patients with CRF, even with specialist care and the use of multiple antihypertensive drugs.
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Saelen MG, Prøsch LK, Gudmundsdottir H, Dyrbekk D, Helge Hunderi O, Arnesen E, Paulsen D, Skjønsberg H, Os I. Controlling systolic blood pressure is difficult in patients with diabetic kidney disease exhibiting moderate-to-severe reductions in renal function. Blood Press 2005; 14:170-6. [PMID: 16036497 DOI: 10.1080/08037050510008959] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
This study compared the use of antihypertensive treatment and blood pressure (BP) controls between patients with diabetic kidney disease (DK+) and patients with non-diabetic kidney disease (DK-) exhibiting moderate-to-severe chronic renal failure who did not need renal replacement therapy. A cross-sectional survey included all renal patients with s-creatinine at ?200 micromol/l attending regular control sessions at six renal units in Norway. Of the 351 patients included, 73 (20.8%) were DK+. The proportion reaching a BP goal of <130/80 mmHg was similar in DK+ and DK- (14.1% vs 13.6%, p = 0.92), while 38% and 39% achieved a BP of <140/90 mmHg, respectively. The systolic BP goal was more difficult to achieve than the diastolic BP goal in DK+ patients (35% vs 15%) despite a mean of three different types of drugs being used. Loop diuretics and beta-adrenergic-receptor antagonists were the most frequently prescribed drugs, and the use of angiotensin-converting enzyme inhibitors or angiotensin-II-receptor antagonists declined when renal function deteriorated, from 80% to 0% and from 66% to 20% in the DK+ and DK- groups, respectively (p = 0.001). Thus, despite the use of multiple antihypertensive drugs, controlling BP - especially the systolic BP - is difficult in high-risk patients with chronic renal failure caused by diabetic kidney disease.
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Affiliation(s)
- Marie Grøn Saelen
- Department of Pharmacotherapeutics, University of Oslo, Olso, Norway
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Hovda KE, Froyshov S, Gudmundsdottir H, Rudberg N, Jacobsen D. Fomepizole may change indication for hemodialysis in methanol poisoning: prospective study in seven cases. Clin Nephrol 2005; 64:190-7. [PMID: 16175943 DOI: 10.5414/cnp64190] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Treatment of methanol poisoning includes administration of buffer, antidote and hemodialysis. The role of hemodialysis using the new antidote fomepizole has not been studied. We studied the kinetics of methanol and formate during hemodialysis, and the possibility for delayed hemodialysis in the methanol poisoned patients without severe metabolic acidosis or visual disturbances. PATIENTS AND METHODS Prospective case series study on methanol, formate and dialysis kinetics in 7 cases of severe methanol poisoning treated with buffer, fomepizole and hemodialysis (average 7 hours, range 5 - 8). Four patients were dialyzed early after diagnosis was obtained, while three were dialyzed "electively" the next day. RESULTS The median pH upon admission was 6.9 (range 6.6 - 7.5) and median base deficit 20.4 mmol/l (range 5.1 - 30.0). Their median S-methanol was 76.3 mmol/l (range 15.6 - 140.6) and S-formate 13.6 mmol/l (range 3.3 - 21). The median half-life of methanol during fomepizole treatment before dialysis was 71.2 hours (range 69.3 - 77); compared to 2.5 hours (range 1.7 - 3.3) during procedure. The median half-life of formate during dialysis was 1.7 hours (range 1.5 - 1.9). The median dialysis clearance of methanol was 222 ml/min (range 204 - 232) and for formate 225 ml/min (range 220 - 229) at a blood flow of 250 ml/min. One patient died and 2 were discharged with permanent visual and cerebral sequelae, whereas one died one year later. All three patients, in whom "elective" hemodialysis was performed, were discharged without sequelae. CONCLUSION The efficacy and side effect profile of fomepizole may change the role of hemodialysis in methanol poisoning. More patients may be stabilized in local hospitals and transferred for "elective" dialysis, if methanol removal is still indicated after correction of metabolic acidosis.
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Affiliation(s)
- K E Hovda
- Department of Acute Medicine, Ullevaal University Hospital, 0407 Oslo, Norway.
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Gretarsdottir S, Thorleifsson G, Reynisdottir ST, Manolescu A, Jonsdottir S, Jonsdottir T, Gudmundsdottir T, Bjarnadottir SM, Einarsson OB, Gudjonsdottir HM, Hawkins M, Gudmundsson G, Gudmundsdottir H, Andrason H, Gudmundsdottir AS, Sigurdardottir M, Chou TT, Nahmias J, Goss S, Sveinbjörnsdottir S, Valdimarsson EM, Jakobsson F, Agnarsson U, Gudnason V, Thorgeirsson G, Fingerle J, Gurney M, Gudbjartsson D, Frigge ML, Kong A, Stefansson K, Gulcher JR. Erratum: Corrigendum: The gene encoding phosphodiesterase 4D confers risk of ischemic stroke. Nat Genet 2005. [DOI: 10.1038/ng0505-555a] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Gudmundsdottir H, Sigurjonsdottir JF, Masson M, Fjalldal O, Stefansson E, Loftsson T. Intranasal administration of midazolam in a cyclodextrin based formulation: bioavailability and clinical evaluation in humans. Pharmazie 2001; 56:963-6. [PMID: 11802661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Intranasal administration of midazolam has been of particular interest because of the rapid and reliable onset of action, predictable effects, and avoidance of injections. The available intravenous formulation (Dormicum i.v. solution from Hoffmann-La Roche) is however less than optimal for intranasal administration due to low midazolam concentration and acidity of the formulation (pH 3.0-3.3). In this study midazolam was formulated in aqueous sulfobutylether-beta-cyclodextrin buffer solution. The nasal spray was tested in 12 healthy volunteers and compared to intravenous midazolam in an open crossover trial. Clinical sedation effects, irritation, and serum drug levels were monitored. The absolute bioavailability of midazolam in the nasal formulation was determined to be 64 +/- 19% (mean +/- standard deviation). The peak serum concentration from nasal application, 42 +/- 11 ng ml-1, was reached within 10-15 min following administration and clinical sedative effects were observed within 5 to 10 min and lasted for about 40 min. Intravenous administration gave clinical sedative effects within 3 to 4 min, which lasted for about 35 minutes. Mild to moderate, transient irritation of nasal and pharyngeal mucosa was reported. The nasal formulation approaches the intravenous form in speed of absorption, serum concentration and clinical sedation effect. No serious side effects were observed.
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Affiliation(s)
- H Gudmundsdottir
- Department of Ophthalmology, National University Hospital, University of Iceland, Reykjavik, Iceland
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Gudmundsdottir H, Turka LA. A closer look at homeostatic proliferation of CD4+ T cells: costimulatory requirements and role in memory formation. J Immunol 2001; 167:3699-707. [PMID: 11564785 DOI: 10.4049/jimmunol.167.7.3699] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Ag-specific proliferation of CD4+ T cells is regulated, in part, by costimulatory signals through CD28. The proliferative response during primary activation is an important determinant of the ability of the T cell to respond to Ag re-encounter. Proliferation of mature CD4+ T cells during lymphopenia (homeostatic proliferation) requires interaction with endogenous peptide MHC. However, the role of costimulation during homeostatic proliferation is unclear, as is the ability of homeostatic proliferation to regulate secondary T cell responses. Using a TCR transgenic system and serial adoptive transfers we find that homeostatic proliferation of CD4+ T cells occurs for at least 5 wk after adoptive transfer into recombination-activating gene (RAG)-/- recipients. Two discrete populations of proliferating T cells can be resolved, one that is highly proliferative and dependent on CD28 signaling, and the other that contains cells undergoing low levels of CD28-independent proliferation. Importantly, naive CD4+ T cells that have undergone homeostatic proliferation acquire both phenotypic and functional characteristics of true memory cells. These studies indicate that functional memory T cells can be generated by encounters with endogenous Ags only. This mechanism of T cell regeneration is possibly active during lymphopenia due to viral infections, such as HIV, transplantation, or cancer therapy, and may explain selected autoimmune diseases.
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Affiliation(s)
- H Gudmundsdottir
- Department of Medicine, University of Pennsylvania, 415 Curie Blvd., Philadelphia, PA 19104, USA
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Os I, Ström EH, Stenehjem A, Gudmundsdottir H, Langberg H, Draganov B, Godøy J, Dunlop O, von der Lippe B. Varicella infection in a renal transplant recipient associated with abdominal pain, hepatitis, and glomerulonephritis. Scand J Urol Nephrol 2001; 35:330-3. [PMID: 11676362 DOI: 10.1080/003655901750425945] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
A 36-year-old renal transplant patient developed 9 years after a successful transplantation a fatal secondary varicella infection. The disseminated varicella infection was associated with hepatitis with liver necrosis, disseminated intravascular coagulation and fibrinolysis and glomerulonephritis. To our knowledge this is the first description of glomerulonephritis associated with varicella infection in a renal transplanted patient. The autopsy showed morphologically a mesangial glomerulonephritis with minor proliferative activity and extensive deposits by electronmicroscopy, mainly in the mesangium. The ongoing immunosuppression may have modified the mesangial cell response to the deposition of immune complexes.
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Affiliation(s)
- I Os
- Department of Nephrology, Ulleval University Hospital, Oslo, Norway.
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Gudmundsdottir H, Turka LA. Transplantation tolerance: mechanisms and strategies? Semin Nephrol 2000; 20:209-16. [PMID: 10746862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
The goal of transplantation is to induce tolerance to the transplanted tissue. We believe that this will only be possible by exploring strategies normally used to endure and maintain self-tolerance. Tolerance can be defined as a state where the immune system does not respond to a specific antigen. This is in sharp contrast with immunosuppression, which decreases the immune response to a myriad of antigens and requires continued medication. T cells play an essential role in the immune response to alloantigens, because animals devoid of T cells do not reject transplanted organs. In this article we will focus on the mechanism of T cell tolerance and how the immune system may be manipulated to achieve tolerance to alloantigens.
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Affiliation(s)
- H Gudmundsdottir
- Department of Medicine, University of Pennsylvania, Philadelphia 19104-6100, USA
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Abstract
Optimal T cell responses occur when T cells receive both antigen-specific signals through the T cell receptor and non-antigen-specific costimulatory signals through accessory cell surface molecules. The best understood costimulatory receptor is CD28. Signals through the T cell receptor and CD28 cooperatively induce cytokine gene expression and promote T cell proliferation and survival. Negative signals delivered through a related cell surface receptor, cytotoxic T lymphocyte antigen (CTLA-4), act to terminate immune responses and are required for normal immune homeostasis. This article reviews T cell costimulation, including the CD28/CTLA-4 system and other potential costimulatory pathways (such as CD40/CD154), the role of these pathways in normal immune responses, and the potential for the inhibition of these pathways to induce transplantation tolerance.
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Affiliation(s)
- H Gudmundsdottir
- Department of Medicine, University of Pennsylvania, Philadelphia 19104-6100, USA
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Gudmundsdottir H, Wells AD, Turka LA. Dynamics and requirements of T cell clonal expansion in vivo at the single-cell level: effector function is linked to proliferative capacity. J Immunol 1999; 162:5212-23. [PMID: 10227995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
The adoptive transfer of TCR-transgenic T cells into syngeneic recipients allows characterization of individual T cells during in vivo immune responses. However, the proliferative behavior of individual T cells and its relationship to effector and memory function has been difficult to define. Here, we used a fluorescent dye to dissect and quantify T cell proliferative dynamics in vivo. We find that the average Ag-specific CD4+ T cell that undergoes division in vivo generates >20 daughter cells. TCR and CD28 signals cooperatively determine the degree of primary clonal expansion by increasing both the proportion of Ag-specific T cells that divide and the number of rounds of division the responding T cells undergo. Nonetheless, despite optimal signaling, up to one-third of Ag-specific cells fail to divide even though they show phenotypic evidence of Ag encounter. Surprisingly, however, transgenic T cells maturing on a RAG-2-/- background exhibit a responder frequency of 95-98% in vivo, suggesting that maximal proliferative potential requires either a naive phenotype or allelic exclusion at the TCRalpha locus. Finally, studies reveal division cycle-dependent expression of markers of T cell differentiation, such as CD44, CD45RB, and CD62L, and show also that expression of the cytokines IFN-gamma and IL-2 depends primarily on cell division rather than on receipt of costimulatory signals. These results provide a quantitative assessment of T cell proliferation in vivo and define the relationship between cell division and other parameters of the immune response including cytokine production, the availability of costimulation, and the capacity for memory.
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Affiliation(s)
- H Gudmundsdottir
- Department of Medicine, University of Pennsylvania, Philadelphia 19104, USA
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Johnston M, Foulkes J, Johnston DW, Pollard B, Gudmundsdottir H. Impact on patients and partners of inpatient and extended cardiac counseling and rehabilitation: a controlled trial. Psychosom Med 1999; 61:225-33. [PMID: 10204976 DOI: 10.1097/00006842-199903000-00015] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study evaluated the effectiveness of cardiac counseling and rehabilitation programs led by a nurse counselor, compared with normal care on outcomes for myocardial infarction (MI) patients and their partners. METHODS A randomized controlled trial with follow-up to 1 year was conducted with 100 patients recruited within 72 hours of a first MI and their partners: a Control group received normal care; an Inpatient group received cardiac rehabilitation from a nurse counselor while in hospital; and an Extended group received the same cardiac rehabilitation as the Inpatient group, but with additional sessions continuing up to 6 weeks after discharge from hospital. The scales for main outcome measures were 1) knowledge of heart disease and treatment (correct, misconceptions, and uncertainty); 2) mood (Hospital Anxiety and Depression Scale); 3) satisfaction; 4) disability (Functional Limitations Profile). RESULTS Inpatient cardiac counseling and rehabilitation resulted in more knowledge, less anxiety, less depression, and greater satisfaction with care in both patients and partners and in less disability in patients, with effects enduring to 1 year. There was some evidence of additional benefit from the Extended program. Both nurse counselors achieved benefits on all outcome variables. CONCLUSIONS This Inpatient cardiac counseling and rehabilitation program resulted in significant and enduring benefits of clinical value. It is likely that it would be acceptable to most post-MI patients, many of whom are not offered or are unable to accept outpatient cardiac rehabilitation.
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Affiliation(s)
- M Johnston
- School of Psychology, University of St. Andrews, Fife, Scotland
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Affiliation(s)
- A Wells
- Department of Microbiology/Immunology, University of Pennsylvania, Philadelphia, USA
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Wells AD, Gudmundsdottir H, Turka LA. Following the fate of individual T cells throughout activation and clonal expansion. Signals from T cell receptor and CD28 differentially regulate the induction and duration of a proliferative response. J Clin Invest 1997; 100:3173-83. [PMID: 9399965 PMCID: PMC508531 DOI: 10.1172/jci119873] [Citation(s) in RCA: 407] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
A detailed understanding of the effects of costimulatory signals on primary T cell expansion has been limited by experimental approaches that measure the bulk response of a cell population, without distinguishing responses of individual cells. Here, we have labeled live T cells in vitro with a stable, fluorescent dye that segregates equally between daughter cells upon cell division, allowing the proliferative history of any T cell present or generated during a response to be monitored over time. This system permits simultaneous evaluation of T cell surface markers, allowing concomitant assessment of cellular activation and quantitative determination of T cell receptor (TCR) occupancy on individual cells. Through this approach, we find that TCR engagement primarily regulates the frequency of T cells that enter the proliferative pool, but has relatively little effect on the number of times these cells will ultimately divide. In contrast, CD28-costimulation regulates both the frequency of responding cells (particularly at sub-maximal levels of TCR engagement), and more prominently, the number of mitotic events that responding cells undergo. When CD28-stimulation is blocked, provision of IL-2 restores the frequency of responding cells and the normal pattern of mitotic progression, indicating that the other CD28-induced genes are not required for this effect. An unexpected finding was that even at maximal levels of TCR engagement and CD28-mediated costimulation, only 50-60% of the original T cells in culture can be induced to divide. The nondividing cells are heterogeneous for naive versus memory markers, suggesting a more complex relationship between expression of memory markers and the ability to be recruited into the dividing pool. From these studies, we conclude that a stringent checkpoint regulates the participation of activated T cells in clonal expansion, with TCR and CD28 signals having both overlapping and differential effects on the induction and maintenance of T cell responses.
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Affiliation(s)
- A D Wells
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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Jonsson PV, Jensdottir AB, Gudmundsdottir H, Palsson H, Hjaltadottir I, Hardarson O, Sigurgeirsdottir S. [Assessment of health and caring needs in nursing homes. The Resident Assessment Instrument, its development and some pilot study results.]. LAEKNABLADID 1997; 83:640-647. [PMID: 19679910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Abstract
Those elderly living in institutions have multiple social, health and mental problems, in addition to loss of function. The Resident Assessment Instrument assesses the individual in detail and his caring needs. Resident Assessment Protocols come with the instrument and a handbook that describes how to evaluate specific problems further. Quality indicators allow comparisons between institutions and thus the quality of care can be assessed in comparable groups of residents. The elderly can be put into defined resource utilisation groups and an average cost calculated per unit or nursing home. A pilot study was conducted in Iceland in 1994 to examine the utility of the instrument. It was shown that most of the residents were viewed as competent according to documents, even if about half of them had considerable cognitive dysfunction. Dementia was the most common diagnosis. One fourth of the residents took antidepressant medications and 54-62% took sedatives or hypnotic drugs. Eight out of 10 had dentures and one third had difficulty chewing. Many more interesting findings showed up that are described in a special report.
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Magnusson V, Jonsdottir T, Gudmundsdottir H, Erlendsdottir H, Gudmundsson S. The in-vitro effect of temperature on MICs, bactericidal rates and postantibiotic effects in Staphylococcus aureus, Klebsiella pneumoniae and Pseudomonas aeruginosa. J Antimicrob Chemother 1995; 35:339-43. [PMID: 7759398 DOI: 10.1093/jac/35.2.339] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Varying temperatures (35.5 degrees C, 38.5 degrees C, 41 degrees C) only minimally affected growth rates in vitro of Staphylococcus aureus, Klebsiella pneumoniae, and Pseudomonas aeruginosa, as well as bactericidal rates and postantibiotic effects of several antibiotics. However, MICs were reduced at least four-fold by increasing temperature in 25% of the drug-organism combinations tested.
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Affiliation(s)
- V Magnusson
- Department of Clinical Microbiology, Borgarspitalinn (Reykjavik City Hospital), Iceland
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Gudmundsdottir H, Jonsdottir B, Kristinsson S, Johannesson A, Goodenough D, Sigurdsson G. Vertebral bone density in Icelandic women using quantitative computed tomography without an external reference phantom. Osteoporos Int 1993; 3:84-9. [PMID: 8453195 DOI: 10.1007/bf01623378] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Vertebral trabecular bone mineral density (BMD) was measured in 187 healthy Icelandic women, age 35-64 years, by quantitative computed tomography (QCT) with the use of internal references (muscle and subcutaneous fat) instead of the traditional external references (phantoms). We found a mean 2.4 mg/cm3 (1.8%) bone loss per year in the age range 35-64 years. There was an accelerated phase (exponential) after menopause, with 4% loss per year for the first 1-5 years after menopause or 5-fold trabecular bone loss compared with the subsequent 11-15 years after menopause. Reproducibility was found to be 1.9%. This method thus compares with traditional QCT measurements and is highly reproducible. We find QCT using internal references a promising method for assessing fracture risk in perimenopausal women and for follow-up in osteoporotic patients.
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Affiliation(s)
- H Gudmundsdottir
- Department of Internal Medicine, Reykjavík City Hospital, Iceland
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