Effect of far infrared therapy on arteriovenous fistula maturation, survival and stenosis in hemodialysis patients, a randomized, controlled clinical trial: the FAITH on fistula trial

BACKGROUND

An arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis treatment. After creation many of the AVFs will never mature or if functioning will need an intervention within 1 year due to an AVF stenosis. Studies investigating possible therapies that improves the AVF maturation and survival are scarce. Far infrared therapy (FIR) has shown promising results. In minor single centre and industry supported trials FIR has shown improved AVF maturation and survival. There is a need of a randomized multicentre controlled trial to examine the effect of FIR on the AVF maturation and survival and to explore the possible AVF protective mechanism induced by the FIR treatment.

METHODS

This investigator initiated, randomized, controlled, open-labeled, multicenter clinical trial will examine the effect of FIR on AVF maturation in patients with a newly created AVF (incident) and AVF patency rate after 1 year of treatment in patients with an existing AVF (prevalent) compared to a control group. The intervention group will receive FIR to the skin above their AVF three times a week for 1 year. The control group will be observed without any treatment. The primary outcome for incident AVFs is the time from surgically creation of the AVF to successful cannulation. The primary outcome for the prevalent AVFs is the difference in number of AVFs without intervention and still functioning in the treatment and control group after 12 months. Furthermore, the acute changes in inflammatory and vasodilating factors during FIR will be explored. Arterial stiffness as a marker of long term AVF patency will also be examined.

DISCUSSION

FIR is a promising new treatment modality that may potentially lead to improved AVF maturation and survival. This randomized controlled open-labelled trial will investigate the effect of FIR and its possible mechanisms.

TRIAL REGISTRATION

Clinicaltrialsgov NCT04011072 (7th of July 2019).

Negotiated mobilisation: An ethnographic exploration of nurse-patient interactions in an intensive care unit

AIMS AND OBJECTIVES

To explore nurse-patient interactions in relation to the mobilisation of nonsedated and awake, mechanically ventilated patients in the intensive care unit.

BACKGROUND

Lighter sedation has enabled the early mobilisation of mechanically ventilated patients, but little is known about the nurses' role and interaction with critically ill patients in relation to mobilisation.

DESIGN AND METHODS

The study had a qualitative design using an ethnographic approach within the methodology of interpretive description. Data were generated in two intensive care units in Denmark, where a strategy of no sedation was applied. Participant observation was conducted during 58 nurse-patient interactions in relation to mobilisation between nurses (n = 44) and mechanically ventilated patients (n = 25). We conducted interviews with nurses (n = 16) and patients (n = 13) who had been mechanically ventilated for at least 3 days. The data were analysed using inductive, thematic analysis. The report of the study adhered to the COREQ checklist.

FINDING

We identified three themes: "Diverging perspectives on mobilisation" showed that nurses had a long-term and treatment-oriented perspective on mobilisation, while patients had a short-term perspective and regarded mobilisation as overwhelming in their present situation. "Negotiation about mobilisation" demonstrated how patients actively negotiated the terms of mobilisation with the nurse. "Inducing hope through mobilisation" captured how nurses encouraged mobilisation by integrating aspects of the patient's daily life as a way to instil hope for the future.

CONCLUSIONS

Exploring the nurse-patient interactions illustrated that mobilisation is more than physical activity. Mobilisation is accomplished through nurse-patient collaborations as a negotiated, complex and meaningful achievement, which is driven by the logic of care, leading to hope for the future.

RELEVANCE TO CLINICAL PRACTICE

The study demonstrated the important role of nurses in achieving mobilisation in collaboration and through negotiation with mechanically ventilated patients in the intensive care unit.

Storytelling as part of cancer rehabilitation to support cancer patients and their relatives

Previous research on psychosocial support for cancer-related concerns has primarily focused on either patients or their relatives, although limited research is available on how patients and their relatives can be supported together. The aim of this article is to explore the use of storytelling as a part of a residential cancer rehabilitation intervention for patients together with their relatives, with a specific focus on their management of cancer-related concerns. Ten pairs participated in the intervention and data were generated through ethnographic fieldwork, including participant observations, informal conversations and follow-up interviews conducted one month after completing the intervention. Analysis was performed drawing on narrative theory combined with social practice theory. The results demonstrate that the use of storytelling and metaphors intertwined with other course activities, such as dancing and arts & crafts, provided the patients and their relatives with strategies to manage cancer-related concerns, which they were later able to apply in their everyday lives. The study results may be useful to other professionals in clinical practice for rehabilitation purposes for addressing issues of fear and worry.

How Narrative Journalistic Stories Can Communicate the Individual's Challenges of Daily Living with Amyotrophic Lateral Sclerosis

BACKGROUND

To complement the clinical and therapeutic knowledge about the symptoms, prognosis, and social implications of amyotrophic lateral sclerosis (ALS), health research and care need to develop methods that capture and communicate the unique individual impact on daily living with the disease.

OBJECTIVE

To explore how narrative journalistic stories can communicate experiences of daily living with ALS and compensate the progressive loss of the ability to speak.

METHODS

Twenty-four interviews at home with six people diagnosed with ALS were transformed into narrative journalistic stories. A formal readership was selected by the participant among his or her most significant health professionals. Topics of stories were categorized and selected themes analysed and interpreted.

RESULTS

The stories communicated daily living with ALS as a continuous process of creating a new normality of everyday life. The stories also revealed conflicting views between patient and professionals regarding information about disease and prognosis. The approach used provided an understanding of the individual healthcare professionals' engagement with the patient.

CONCLUSIONS

The narrative journalistic story enhances communication about daily living with ALS by offering a mode of sharing experiences that compensate the progressive loss of communicative abilities. The story sustains meaning for patients living with ALS, and supports them in appreciating a day-to-day life where they are not just waiting for death. Narrative journalistic storytelling may educate health professionals to more effectively comprehend that a medical prognosis should be complemented by understanding the individual's unique experience of vulnerability. In particular, this applies to severe rare diseases where insight is difficult to obtain.

Informed Choice for Participation in Down Syndrome Screening: Development and Content of a Web-Based Decision Aid

Background

In Denmark, all pregnant women are offered screening in early pregnancy to estimate the risk of having a fetus with Down syndrome. Pregnant women participating in the screening program should be provided with information and support to allow them to make an informed choice. There is increasing interest in the use of Web-based technology to provide information and digital solutions for the delivery of health care.

Objective

The aim of this study was to develop an eHealth tool that contained accurate and relevant information to allow pregnant women to make an informed choice about whether to accept or reject participation in screening for Down syndrome.

Methods

The development of the eHealth tool involved the cooperation of researchers, technology experts, clinicians, and users. The underlying theoretical framework was based on participatory design, the International Patient Decision Aid Standards (IPDAS) Collaboration guide to develop a patient decision aid, and the roadmap for developing eHealth technologies from the Center for eHealth Research and Disease Management (CeHRes). The methods employed were a systematic literature search, focus group interviews with 3 care providers and 14 pregnant women, and 2 weeks of field observations. A qualitative descriptive approach was used in this study.

Results

Relevant themes from pregnant women and care providers with respect to information about Down syndrome screening were identified. Based on formalized processes for developing patient decision aids and eHealth technologies, an interactive website containing information about Down syndrome, methods of screening, and consequences of the test was developed. The intervention was based on user requests and needs, and reflected the current hospital practice and national guidelines.

Conclusions

This paper describes the development and content of an interactive website to support pregnant women in making informed choices about Down syndrome screening. To develop the website, we used a well-structured process based on scientific evidence and involved pregnant women, care providers, and technology experts as stakeholders. To our knowledge, there has been no research on the combination of IPDAS standards and the CeHRes roadmap to develop an eHealth tool to target information about screening for Down syndrome.

Healthcare professionals experience with motivational interviewing in their encounter with obese pregnant women

OBJECTIVE

to explore and describe how healthcare professionals in the Southern Region of Denmark experienced motivational interviewing as a communication method when working with pregnant women with obesity.

DESIGN

a qualitative, descriptive study based on face-to-face interviews with 11 obstetric healthcare professionals working in a perinatal setting.

METHODS

a thematic descriptive method was applied to semi-structured interviews. The healthcare professional's experiences were recorded verbatim during individual semi-structured qualitative interviews, transcribed, and analysed using a descriptive analysis methodology.

FINDINGS

motivational interviewing was found to be a useful method when communicating with obese pregnant women. The method made the healthcare professionals more aware of their own communication style both when encountering pregnant women and in their interaction with colleagues. However, most of the healthcare professionals emphasised that time was crucial and they had to be dedicated to the motivational interviewing method. The healthcare professionals further stated that it enabled them to become more professional in their daily work and made some of them feel less 'burned out', 'powerless' and 'stressed' as they felt they had a communication method in handling difficult workloads.

CONCLUSION

healthcare professionals experienced motivational interviewing to be a useful method when working perinatally. The motivational interviewing method permitted heightened awareness of the healthcare professionals communication method with the patients and increased their ability to handle a difficult workload. Overall, lack of time restricted the use of the motivational interviewing method on a daily basis.

Nurses' experiences of caring for critically ill, non-sedated, mechanically ventilated patients in the Intensive Care Unit: a qualitative study

OBJECTIVE

The objective was to explore nurses' experiences of caring for non-sedated, critically ill patients requiring mechanical ventilation.

DESIGN AND SETTING

The study had a qualitative explorative design and was based on 13 months of fieldwork in two intensive care units in Denmark where a protocol of no sedation is implemented. Data were generated during participant observation in practice and by interviews with 16 nurses. Data were analysed using thematic interpretive description.

FINDINGS

An overall theme emerged: "Demanding, yet rewarding". The demanding aspects of caring for more awake intubated patients included unpredictability, ambiguous needs and complex actions, while the rewarding aspects included personal interaction. Three sub-themes were identified: (i) caring for and with the patient, (ii) negotiating relational and instrumental care and (iii) managing physical and emotional closeness.

CONCLUSION

Despite the complexity of care, nurses preferred to care for more awake rather than sedated patients and appreciated caring for just one patient at a time. The importance of close collaboration between nurses and doctors to ensure patient comfort during mechanical ventilation was valued. Caring for more awake non-sedated patients required the nurses to act at the interface between ambiguous possibilities and needs, which was perceived as both demanding and rewarding.

Outcome of supportive talks in a hospital setting: insights from cancer patients and their relatives

BACKGROUND

In psychosocial cancer rehabilitation, relatives are often central to patients' experiences and management of their cancer disease, and they need to be actively involved in rehabilitation. To address this need we developed a psychosocial rehabilitation intervention. As part of the intervention, lung or gynecological cancer patients and a relative as a pair were offered three supportive talks initiated on the date of admission and completed within 2 months.

OBJECTIVE

The objective of this study was to qualitatively assess the outcome of supportive talks from the pairs' perspectives and to provide a nuanced understanding of psychosocial support offered to pairs in a hospital setting in Denmark.

METHODS

Using a qualitative approach, we conducted semi-structured interviews with pairs receiving supportive talks and pairs receiving usual care. The interviews focused on the pairs' experiences of psychosocial supportive talks in a hospital setting. A constant comparative analysis was applied to identify themes related to the ways the pairs experienced the talks.

RESULTS

The analysis revealed two main themes: 'appreciation of the supportive talks' and 'the influence of the hospital setting'. The majority of pairs valued the focus on relationship and interpersonal communication, although they appreciated various aspects of the talks. The hospital setting provided valuable resources (trained nurses and medical expertise), but existing clinical routines challenged the implementation of the supportive talks.

CONCLUSIONS

The supportive talks were appreciated as psychosocial support in line with the objective, or as information on cancer treatment and routine care. The implementation of a new rehabilitation practice was challenged by the influence of the hospital setting.

Existential concerns about death: a qualitative study of dying patients in a Danish hospice

Research suggests that addressing dying patients' existential concerns can improve their quality of life. We aimed to illuminate dying patients' existential concerns about the impending death through a descriptive analysis of semistructured interviews with 17 patients in Danish hospices. The main findings demonstrated how the patients faced the imminent death without being anxious of death but sorrowful about leaving life. Some patients expressed that they avoided thinking about death. They wished to focus on positive aspects in their daily life. We argue that the patients' existential concerns could not be fully captured by Yalom's existential psychology or by Kübler-Ross's theory about death stages. Patients' complex concerns could be more fully explained taking an outset in Heidegger's phenomenological thinking.

Urinary sulphate excretion and progression of diabetic nephropathy in Type 1 diabetes

AIMS

Hydrogen sulphide levels are reduced in many disease states, including diabetes and end-stage renal disease. We aimed to determine whether urinary sulphate excretion, as a proxy for hydrogen sulphide, was associated with progression of diabetic nephropathy.

METHODS

We conducted a post-hoc study of a prospective, randomized, controlled trial on the effect of a low vs. normal protein diet for 4 years, on decline of renal function in patients with Type 1 diabetes and diabetic nephropathy. We excluded patients with less than three measurements of glomerular filtration rate assessed by (51)Cr-EDTA plasma clearance (GFR) and less than 1 year of follow-up (n = 10), leaving 72 patients eligible for analyses. We studied both association of rate of decline in GFR and association of the combined endpoint of end-stage renal disease and death with baseline 24-h urinary sulphate excretion.

RESULTS

Sulphate excretion was significantly associated with the slope of GFR (rs = -0.28, P = 0.02). In a multivariate regression model, sulphate excretion was a significant determinant of decline in GFR, independent of age, gender, blood pressure, HbA1c , smoking, albuminuria, baseline GFR and diet group (P < 0.01). In addition, adjusted r(2) increased from 5% in a model with the aforementioned risk factors to 22% when sulphate excretion was included in the model. Cox regression revealed a hazard ratio of 0.34 (95% CI 0.13-0.88, P = 0.026) for each natural log unit increase in urinary sulphate excretion.

CONCLUSION

High urinary sulphate excretion was significantly associated with slower decline in (51)Cr-EDTA-assessed GFR in diabetic nephropathy, independent of known progression promoters.

The ritualization of rehabilitation

There is widespread and increasing political interest in devising plans to support people who have or have had cancer to recover and recommence 'normal' lives. Educating cancer patients for this purpose is a central element in cancer rehabilitation in both Europe and the United States. One of the challenges in intervention research pertaining to rehabilitation is how to measure and explain the effects of a particular rehabilitation program. The social processes of particular programs are often a 'closed box' and not taken into consideration methodologically or analytically. In this article, we unpack and explicate the 'closed box' of a particular cancer rehabilitation program in Denmark by drawing on approaches from the study of ritual. By analyzing rehabilitation as a ritual and as ritualization, we identify and conceptualize some of the transformative activities involved in cancer rehabilitation. We highlight the significance of the ritual site, its aesthetics, its exaggerations, and the social and temporal organization of the program.

[Journalistic narrative can complement health professional understanding in rehabilitation]

Narrative journalism was used to convey subjective patient perspectives in a study of multidisciplinary rehabilitation of six people with amyotrophic lateral sclerosis. Narratives brought out complementary issues and compensated for loss of speech. A majority of health professionals assessed the narratives as relevant and useful for their professional duties. We suggest that when dealing with rehabilitation in chronic cases demanding palliation, a narrative method should be incorporated in order to complement health disciplines in the field.

Cancer incidence among Danish Seventh-day Adventists and Baptists

INTRODUCTION

American Seventh-day Adventists have been reported to have lower cancer mortality and incidence than the general population. Adventists do not consume tobacco, alcohol or pork, and many adhere to a lacto-ovo-vegetarian lifestyle. Baptists discourage excessive use of alcohol and tobacco. In this study, we investigated whether the incidence of cancer in a large cohort of Danish Adventists and Baptists was different compared to the general Danish population.

MATERIAL AND METHODS

We followed 11,580 Danish Adventists and Baptists in the nationwide Danish Cancer Registry, which contains information on cases of cancer for 1943-2008. Cancer incidence in the cohort was compared with that in the general Danish population as standardized incidence ratios (SIRs) with 95% confidence intervals (CIs), and within-cohort comparisons were made with a Cox model.

RESULTS

Lower cancer incidences were observed for both Seventh-day Adventist men (SIR, 66; 95% CI, 60-72) and women (85; 80-91). The same result was observed for Baptists although not as low. The differences were most pronounced for smoking-related cancers such as those of the buccal cavity and lung (SIR, 20; 13-30 for Seventh-day Adventist men and 33; 22-49 for Seventh-day Adventist women). The incidences of other lifestyle-related cancers, such as of stomach, rectum, liver and cervix, were also decreased. In general, the SIRs were lower for men than for women, and Adventists had lower hazard rates than Baptists.

DISCUSSION

Our findings point to the benefits of compliance with public health recommendations and indicate that lifestyle changes in the population might change the cancer risks of individuals.

Exploring qualitative research synthesis: the role of patients' perspectives in health policy design and decision making

Health systems are placing more and more emphasis on the design and delivery of services that are focused on the patient, and there is a growing interest in patient involvement in health policy research and health technology assessment (HTA). Furthermore, there is a growing research interest in eliciting patients' views, not only on 'what works' for patients but also on the need for intervention and on factors influencing the implementation of particular health technologies, their appropriateness and acceptability. This article focuses on qualitative research synthesis in eliciting patients' perspectives. Its aim is to bring research closer to policy development and decision making, to facilitate better use of research findings for health and welfare, to generate a body of evidence, and to ensure that effective and appropriate information is used in health policy decision design. A variety of synthesizing approaches in qualitative research are explored, such as meta-synthesis, meta-summary, meta-ethnography, and meta-study, focusing especially on methodology. Meta-synthesis and meta-ethnography are probably the most frequently cited approaches in qualitative research synthesis and have perhaps the most developed methodology. The implications of these various synthesizing approaches in relation to health policy and HTA are discussed, and we suggest that meta-synthesis and meta-summary are particularly useful approaches. They have an explicit focus on 'evidence synthesis', fairly clear methodologies, and they are designed to not only present interpretations of the findings but also integrate research findings. Qualitative research synthesis enables researchers to synthesize findings from multiple qualitative studies on patients' perspectives instead of establishing new, expensive, and perhaps redundant studies that might intrude on the lives of patients. Qualitative research synthesis is highly recommended by decision makers and in health policy research and HTA. In cases where patient assessment is important to overall success, it can provide those responsible for policy and decision making with a broad and varied range of knowledge about patients' perspectives before they make decisions on the application of health technologies.

Aesthetic Engagements

Living with advanced cancer can present an overwhelming challenge. It may impact the everyday life of the individual with respect to an array of psychological, physical, social, and existential issues. We focus on ways in which people with advanced cancer experience and use their engagement in daily activities when confronting nearing death. Through a phenomenological analysis based on Heidegger’s thinking, we illuminate the complexities of “being toward death” and the human striving for authentic being through engagement in daily living. The main findings demonstrate how sensory experiences support being through an appreciation of everyday aesthetics. Furthermore, the making of material things was identified as a means to express the value of self and others in relation to the involved individual’s past, present, and future.

[Adult cancer rehabilitation]

The aim of cancer rehabilitation is to enable patients to reach and maintain the physical and psychosocial functional levels needed to attain an independent and meaningful life. Rehabilitation should be integrated in cancer programs. Taking a systematic approach aiming to identify patients in need is essential and should include coordination amongst professionals. Research may add knowledge to the sparse evidence of the effect of the various interventions and the need of rehabilitation when living with cancer. Patient, organisational and economic perspectives are important.

Illness, everyday life and narrative montage: The visual aesthetics of cancer in Sara Bro’s Diary

This article presents a study of Sara Bro’s Diary (2004), a book montage of images and texts recording the experiences of a Danish breast cancer survivor, Sara Bro. It examines two montages of photography and text, drawing on Roland Barthes’ concept of ‘the third meaning’ to explain and discuss the effect of the layered meanings in the montage alongside their multi-medium and self-referential expression. The discussion is centred on the aesthetic practices that are invited by Bro’s book montage. The article considers how the juxtaposition of images and texts are experienced and co-created by the reader. It points to the effect of the aesthetics of disguise and carnival implicit in the visual—verbal montage and argues that these generate a third meaning. This meaning is associated with the breast cancer experience but is not directly discernible in the montage. The article concludes by discussing how Bro’s montage acts as an ideological statement, subverting or ‘poaching on’ the health care system.

Rehabilitation interventions for cancer survivors: The influence of context

BACKGROUND

Today more and more people survive cancer. Cancer survivors need help to recover both from the cancer and the treatment. Rehabilitative interventions have been set up to meet their needs. However, there are studies that report no major effects following careful, targeted intervention. Furthermore, it seems difficult to define whether an effect is caused by the intervention or whether it is due to contextual parameters such as human interactions, the organisation, the staff, the physical surroundings or the general atmosphere. The present study examines the influence of three contextual parameters in rehabilitation courses for cancer survivors in Denmark.

METHODS

The study was based on an ethnographic fieldwork with participant observation at nine week-long courses, on in-depth interviews and on written sources. Fieldwork is well-suited for studying interventions in context, such as social interactions between people and their physical, material and institutional surroundings. The analysis is based on Duranti's and Goodwin's theoretical approach to context.

RESULTS

The findings are categorised into three contextual parameters. The setting, including its aesthetic value, its physical surroundings and the scheduling of the courses. The behavioural environment, which comprised work commitment and the care provided by the staff. The language environment insofar as it facilitated a sense of community.

DISCUSSION

The results demonstrate the influence of contextual parameters not formalised in the intervention programme. Contexts affect the outcome of an intervention because they frame and inform the teaching, communication and various forms of social gathering. The study suggests that the effects of the intervention as measured by quantitative studies cannot be properly interpreted without taking into account the context within which the intervention is embedded.

How cancer survivors experience their changed body encountering others

BACKGROUND

Psychosocial cancer research illustrates how women treated for breast cancer experience physical changes in their bodies and the way they perceive, that, others see their body. But how patients with other types of cancer have experienced changes in their bodies and how this affects their relationship with others is less researched.

OBJECTIVES

To explore how cancer survivors with different types of cancer and cancer treatment, experience and handle their changed body, especially when meeting others, and how this influences their everyday life of survivorship, i.e. long after treatment has been completed.

METHODS

Participant observation at a Cancer Rehabilitation Centre (CRC). Of the observed participants 23 were selected and interviewed twice.

RESULTS

Many participants had a changed body due to the cancer and its treatment. When the cancer survivors meet others they experience that their changed body means that they are avoided, looked at in specific ways, or greeted with a specific compliment. The verbal and nonverbal language that the cancer survivors are met with indicates the existence of a specific discursive aesthetic in relation to the disease and the changed body. This discursive aesthetic represents a silence and secrecy about cancer, which makes it impossible for survivors to talk about their experiences with cancer and a changed body.

CONCLUSION

The changed body not only represents the physical sign of cancer, it also represents the social presence and representation of cancer. The analysis gives an insight into general questions of meaning related to the changed body in late modernity.

Cancer rehabilitation in Denmark: the growth of a new narrative

A fundamental assumption behind cancer rehabilitation in many Western societies is that cancer survivors can return to normal life by learning to deal with the consequences of their illness and their treatment. This assumption is supported by increasing political attention to cancer rehabilitation and a growth in residential cancer-rehabilitation initiatives in Denmark (Danish Cancer Society 1999; Government of Denmark 2003). On the basis of their ethnographic fieldwork in residential-cancer rehabilitation courses, the authors examine the new rehabilitation discourse. They argue that this discourse has challenged the dominant illness narrative, "sick-helped-cured," producing a new narrative, "sick-helped-as if cured," and that this new narrative is produced and reproduced through technologies of power and of the self.

Marked bodies and selves: a literary-semiotic perspective on breast cancer and identity

A diagnosis of breast cancer is not just life-threatening but often also disfiguring. Breast cancer research has pointedly focused on the connection between bodily loss and loss of self. We will examine the narratives of two Danish women who have been treated for breast cancer and are dealing with the consequences of their treatment. Drawing upon theories of phenomenology and literary-semiotics we demonstrate how the women are negotiating their identities. In narratives of breast cancer bodily practices play a prominent role in helping or hindering the re-construction of identity. We will focus on breast reconstruction as a bodily practice and seek to understand how and why breast cancer survivors either accept or reject the possibility of reconstructing their identity through breast reconstruction. We suggest that the literary-semiotic concept of marking can lead to a broader understanding of the connection between illness, body and identity. Breast reconstruction and the refusal of breast reconstruction can be viewed as part of a semiotic monitoring and marking of the body that can take place in the aftermath of treatment for breast cancer.

Long-term prevention of diabetic nephropathy: an audit

AIMS/HYPOTHESIS

In type 1 diabetic patients with microalbuminuria not receiving antihypertensive treatment, an increase in urinary AER (UAER) of 6-14%/year and a risk of developing diabetic nephropathy (DN) of 3-30%/year have been reported. We audited the long-term effect of blocking the renin-angiotensin-aldosterone system (RAAS) with an ACE inhibitor (ACEI) or angiotensin II receptor blocker (ARB) in microalbuminuric type 1 diabetic patients on progression of microalbuminuria and development of DN.

METHODS

All patients with type 1 diabetes and persistent microalbuminuria (30-300 mg/24 h) were identified (n=227) in 1995 at Steno Diabetes Center and followed for 11 years. Development of DN was defined as a UAER of >300 mg/24 h in two of three consecutive urine samples.

RESULTS

Age and duration of diabetes at baseline (mean+/-SD) were 46+/-15 and 28+/-13 years, respectively. During follow-up 14 patients emigrated and 58 (26%) died. Over the same period 79% were treated with an ACEI or ARB. There was a mean decline in UAER of 4%/year. Sixty-five patients (29%) progressed to overt DN, corresponding to 3.1%/year. However, 29 of them regressed to normo- or microalbuminuria on intensified antihypertensive treatment. Glycaemic control and blood pressure remained nearly unchanged.

CONCLUSIONS/INTERPRETATION

In our outpatient clinic, the implementation of RAAS-blocking treatment in type 1 diabetic patients with microalbuminuria successfully reduced long-term progression to overt DN to a rate similar to those previously reported in randomised, double-blind intervention trials of shorter duration using RAAS blockade.

[Hand hygiene--is it really that difficult?]

This paper addresses the apparent discrepancy between knowledge of infection control guidelines--in particular concerning hand hygiene--and the lack of compliance by health care workers. Several factors are involved, including the personal experiences of the single person and the group of staff members--the authentic knowledge. This must be taken into consideration when preparing guidelines, which should reflect daily work situations in health care.

Preventing diabetic nephropathy: an audit

In type 1 diabetic patients with microalbuminuria not receiving antihypertensive treatment, an increase in urinary albumin excretion rate (AER) of 6% to 14%/year and a risk for the development of diabetic nephropathy of 3% to 30%/year have previously been reported. The aim of the present study was to audit the effect of angiotensin converting enzyme (ACE) inhibition on the progression of microalbuminuria and development of diabetic nephropathy. We consecutively identified 227 type 1 diabetic patients with persistent microalbuminuria (urinary AER between 30 and 300mg/24h, ELISA). According to the level (> or = 100 or < 100mg/24 h) and/or rate of progression in urinary AER (>6% or < or =6%/year), patients were divided into a high-risk group (n= 177) and a low-risk group (n= 50) for development of diabetic nephropathy. According to international guidelines, all patients at high-risk were recommended ACE-inhibitor treatment. Throughout the study, 67% of the patients were treated with an ACE inhibitor. Urinary AER significantly declined by 8.3%/year (95% CI: 2.8 to 13.9) in the whole group of patients, and the risk for the development of diabetic nephropathy during follow-up was 3.5%/year. Glycaemic control and blood pressure remained unchanged during the study. The implementation of modified international guidelines regarding the use of ACE inhibition in the treatment of microalbuminuric type 1 diabetic patients reduced progression to diabetic nephropathy comparable to what has previously been reported in intervention trials.

Long-term beneficial effect of ACE inhibition on diabetic nephropathy in normotensive type 1 diabetic patients

BACKGROUND

The purpose of this study was to assess whether long-term (8 years) inhibition of angiotensin-converting enzyme (ACE) protects kidney function in normotensive type 1 diabetic patients with diabetic nephropathy.

METHODS

We performed an open randomized follow-up study of normotensive type 1 diabetics with nephropathy either treated (N = 15) or not (N = 17) with captopril twice per day (average 74, range 12.5 to 125 mg/day). The main outcome measures were arterial blood pressure, albuminuria, and glomerular filtration rate (GFR; 51Cr-EDTA plasma clearance, twice yearly).

RESULTS

Arterial blood pressure (mm Hg) was kept constant in the captopril group, at baseline (mean, SEM), 128/78 (3/2) and during follow-up 129/77 (4/1) but increased significantly in the control group from 127/79 (2/1) to 137/84 (5/2) (P < 0.01). Furthermore, 8 out of the 17 control subjects required treatment with blood pressure-lowering drugs because they developed hypertension. The fractional albumin clearance (x10-5) remained unchanged in the captopril group: baseline [10.8 (1.25) geometric mean and antilog (SEM)] during the eight years [11.8 (1.47)], while a significant rise occurred in control patients: 13.3 (1.23) to 26.2 (1.42) (P < 0.05). Baseline GFR was nearly identical: 111 (6) and 115 (4) mL/min/1.73 m2 in the captopril and control group, respectively. The median (range) rate of decline in GFR (mL/min/year) was 1.7 (10.7 to -2.0) in the captopril group versus 2.8 (17.7 to -2.6) in the control group (P = NS).

CONCLUSIONS

The beneficial effect of captopril in arresting the rise in systemic blood pressure and albuminuria is long lasting. A loss in GFR is minimal in most patients with diabetic nephropathy if normotension is sustained by prospective treatment with ACE inhibitors or restored by implementation of other antihypertensive medications with the development of hypertension.

CD30 shedding from Karpas 299 lymphoma cells is mediated by TNF-alpha-converting enzyme

CD30 is a costimulatory receptor on activated lymphocytes and a number of human lymphoma cells. Specific ligation of membrane-bound CD30 or cellular stimulation by PMA results in a metalloproteinase-mediated down-regulation of CD30 and release of its soluble ectodomain (sCD30). In this report, it is demonstrated that PMA-induced CD30 cleavage from Karpas 299 cells was mediated by a membrane-anchored metalloproteinase which was active on intact cells following 3-[(3-cholamidopropyl)dimethylammonio]-1-propanesulfonate extraction of membrane preparations. Moreover, CD30 shedding was blocked by the synthetic hydroxamic acid-based metalloproteinase inhibitor BB-2116 (IC(50), 230 nM) and the natural tissue inhibitor of metalloproteinases (TIMP)-3 (IC(50), 30 nM), but not by the matrix metalloproteinase inhibitors TIMP-1 and TIMP-2. This inhibition profile is similar to that of the TNF-alpha- converting enzyme (TACE) and, indeed, mRNA transcripts of the membrane-bound metalloproteinase-disintegrin TACE could be detected in Karpas 299 cells. The ectodomain of TACE was expressed in bacteria as a GST fusion protein (GST-TACE) which cleaved CD30 from the surface of Karpas 299 cells and concomitantly increased the level of sCD30 in the cell supernatants. Hence, TACE does not only control the release of TNF-alpha, but also that of sCD30.

Lack of impact of low-dose acetylsalicylic acid on kidney function in type 1 diabetic patients with microalbuminuria

OBJECTIVE

High-dose treatment with cyclooxygenase inhibitors reduces urinary albumin excretion rate (AER) in type 1 diabetic patients with microalbuminuria and macroalbuminuria. This effect may lead to an incorrect classification of albuminuria (normo-, micro-, and macroalbuminuria) and jeopardize the monitoring of antiproteinuric treatment (e.g., ACE inhibition). Whether similar difficulties exist using low-dose acetylsalicylic acid (ASA), now widely recommended for primary and secondary prevention of cardiovascular events in type 1 diabetic patients with micro- and macroalbuminuria, remains to be elucidated.

RESEARCH DESIGN AND METHODS

We performed a randomized double-blind crossover trial in 17 type 1 diabetic patients with microalbuminuria (urinary AER 30-300 mg/24 h). Patients were given ASA (150 mg/daily) for 4 weeks followed by placebo for 4 weeks with at least a 2-week washout period in random order. At the end of each treatment period, AER (enzyme-linked immunosorbent assay), glomerular filtration rate (GFR) (plasma clearance of 51Cr-EDTA), blood pressure (BP) (Hawksley), and HbA1c (by high-performance liquid chromatography) were measured. Patients were advised to follow a normal diabetes diet without sodium restriction and received their usual antihypertensive treatment during the investigation.

RESULTS

During the study (ASA vs. placebo), urinary AER (geometric mean 64 [95% CI 39-105] vs. 59 [40-87] mg/24 h), GFR (mean 106 [93-118] vs. 104 [90-117] ml x min(-1) x 1.73 m(-2)), systolic BP (mean 130 [119-141] vs. 130 [119-142] mmHg), diastolic BP (mean 71 [65-78] vs. 71 [64-78] mmHg), and HbA1c (mean 8.4% [8.0-9.0] vs. 8.5% [8.1-9.0]) remained unchanged.

CONCLUSIONS

Treatment with 150 mg ASA daily does not have any impact on AER or GFR in type 1 diabetic patients with microalbuminuria. Consequently, primary and secondary prevention of cardiovascular events with low-dose ASA does not interfere with the classification of AER or monitoring of antiproteinuric treatment in such patients.

Increased sympathetic activity during sleep and nocturnal hypertension in Type 2 diabetic patients with diabetic nephropathy

AIMS

To elucidate the putative factors involved in the blunted nocturnal blood pressure reduction in hypertensive Type 2 diabetic patients with diabetic nephropathy.

METHODS

Extracellular fluid volume and fluid shift from interstitial to plasma volume (haematocrit), sympathetic nervous activity (plasma noradrenaline and adrenaline) and the internal 'body clock' (serum melatonin) were investigated in 31 hypertensive Type 2 diabetes mellitus (DM) patients with diabetic nephropathy (24 males, age 60 (45-73) years). All variables, except extracellular volume, were measured repeatedly with the patients lying awake in bed from 21:30 to 23:00 h (baseline) and during sleep from 23:00 to 07:00 h. Using the median nocturnal blood pressure reduction (8.4%) as a guide, the patients were divided into groups; group 1 with the highest and group 2 with the lowest nocturnal blood pressure reduction.

RESULTS

Haematocrit decreased from baseline to the sleep period in group 1 by a mean (95% confidence interval (CI)) of 1.7 (0.3-3.1)%, but it increased by 0.5 (-1.0-1.9)% in group 2, mean difference (95% CI), -2.1 (-4.0 to -0.2)% (P = 0.029). Noradrenaline decreased from baseline to the sleep period, mean (95% CI), by 13.3 (0.0-25.0)% in group 1 but rose by 7.7 (-9.7-28.4)% in group 2, mean difference (95% CI), -19.6 (-35-0.0)% (P = 0.049). The nocturnal blood pressure change correlated to the nocturnal change in both noradrenaline (r = 0.51, P = 0.004) and haematocrit (r = 0.42, P = 0.018). Adrenaline remained constant in both groups. Extracellular fluid volume and plasma melatonin levels were comparable in the two groups.

CONCLUSION

Sustained adrenergic activity during sleep is associated with blunted nocturnal blood pressure reduction in hypertensive Type 2DM patients with diabetic nephropathy, probably mediated through a lack of peripheral vasodilatation whereas changes in extracellular fluid volume distribution and melatonin secretion have no impact.

Low-protein diet and kidney function in insulin-dependent diabetic patients with diabetic nephropathy

BACKGROUND

Initiation of a low-protein diet (LPD) in patients with various nephropathies induces a faster initial and slower subsequent decline in the glomerular filtration rate (GFR). Whether this initial phenomenon is reversible or irreversible remains to be elucidated.

METHODS

We performed an eight-week prospective, randomized, controlled study comparing the effect of an LPD with a normal-protein diet (NPD) in 29 insulin-dependent diabetic patients with diabetic nephropathy. At baseline, the patients were randomized to either an LPD (0.6 g.kg-1.24 hr-1, LPD group, N = 14) or their NPD (NPD group, N = 15) for four weeks (phase I). Between weeks 4 and 8, all patients received their NPD (phase II, recovery). Dietary protein intake (g.kg-1.24 hr-1), GFR (51Cr-EDTA, ml.min-1.1.73 m-2), albuminuria (enzyme-linked immunoadsorbent assay, mg.24 hr-1), and arterial blood pressure (Hawksley random zero sphygmomanometer, mm Hg) were measured at baseline and after four- and eight-weeks of follow-up. During the investigation, all patients in the LPD group (N = 12) and in the NPD group (N = 14) received their usual antihypertensive treatment.

RESULTS

At baseline, the LPD group and the NPD group were comparable regarding dietary protein intake, GFR, albuminuria, and arterial blood pressure. During phase I, a significant decline in dietary protein intake, GFR, and albuminuria (mean, 95% CI) was observed in the LPD group [0.4 (0.3 to 0.5) g.kg-1.24 hr-1, 8.6 (3.2 to 13.9) ml.min-1.1.73 m-2, and 28.7 (14.0 to 40.9)%, respectively] compared with the NPD group [0.0 (-0.1 to 0.2) g.kg-1.24 hr-1 (P < 0.0001 between diets), 2.5 (-1.8 to 6.8) ml.min-1.1.73 m-2 (P = 0.07 between diets), and 0.0 (-20.1 to 23.5)% (P < 0.05 between diets), respectively]. Conversely, during phase II, a significant increase in dietary protein intake, GFR, and albuminuria [mean, 95% CI; 0.3 (0.2 to 0.5) g.kg-1.24 hr-1, 5.9 (0.8 to 11.1) ml.min-1.1.73 m-2, and 25.0 (4.5 to 49.6)%, respectively] took place in the LPD group compared with the NPD group [0.0 (-0.2 to 0.1) g.kg-1.24 hr-1 (P < 0.0001 between diets), -2.9 (-6.4 to 0.6) ml.min-1.1.73 m-2 (P < 0.01 between diets), and 2.9 (-18.3 to 29.7)% (P = 0.16 between diets), respectively]. Arterial blood pressure was comparable in the two groups of patients during phase I and II.

CONCLUSIONS

Dietary protein restriction for four weeks induces a reversible decline in GFR and albuminuria in insulin-dependent diabetic patients with diabetic nephropathy, whereas systemic blood pressure remains unchanged.

Assessment of glomerular filtration rate in diabetic nephropathy using the plasma clearance of 51Cr-EDTA

Plasma clearance of 51Cr-EDTA is widely used to assess the glomerular filtration rate (GFR) in diabetic nephropathy. Originally, the ratio between the intravenously injected amount of tracer and the total area under the plasma concentration curve was used for the calculation of total 51Cr-EDTA plasma clearance (C(T)). Simplified methods, using the final mono-exponential part of the plasma curve, have been suggested, e.g. four samples, taken 180 to 240 min after injection (C(IV)), or using one sample taken at 240 min (C(I)). Our aim was to evaluate the agreement between measurements of GFR and rate of decline in GFR based upon these three methods. Bland & Altman plots were used to illustrate the range of agreement. We investigated 76 insulin-dependent diabetic (IDDM) patients with microalbuminuria or diabetic nephropathy. GFR was measured after a single intravenous injection of 3.7 MBq 51Cr-EDTA by determining the radioactivity in venous blood samples taken 5, 7, 10, 15, 30, 45, 60, 90, 120, 150, 180, 200, 220, and 240 min after the injection. Rate of decline in GFR was assessed using 12 (6-17) determinations of GFR over a period of time of 8 (4-10) years. Mean (SD) GFRT was 123 (21) ml x min(-1) compared to GFR(IV) 123 (21) ml x min(-1) (NS) and GFR(I) 115 (17) ml x min(-1) (p < 0.00001). The mean difference (95% limits of agreement) between GFR(T) and GFR(IV) was +0.6 (-16.6 to +17.7) ml x min(-1), and between GFR(T) and GFR(I) +8.0 (-6.0 to +22.2) ml x min(-1). The difference between GFR(T) and GFR(I) was significantly correlated with their mean value (r = 0.56, p < 0.00001), indicating increasing underestimation by GFR(I) with increasing GFR levels. The mean (SD) rate of decline in GFR(T) was 2.3 (3.9) ml x min(-1) x year(-1), compared to a mean rate of decline in GFR(IV) of 2.4 (3.6) ml x min(-1) x year(-1) (NS), and a mean rate of decline in GFR(I) of 2.2 (3.5) ml x min(-1) x year(-1) (NS). The mean difference (95% limits of agreement) between rate of decline in GFR(T) and rate of decline in GFR(IV) was +0.16 (-1.59 to +1.91) ml x min(-1) x year(-1), and between rate of decline in GFR(T) and rate of decline in GFR(I) -0.01 (-1.64 to +1.61) ml x min(-1) x year(-1), respectively. In conclusion, our cross-sectional study revealed a close agreement between GFR(T) and GFR(IV) with acceptable limits of agreement (precision), while GFR(I) lacked accuracy. However, a close agreement between rate of decline in GFR(T) and rate of decline in GFR(IV), and between rate of decline in GFR(T) and rate of decline in GFR(I), with acceptable limits of agreement (precision), suggests that both simplified methods are applicable for long-term follow-up.

Characterization, mapping and partial cDNA sequence of the 57-kD intracellular Ki-1 antigen

A novel antigen was identified by the cross-reactivity of the anti-CD30 antibody Ki-1. This 57-kD intracellular Ki-1 antigen (Ki-1/57) is induced upon activation of leukocytes and is transported to the nuclear compartment. We describe the partial cloning and sequencing of the Ki-1/57 cDNA from a lambda gt 11-cDNA library derived from the Hodgkin-analogous cell line L540. New monoclonal antibodies were produced against the recombinant Ki-1/57 protein fragment which were used to confirm that the Ki-1/57 antigen is associated with kinase activity and is expressed in a variety of tumor cell lines and in activated but not resting leukocytes. The Ki-1/57 gene was mapped to the bands 9q22.3-31 of human chromosome 9. This is an area which appears to be associated with secondary chromosomal aberrations in acute myeloid leukemias.

Kidney function after withdrawal of long-term antihypertensive treatment in diabetic nephropathy

Initiation of antihypertensive treatment in hypertensive non-insulin-dependent diabetic (NIDDM) patients with diabetic nephropathy induces a faster initial (0 to 6 months) and slower subsequent (6 months-end) decline in GFR [delta GFR (ml.min-1.1.73 m-2.month-1) approximately 1.5 vs. 0.4]. Whether this initial phenomenon is reversible (hemodynamic) or irreversible (structural damage) after prolonged antihypertensive treatment is not known. To elucidate these mechanisms we investigated 40 hypertensive NIDDM patients (age 61 +/- 7 years, mean +/- SD), known duration of diabetes 14 years (2 to 33 years) [median (range)] with diabetic nephropathy receiving antihypertensive treatment (angiotensin converting enzyme inhibition, N = 30) for 5 years (1 to 20 years). The following variables were measured the last day on antihypertensive treatment and one month after withdrawal of treatment; GFR (51Cr-EDTA), 24-hour arterial blood pressure (24 hr MABP, Takeda TM2420) and albuminuria (ELISA); the mean 24-hour MABP rose from 102 +/- 11 to 111 +/- 10 (P < 0.0001) and albuminuria [geometric mean (antilog SEM)] increased from 634 (1.3) to 1159 (1.2) (P < 0.0001), while GFR (mean +/- SD) remained unchanged (69 +/- 25 to 70 +/- 26 ml.min-1.1.73 m-2, P = 0.21), after withdrawal of antihypertensive treatment. A significant correlation between the relative change in the 24 hour MABP measurement and the relative change in GFR (r = 0.44, P < 0.01) was found. In conclusion, our results suggest that the faster initial decline in GFR after initiating antihypertensive treatment in hypertensive NIDDM patients with diabetic nephropathy is due to a irreversible effect, and should be accounted for when evaluating the beneficial effect of antihypertensive treatment on the progression of diabetic nephropathy in these patients.

Impaired autoregulation of GFR in hypertensive non-insulin dependent diabetic patients

We investigated the effect of acute lowering of blood pressure (BP) upon glomerular filtration rate (GFR) in hypertensive non-insulin-dependent diabetes mellitus (NIDDM) patients, 14 with diabetic nephropathy and 12 with normoalbuminuria. The study was performed twice with the subjects receiving an intravenous injection of either clonidine (150 to 225 micrograms) or saline (0.154 mmol/liter). We assessed GFR, albuminuria, and BP. The two groups were well matched with respect to demographic data, baseline GFR and BP. Clonidine induced similar reductions in mean arterial blood pressure 19 (SE +/- 4) and 21 (SE +/- 3) mm Hg in patients with and without nephropathy, respectively. In the nephropathy group GFR diminished in average from 90 (SE +/- 6) to 81 (SE +/- 7) ml/min/1.73 m2 (P = 0.006), fractional clearance of albumin (x 10(-6)) declined from a geometric mean of 219 (antilog SE /divided by 1.3) to 186 (antilog SE /divided by 1.3) (P = 0.04), and four patients had a complete pressure-passive vasculature, defined as delta GFR% = delta MABP%. A significant correlation between relative reductions in MABP and GFR (r = 0.78, P < 0.001) was demonstrated in albuminuric patients. None of the normoalbuminuric patients had a complete pressure-passive vasculature and there were no significant differences in GFR between the two examinations, but five had abnormal autoregulation of GFR. Mean difference between changes in GFR (95% confidence interval) between the nephropathic and normoalbuminuric group was 5.5 (divided by 2.7 to 13.7) ml/min/1.73 m2 (P = 0.18). Our study suggests that hypertensive NIDDM patients, particularly patients with nephropathy, frequently suffer from impaired or abolished autoregulation of GFR.

Circadian rhythm of arterial blood pressure and albuminuria in diabetic nephropathy

The aim of our study was to evaluate the diurnal relationship between arterial blood pressure and albuminuria, and some potential mechanisms responsible for impaired nocturnal blood pressure reduction (non-dippers, groups I and II) in diabetic nephropathy (DN). Twenty-four-hour ambulatory blood pressure, heart rate (HR) variation (autonomic nervous function) and extracellular fluid volume (ECV) were measured, and urine samples were collected three times during the corresponding day- and nighttimes in 47 insulin-dependent diabetic (IDDM) patients with DN. Mean arterial blood pressure (MABP) during the daytime [mm Hg, median (range)] was identical in group I [105 (96-137)], group II [109 (86-124)] and group III [dippers; average blood pressure reduction from day to night > 10%, 107 (93-132), P = NS], while the nighttime MABP differed [group I, 106 (95-144); group II, 100 (78-118); group III, 91 (76-118); P < 0.001]. No significant difference between the groups concerning the daytime or nighttime albuminuria [microgram/min; median (range)] was observed; [Day: group I, 1467 (235-3933); group II, 695 (170-6719); group III, 875 (228-3173). Night: group I, 1079 (279-4665); group II, 572 (113-3807); group III, 659 (81-2493)]. A significant correlation between MABP and albuminuria was demonstrated during day- (rho = 0.50, P < 0.0005) and nighttime (rho = 0.46, P < 0.005), while neither the absolute nor the relative changes in MABP from day to night correlated significantly with absolute or relative changes in albuminuria from day to night. The night/day ratio of HR was higher in group I [0.93 (0.76-1.09), median (range)] compared to group III [0.83 (0.74-1.02), P < 0.005] and a significant correlation between this ratio and the night/day ratio of MABP was found (rho = 0.54, P < 0.0005). ECV was about the same in the three groups. Our study indicated an association between blood pressure and albuminuria, but the mechanisms involved in the reduction of albuminuria from day to night was not unraveled. A relative lack of sympathetic withdrawal during sleep seems to be an important feature of nocturnal hypertension in diabetic nephropathy.

The acute effect of smoking on systemic haemodynamics, kidney and endothelial functions in insulin-dependent diabetic patients with microalbuminuria

The acute effect of smoking upon arterial blood pressure, urinary albumin excretion rate, glomerular filtration rate and transcapillary escape rate of albumin were investigated in nine normotensive insulin-dependent diabetic patients with microalbuminuria, who had been smoking for 19 (range 4-30) years. In a prospective, open randomized cross-over design, patients were investigated with and without smoking three cigarettes per hour during a 5.5-h period. A rise in systolic blood pressure and heart rate (Takeda TM2420, median (range)) was observed during the smoking day (10(-11 to 14) mmHg and 8 (-1 to 19) beats min-1), compared to the non-smoking day (1 mmHg (-7 to 13) (p = 0.05) and 0 beats min-1 (-2 to 4) (p < 0.01)). Urinary albumin excretion rate (ELISA), glomerular filtration rate (plasma clearance of 51Cr-EDTA) and transcapillary escape rate of albumin (125I-albumin) remained the same with or without smoking. Our study suggests that heavy smoking induces an abrupt rise in systolic blood pressure and heart rate, while vascular leakage of albumin and glomerular filtration rate remain unaltered in normotensive insulin-dependent diabetic patients with microalbuminuria who had been smoking for several years.

A zinc metalloproteinase is responsible for the release of CD30 on human tumor cell lines

The activation marker CD30 is expressed on the cell surface of the malignant cells in Hodgkin's disease and a few non-Hodgkin lymphomas. We have analyzed the regulation of membrane-bound CD30 and found that the binding of a variety of anti-CD30 antibodies induced down-regulation of CD30 on cell lines. In addition, such down-modulation was also observed after treatment of the cell surface proteins with the sulfhydryl reagent iodoacetamide or after stimulation of the second messenger pathway with phorbol ester or calcium ionophore. This modulation was abolished at 4 degrees C and strongly inhibited by chelators like EDTA or 1,10-phenanthroline, whereas EGTA, a selective inhibitor of Ca(2+)-dependent proteinases and other inhibitors of serine, thiol and acid proteinases, showed no effect. The down-modulation was strengthened by Zn2+ or Cd2+, but not by other divalent cations such as Fe2+, Mn2+, Mg2+, Ca2+ or Co2+, thus indicating the involvement of a zinc metalloproteinase in CD30 modulation which can be activated by protein kinase C and by alkylation of sulfhydryl groups. Pulse-chase experiments, analysis of the CD30 glycosylation and specific measurement of the 90-kDa soluble form of CD30 (sCD30) with a sandwich radioimmunoassay revealed that CD30 down-modulation results from enhanced release of 90-kDa sCD30 by the site-specific cleavage of CD30 accomplished by a zinc metalloproteinase. This release occurs at the cell membrane without prior endocytosis.

Increased glomerular filtration rate after withdrawal of long-term antihypertensive treatment in diabetic nephropathy

Initiation of antihypertensive treatment (AHT) in hypertensive insulin-dependent diabetic (IDDM) patients with diabetic nephropathy (DN) induces a faster initial (0 to 6 months) and a slower subsequent (6 months to end of observation) decline in GFR [delta GFR (ml/min/month) approximately 1.5 vs. 0.35]. Whether this initial phenomenon is reversible (hemodynamic) or irreversible (structural damage) after prolonged AHT is not known. To elucidate these mechanisms we investigated 42 hypertensive IDDM patients (16F/26M, age 40 +/- 7 years, mean +/- SD) with DN receiving AHT (angiotensin converting enzyme inhibition, N = 30) for 6 (2 to 15) years [median (range)]. GFR (ml/min/1.73 m2), arterial blood pressure (BP, mm Hg) and albuminuria (mg/24 hr) were measured the last day on AHT and one month after withdrawal of AHT. The measured variables were all significantly elevated after withdrawal of AHT: GFR [mean(SEM)] from 76(4) to 81(4) (P < 0.0001), BP [mean(SEM)] from 140/82 (2/1) to 151/89 (2/1) (P < 0.0005) and albuminuria [geometric mean (antilog SEM)] from 704 (1.2) to 1122 (1.2) (P < 0.0001). A correlation between relative rise in systolic blood pressure (delta Sys%) and relative change in GFR (delta GFR%) was found (r = 0.44, P < 0.005). Our results render some support of the hypothesis that the faster initial decline in GFR is due to a functional (hemodynamic) effect of AHT, which does not attenuate over time, while the subsequent slower decline reflects the beneficial effect on progression of diabetic nephropathy.