Using Causal Bayesian Networks to Assess the Role of Patient-Centered Care and Psychosocial Factors on Durable HIV Viral Suppression

We assessed the role of patient-centered care on durable viral suppression (i.e., all viral load test results < 200 copies per ml during 2019) by conducting a retrospective cohort study of clients medically case managed by the Miami-Dade County Ryan White Program (RWP). Summary measures of patient-centered care practices of RWP-affiliated providers were obtained from a survey of 1352 clients. Bayesian network models analyzed the complex relationship between psychosocial and patient-centered care factors. Of 5037 clients, 4135 (82.1%) had durable viral suppression. Household income was the factor most strongly associated with durable viral suppression. Further, mean healthcare relationship score and mean "provider knows patient as a person" score were both associated with durable viral suppression. Healthcare relationship score moderated the association between low household income and lack of durable viral suppression. Although patient-centered care supports patient HIV care success, wrap around support is also needed for people with unmet psychosocial needs.

Exploring the use of self-management strategies for antiretroviral therapy adherence among women with HIV in the Miami-Dade County Ryan White Program

Women with HIV (WWH) face increased difficulties maintaining adherence to antiretroviral therapy (ART) due to a variety of demographic and psychosocial factors. To navigate the complexities of ART regimens, use of strategies to maintain adherence is recommended. Research in this area, however, has largely focused on adherence interventions, and few studies have examined self-reported preferences for adherence strategies. The purpose and objectives of this study were to explore the use of ART self-management strategies among a diverse sample of WWH, examine demographic and psychosocial differences in strategy use, and assess the association between strategies and ART adherence. The current study presents secondary data of 560 WWH enrolled in the Miami-Dade County Ryan White Program. Participants responded to questionnaire items assessing demographic and psychosocial characteristics, use of adherence strategies, and ART adherence during the past month. Principal component analysis identified four categories among the individual strategies and multivariable binomial logistic regression assessed adherence while controlling for individual-level factors. The majority of WWH reported optimal ART adherence, and nearly all used multiple individual strategies. The number of individual strategies used and preferences for strategy types were associated with various demographic and psychosocial characteristics. Adjusting for demographic and psychosocial characteristics, optimal ART adherence during the past month was associated with the use of four or more individual strategies. When conducting regular assessments of adherence, it may be beneficial to also assess use of adherence strategies and to discuss with WWH how using multiple strategies contributes to better adherence.

Perceptions and Current Practices in Patient-Centered Care: A Qualitative Study of Ryan White HIV Providers in South Florida

Background: Patient-centered care (PCC) improves HIV adherence and retention, though lack of consensus on its conceptualization and understanding how it is interpreted has hindered implementation. Methods: We recruited 20 HIV providers at Ryan White Programs in FL for in-depth interviews. Thematic analysis identified core consistencies pertaining to: 1) provider perceptions, 2) current practices promoting PCC. Results: Provider perceptions of PCC emerged under four domains: 1) holistic, 2) individualized care, 3) respect for comfort and security, and 4) patient engagement and partnership. PCC practices occurred at multiple levels: 1) individual psychosocial and logistical support, 2) interpersonal support within patient-provider relationships through respectful communication and active engagement, and 3) institutional practices including feedback mechanisms, service integration, patient convenience, and diverse staffing. Conclusions: Our findings highlight the central tenets of PCC as respectful, holistic, individualized, and engaging care. We offer an HIV-adapted framework of PCC as a multilevel construct to guide future intervention.

Sex differences in psychosocial and demographic factors associated with sustained HIV viral suppression in the Miami-Dade County Ryan White Program, 2017

This exploratory study examined sex differences in psychosocial and demographic factors associated with sustained HIV viral suppression (SVS). The study population included 6,489 Miami-Dade Ryan White Program (RWP) clients receiving services during 2017; administrative data was analyzed. SVS was defined as having all viral load tests during 2017 below 200 copies/ml. Multilevel logistic regression models accounted for clustering by medical case management site. Models were stratified by sex. Overall, a higher proportion of females did not achieve SVS (23.5%) than males (18.1%). For females (n = 1,503), having acquired HIV perinatally and not having a partner oradult household member were associated with not achieving SVS. For males (n = 4,986), lacking access to food, Black or Haitian race/ethnicity, problematic substance use, and unknown physician were associated with not achieving SVS. For both sexes, younger age, lower household income, ever having an AIDS diagnosis, feeling depressed or anxious, and experiencing homelessness were associated with not achieving SVS. Elements of the transition from adolescent to adult HIV care that may differentially impact female clients and factors associated with disclosure should be explored further. Male clients may require additional support for food security. Improving culturally specific care for Haitian and non-Hispanic Black male clients should also be explored.

Increased alcohol use during the COVID-19 pandemic among people with HIV from racial/ethnic minority groups in South Florida

People with HIV (PWH) from racial/ethnic minority groups may be particularly vulnerable to the effects of the COVID-19 Pandemic. Exacerbated COVID-19-related stressors may lead to maladaptive coping mechanisms such as increased alcohol use. This study examined socioeconomic and psychosocial predictors of increased alcohol use during the first year of the COVID-19 Pandemic among PWH from racial/ethnic minority groups in South Florida. Data were collected from Ryan White Program clients during October 2020-January 2021 using a cross-sectional phone survey, and were analyzed using logistic regression modeling. Among 139 participants, 20% reported increased alcohol use. Findings showed that being unable to buy needed food (adjusted odds ratio [aOR]: 3.37; 95% confidence interval [CI]: 1.01-11.31) and spending more time caring for children (aOR: 5.22, 95% CI: 1.61-16.88) was associated with increased alcohol use during the Pandemic. Providing support to alleviate food insecurity and manage caregiving burden during public health crises like the COVID-19 Pandemic might help prevent increases in alcohol use among PWH.

Barriers and facilitators to retention in care and treatment adherence among racially/ethnically diverse women with HIV in South Florida: a qualitative study

Women, particularly those from racial/ethnic minority groups, experience disparities in HIV care and treatment, and in achieving viral suppression. This study identified barriers and facilitators influencing retention in HIV care and treatment adherence among women belonging to racial/ethnic minority groups. We conducted semi-structured interviews with 74 African American, Hispanic/Latina and Haitian cisgender women receiving care from the Ryan White HIV/AIDS Program in Miami-Dade County, Florida in 2019. Data were analyzed using a thematic analysis approach. The most salient barriers faced by women were competing life priorities, mental health and substance use issues, medication-related concerns and treatment burden, negative experiences with HIV care services, transportation and parking issues and stigma and discrimination. Important facilitators identified by women included taking personal responsibility for health, social support, and patient-friendly and supportive HIV care services. Our findings suggest that HIV care could be enhanced for this population by understanding the non-HIV needs of the women in care, provide more flexible and relevant services in response to the totality of these needs, and simplify and expand access to care and supportive services.

Patient-Provider Relationships and Antiretroviral Therapy Adherence and Durable Viral Suppression Among Women with HIV, Miami-Dade County, Florida, 2021-2022

Women with HIV in the United States are more negatively affected by adverse social determinants such as low education and poverty than men, and thus, especially need a supportive health care system. This cross-sectional study assessed the role of the patient-provider relationship on antiretroviral therapy (ART) adherence and durable viral suppression among women with HIV (WHIV) in Miami-Dade County, Florida. Patient-provider relationship was measured, in part, using the Health Care Relationship Trust Scale and Consumer Assessment of Health Care Providers and Systems. The survey was administered by telephone to women in the Ryan White Program June 2021-March 2022. Adherence was defined as 90% adherent on the average of three self-reported items. Lack of durable viral suppression was defined by at least one viral load ≥200 copies/mL among all tests conducted in a year. Logistic regression models were generated using backward stepwise modeling. Of 560 cis-gender women, 401 (71.6%) were adherent, and 450 (80.4%) had durable viral suppression. In the regression model, adherence was associated with higher patient-provider trust and provider communication as well as excellent perceived health, lack of significant depressive symptoms, no alcohol use within the last 30 days, and lack of transportation problems. In the regression model using provider as a random effect, durable viral suppression was associated with older age, Hispanic ethnicity, and lack of illegal drug use. While the results show that a strong patient-provider relationship facilitates ART adherence in WHIV, there was no association with durable viral suppression.

Clients' Perspectives on Patient-Centeredness: a Qualitative Study with Low-Income Minority Women Receiving HIV Care in South Florida

Low-income, minority women living with HIV often experience multiple barriers in care that contribute to suboptimal care outcomes. Medical case managers (MCM) and medical providers are key players involved in care coordination and aid women along the HIV care continuum. The objective of this study was to identify current and potential patient-centered practices that facilitate adherence to medication and retention in care, from the perspective of racially and ethnically diverse women living with HIV. We implemented a qualitative study using semi-structured interviews with 75 African American, Hispanic/Latina, and Haitian women who were enrolled in the Ryan White HIV/AIDS Program in South Florida in 2019. We organized domains of exploration using a patient-centered care framework to identify practices in which providers acknowledged, respected, and responded to clients' preferences, needs, and values. Interviews were analyzed using consensual thematic analysis approach. Findings reflect women valued MCMs who were proactive and directive in care, provided motivation, and aided with navigation of shame, fear, and stigma. Women valued medical providers who upheld simple educational communication. Moreover, women reported that providers who reviewed medical results with clients, incorporated questions about families, and inquired about multiple physical and clinical needs beyond HIV created opportunities for women to feel respected, valued, and in turn, enhanced their involvement in their care. Findings identify specific interpersonal practices that can enhance the ability to better meet the needs of diverse groups of women, specifically those from racial/ethnic minority groups who face multiple sociocultural barriers while in care.

Self-reported Nonadherence to Antiretroviral Therapy Among Miami-Dade Ryan White Program Clients During the COVID-19 Pandemic: A Cross-sectional Study

This study examined factors associated with self-reported ART nonadherence during the COVID-19 pandemic among Miami-Dade County Ryan White HIV/AIDS Program (RWHAP) clients. A cross-sectional survey was conducted from October 2020-January 2021 in English, Spanish, and Haitian Creole. The survey included questions on self-reported ART adherence, HIV care access (compared to before the pandemic), social and economic pandemic impacts, and demographics. We carried out descriptive bivariate analyses and weighted logistic regression to estimate unadjusted and adjusted odds ratios (aORs) for self-reported nonadherence. 12.7% of participants reported ART nonadherence. Adjusting for age, sex, race/ethnicity, and nativity, factors associated with nonadherence included greater difficulty accessing an HIV doctor compared with before the COVID-19 pandemic (aOR=3.6, 95% CI: 1.4–9.2) and experiencing financial impacts due to the pandemic (aOR=4.2, 95% CI: 1.5–12.2). Ensuring RWHAP clients maintain access to HIV medical care providers and receive support for financial shocks are critical to sustaining ART adherence.

Dealing with Careless Responding in Survey Data: Prevention, Identification, and Recommended Best Practices

Surveys administered online have several benefits, but they are particularly prone to careless responding, which occurs when respondents fail to read item content or give sufficient attention, resulting in raw data that may not accurately reflect respondents' true levels of the constructs being measured. Careless responding can lead to various psychometric issues, potentially impacting any area of psychology that uses self-reported surveys and assessments. This review synthesizes the careless responding literature to provide a comprehensive understanding of careless responding and ways to prevent, identify, report, and clean careless responding from data sets. Further, we include recommendations for different levels of screening for careless responses. Finally, we highlight some of the most promising areas for future work on careless responding.

Nonfatal opioid-related overdoses treated by emergency medical services in Florida, before and during the COVID-19 pandemic

Previous studies have found increases in nonfatal opioid overdoses during the COVID-19 pandemic, which created difficult conditions for people with substance use disorders. We assessed changes in nonfatal opioid-related overdoses in Florida during the onset of the COVID-19 pandemic. Emergency medical service data was obtained from the Florida Department of Health. Naloxone administration with documented improvement was used as a proxy for nonfatal opioid-related overdoses. Age-adjusted rates were estimated per 100,000 population for April-September 2020 (n = 9,377) and compared to the same time period during 2019 (n = 6,765) using rate ratios. Age-adjusted rates were estimated by sex, race/ethnicity, and metro/nonmetro county classification, as well as county-level measures of medications for opioid use disorder (MOUD) availability, rates of COVID-19 deaths, and unemployment during 2020. The age-adjusted rate of nonfatal opioid-related overdoses increased from 32.41 (95 % CL: 31.64-33.19) during 2019 to 45.35 (95 % CL: 44.42-46.27) during 2020 (RR = 1.40; 95 % CL: 1.36-1.44). The rate for males increased most in metro counties (RR = 1.47, 95 % CL: 1.41-1.53); the rate for females increased most in nonmetro counties (RR = 1.51, 95 % CL: 1.10-2.06). The largest increases were observed among Hispanics (males: RR = 1.56, 95 % CL: 1.37-1.78; females: RR = 1.44, 95 % CL: 1.14-1.81), counties with no MOUD treatment options (RR = 1.66, 95 % CL: 1.14-2.44) and counties with the lowest rates of buprenorphine prescribers (RR = 1.70, 95 % CL: 1.29-2.22). Nonfatal opioid-related overdoses increased in Florida during the first six months of the COVID-19 pandemic. Expanding access to services that support treatment and recovery is critical to addressing the ongoing opioid crisis in Florida.

HIV Care Access During the COVID-19 Pandemic as Perceived by Racial/Ethnic Minority Groups Served by the Ryan White Program, Miami-Dade County, Florida

The Ryan White Program (RWP) in Miami-Dade County, Florida made several modifications to keep HIV care accessible during the COVID-19 Pandemic, including expanding telehealth services, increasing access to HIV medications, and waiving required lab tests for service recertification. We assessed ease of access to medical providers, medical case managers, and antiretroviral medications during the COVID-19 Pandemic among 298 Non-Hispanic Black, Hispanic, and Haitian people with HIV (PWH) served by the RWP Part A, Miami-Dade County, Florida using a telephone-administered survey between October 2020 and January 2021. Overall, most clients reported similar or better access compared to before the Pandemic. Use of videocalls to communicate with HIV medical providers varied by race/ethnicity: Hispanics (49.6%), Non-Hispanic Blacks (37.7%), and Haitian clients (16.0%). Results suggest the modifications helped maintain access to care during an unprecedented health crisis. Permanently adopting many of these modifications should be considered to continue to facilitate access to care.

Provider Perceptions of Barriers to HIV Care Among Women with HIV in Miami-Dade County, Florida, and Possible Solutions: A Qualitative Study

In Miami-Dade County, women with HIV (WWH) enrolled in Ryan White Program (RWP) services belong to groups that have historically faced structural barriers to care. To examine provider perceptions of WWH's barriers to care and elicit possible solutions, we conducted semi-structured interviews (n = 20) with medical case managers and human immunodeficiency virus (HIV) healthcare providers from medical case management sites serving WWH enrolled in the Miami-Dade RWP. Verbatim transcripts were analyzed thematically by two coders through an iterative process; disagreements were resolved through consensus. Barriers included lack of disclosure and stigma, additional psychosocial barriers to care, structural and logistical barriers, and negative interactions with health care providers. Participant suggestions to address these barriers included strategies that support women and foster individualized services that are responsive to their lived experiences and needs. Other solutions, such as those related to transportation, housing, and general funding for the RWP, will require advocacy and policy change.

Effects of a hot ambient operating theatre on manual dexterity, psychological and physiological parameters in staff during a simulated burn surgery

OBJECTIVES

Hot environmental conditions can result in a high core-temperature and dehydration which can impair physical and cognitive performance. This study aimed to assess the effects of a hot operating theatre on various performance, physiological and psychological parameters in staff during a simulated burn surgery.

METHODS

Due to varying activity levels, surgery staff were allocated to either an Active (n = 9) or Less-Active (n = 8) subgroup, with both subgroups performing two simulated burn surgery trials (CONTROL: ambient conditions; 23±0.2°C, 35.8±1.2% RH and HOT: 34±0°C, 28.3±1.9% RH; 150 min duration for each trial), using a crossover design with four weeks between trials. Manual dexterity, core-temperature, heart-rate, sweat-loss, thermal sensation and alertness were assessed at various time points during surgery.

RESULTS

Pre-trials, 13/17 participants were mildly-significantly dehydrated (HOT) while 12/17 participants were mildly-significantly dehydrated (CONTROL). There were no significant differences in manual dexterity scores between trials, however there was a tendency for scores to be lower/impaired during HOT (both subgroups) compared to CONTROL, at various time-points (Cohen's d = -0.74 to -0.50). Furthermore, alertness scores tended to be higher/better in HOT (Active subgroup only) for most time-points (p = 0.06) compared to CONTROL, while core-temperature and heart-rate were higher in HOT either overall (Active; p<0.05) or at numerous time points (Less-Active; p<0.05). Finally, sweat-loss and thermal sensation were greater/higher in HOT for both subgroups (p<0.05).

CONCLUSIONS

A hot operating theatre resulted in significantly higher core-temperature, heart-rate, thermal sensation and sweat-loss in staff. There was also a tendency for slight impairment in manual dexterity, while alertness improved. A longer, real-life surgery is likely to further increase physiological variables assessed here and in turn affect optimal performance/outcomes.

Assessment of glomerular filtration rate during pregnancy using the MDRD formula

It is now recommended practice to use estimated glomerular filtration rate (eGFR) values to screen for and monitor chronic renal disease. The most frequently used formula in the general population is that described following the Modification of Diet in Renal Disease (MDRD) study whereby serum creatinine is adjusted for age, gender and race. This study evaluates the performance of the MDRD formula in pregnancy by comparing eGFR with measured values obtained by inulin clearance studies in early and late normal pregnancy and in pregnancies complicated by renal disease or pre-eclampsia. Our results indicate that in all situations, MDRD substantially underestimates glomerular filtration rate during pregnancy and cannot be recommended for use in clinical practice.

Aluminium intoxication in renal disease

Aluminium intoxication in renal failure occurred over weeks or months when dialysis fluid or parenteral solutions were heavily contaminated and over many years when the main source was oral administration of aluminium-containing phosphate binders. Encephalopathy was common during subacute intoxication but in slow aluminium poisoning the main brunt was borne by the bones. However, in both tempos of intoxication several organs or systems were involved. Encephalopathy was usually accompanied by bone disease, bone disease by parathyroid suppression and both by anaemia. The heart and the lymphocytes are probably damaged by aluminium overload. Among the many questions left unanswered 15 years after the incrimination of aluminium as the cause of this multi-system illness are: (1) does low level aluminium overload in renal failure cause gradual deterioration in cerebral function? And, if so, (2) does it resemble Alzheimer's disease or a slow-onset version of dialysis encephalopathy? The evidence we review suggests that the answer to (1) is 'yes' and to (2) 'probably the latter'.

Sex and the pregnant kidney: Does renal allograft gender influence gestational renal adaptation in renal transplant recipients?

BACKGROUND

Animal work indicates that ovarian hormones are important in initiating and maintaining enhanced renal function in pregnant rats and that a renal response resembling pregnancy can be provoked in male rats exposed to pregnancy hormones. Women becoming pregnant following renal transplantation provide an opportunity to compare the functional response of male and female allografts to the gestational endocrine environment.

METHODS

This retrospective observational study included 20 renal allograft recipients (age 29.7 +/- 2.4 yrs) (mean +/- SE) who had 22 pregnancies beyond 24 weeks (gestation at delivery 35.5 +/- 0.6 weeks). Donor characteristics, transplant details, renal follow-up data, and information about pregnancy and allograft function were obtained from hospital notes.

RESULTS

Thirteen women received male allografts (donor age 30.0 +/- 3.9 years) (mean +/- SEM) and 7 women, female allografts (donor age 45.1 +/- 6.0 years) (P = .04). There were no significant differences between the two groups in maternal recipient age, transplant to pregnancy interval, antenatal complications, pregnancy outcome, or postnatal graft function. Compared to prepregnancy values serum creatinine (SCr) decrements and augmented 24-hour creatinine clearance (CrCl) were observed over the first trimester in both male and female allografts: Delta CrCl from 106.8 +/- 13.2 mL/min to 114.4 +/- 11.4 mL/min (35.6% increase) and 71.8 +/- 7.4 to 89.5 +/- 11.3 mL/min (24.7% increase), respectively, and Delta SCr from 90.1 +/- 5.4 micromol/L to 73.6 +/- 6.6 micromol/L (17.8% decrease) and 99.8 +/- 9.7 micromol/L to 78.0 +/- 5.7 micromol/L (13.5% decrease), respectively. Differences between the two groups did not reach statistical significance.

CONCLUSIONS

Donor gender and/or age do not appear to influence the gestational renal response in kidney transplant recipients.

Long-term follow-up of patients presenting to adult nephrologists with chronic pyelonephritis and 'normal' renal function

We studied the natural history, and therefore prognosis, of patients with chronic pyelonephritis presenting to adult nephrologists with a plasma or serum creatinine <90 mmol/l. From the Newcastle chronic pyelonephritis database, 255 patients with radiologically-proven disease were reviewed. Median follow-up was 95 months (95%CI 82. 3-109.3). Plasma creatinine was < or =90 micromol/l (P(Cr)< or =90 group) at presentation in 138. At presentation, hypertension, bilateral disease and proteinuria were less frequent in the P(Cr)< or =90 group (hypertension 19% vs. 32%, p<0.05; bilateral disease 25% vs. 70%, p<0.001; proteinuria 18% vs. 60%, p<0.001). With the exception of two patients, the renal prognosis of this group was excellent. Patients over the age of 18 years presenting to adult nephrologists with a diagnosis of chronic pyelonephritis and a creatinine < or =90 micromol/l can be reassured that the chances of developing end-stage renal failure in the future are very small. Most could be referred back to their general practitioner for long-term follow-up.

Correction of acidosis in hemodialysis patients increases the sensitivity of the parathyroid glands to calcium

Correction of acidosis in hemodialysis patients increases the sensitivity of the parathyroid glands to calcium. In this study, the parathyroid response to the correction of acidosis in eight hemodialysis patients was determined by performing dynamic assessment of parathyroid function before and after the correction of acidosis. The parathyroid response to intravenous calcitriol before and after the correction of acidosis was also assessed. After optimal correction of acidosis, there were no significant changes in blood pH, ionized calcium, phosphate, or alkaline phosphatase values, but the level of venous total CO2 increased significantly. Parathyroid hormone/ionized calcium curves were displaced downward after correction of acidosis, but not after the administration of intravenous calcitriol. The correction of metabolic acidosis in hemodialysis patients with secondary hyperparathyroidism can suppress parathyroid hormone secretion by increasing the sensitivity of the parathyroid glands to ionized calcium.

Withdrawal of renal replacement therapy in Newcastle upon Tyne: 1964-1993

BACKGROUND

Termination of renal replacement therapy (RRT) is common in North America and Australia but is considered to be rare in Europe.

METHODS

In order to review the phenomenon of RRT termination in all patients treated in Newcastle upon Tyne between 1964 and 1993 a retrospective study of clinical case notes was undertaken. In all RRT patients sex, age at start of RRT, renal diagnosis and history of RRT were recorded. In addition, mortality data and marital and residential status were recorded in all patients who died, and Karnofsky index, bodyweight, complications, history of bereavement, place of death, overall survival, survival after withdrawal of treatment, other medical problems, higher mental function and surgical history in all patients stopping treatment.

RESULTS

1639 patients started RRT between 1964 and September 1993 inclusive. Eighty-eight patients were identified in whom death was a result of treatment being stopped (17% of all deaths). The first was in 1985. In these patients, age was greater (62 vs 47 years, P < 0.001) and diabetes was more prevalent (15 vs 7%, P < 0.03) than in the total RRT population. The Karnofsky index was 70 at the start and 33 at withdrawal of treatment (P < 0.001). The Karnofsky index at the start of RRT was weakly related to that at withdrawal and overall survival (r = 0.36 and 0.28 respectively, P < 0.01). The Karnofsky index at treatment withdrawal correlated with the following survival (r = 0.40, P < 0.001). The median survival of patients stopping treatment was significantly lower than in all RRT patients (16 vs 74 months, P < 0.001) and the majority survived less than 2 years. After dialysis withdrawal the median survival was 8 days, 15 patients survived 3 days or less and 19 more than 10 days. The majority (80%) received terminal care in hospital. At treatment withdrawal 11 patients were demented and 34 showed signs of early dementia. Seventy-eight patients (89%) stopped treatment as a consequence of multiple medical problems. The possibility of dialysis withdrawal was raised by physicians in 50.5%, the patient in 23.8% and the patients' relatives in 21.9% of cases. Four patients (3.8%) committed suicide.

CONCLUSIONS

Death from dialysis termination is a relatively common cause of death in RRT patients in Newcastle upon Tyne. These patients are older with a higher prevalence of diabetes. In 89% of cases the decision to stop treatment was related to multiple medical problems with a recent deterioration. Physicians raised the issue of withdrawal in the majority of cases and most patients subsequently received terminal care in hospital.

Computed tomography evaluation of renal parenchymal volume in patients with chronic pyelonephritis and its relationship to glomerular filtration rate

The measurement of renal parenchymal volume using a calibrated computed tomography image processing method has been evaluated clinically on a cohort of patients with chronic pyelonephritis. Comparison of renal volume with function as assessed by 99Tcm DTPA renography demonstrated a simple linear relationship in patients who were normotensive and aproteinuric. The implications of this result on the interpretation of prognostic factors determining declining renal function in chronic pyelonephritis are discussed.

1% amino acid peritoneal dialysate: single-cycle study in diabetic patients with end-stage renal disease

Uremia is associated with multiple abnormalities of carbohydrate and protein metabolism, which are partially corrected by continuous ambulatory peritoneal dialysis with dextrose-based solutions. The hormonal and metabolic effects of amino acid (AA)-based peritoneal dialysis have been studied in nondiabetic uremic patients. Such solutions may be particularly suitable for diabetic patients with end-stage renal disease provided the safety and efficacy of such solutions can be established. We have studied and compared the metabolic and hormonal responses to a single-cycle exchange of dextrose versus a 1% AA-based continuous ambulatory peritoneal dialysis solution in six diabetic patients with end-stage renal disease. In the fasting state and under similar free insulin concentrations, use of the AA solution led to a higher mean glucose concentration (109 +/- 16 mg/dL with dextrose solution v 128 +/- 25 mg/dL with AA solution, P < 0.05). Levels of alanine, lactate, pyruvate, glycerol, non-esterified fatty acids, and triglycerides were similar with the use of either solution. Use of the AA-based solution led to increases in the mean values of the branched chain AAs for the period of the study (valine 131 +/- 10 mumol/L with dextrose solution v 331 +/- 40 mumol/L with AA solution, P < 0.01; leucine 72 +/- 7 mumol/L with dextrose solution v 129 +/- 11 mumol/L with AA solution, P < 0.01; isoleucine 48 +/- 5 mumol/L with dextrose solution v 103 +/- 11 mumol/L with AA solution, P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Urea kinetic modeling: comparing the options

In this study 6 commercially produced kinetic modeling packages utilizing a variable volume, single pool urea model, as well as formulae to determine the delivery of therapy, have been compared by applying to each the same set of rigorously collected data for a group of 12 patients. Comparison of the kinetically derived parameters (urea generation rate [G], urea distribution volume [V], delivery of therapy [Kt/V], and normalized protein catabolic rate [nPCR]) showed that the values obtained for both G and V differed between packages owing to the numerical methods and the clearance used in the solution of the differential equations. Although a broad agreement between the values established for Kt/V and nPCR was noted, the 95% limits of agreement indicated that it would be prudent to exercise caution when comparing results established by different modeling packages.

Long-term follow-up of non-systemic lupus erythematosus glomerulonephritis in patients with hereditary angioedema: report of four cases

Hereditary angioedema (HAE) is characterized by a deficiency in C1 inhibitor protein (C1 INH) and by clinical symptoms of episodic swelling of subcutaneous or mucosal tissue. It has rarely been reported in association with non-systemic lupus erythematosus (SLE) glomerulonephritis (GN). A recent report of two cases indicates the prognosis to be poor, with both patients progressing to chronic renal failure 8 and 20 years after diagnosis. This report describes the 5-year follow-up of a previously unreported case of an 8-year-old boy with HAE and non-SLE membranoproliferative glomerulonephritis (MPGN). The patient developed macroscopic hematuria, azotemia, and a vasculitic rash. Treatment included prednisone and cyclophosphamide, resulting in clinical improvement. The present report also summarizes the long-term follow-up of three previously reported cases of HAE and non-SLE GN, 25, 16, and 10 years after their initial presentation. Patients monitored for 25 and 16 years had MPGN and normal renal function and received no therapy. The third patient, monitored for 10 years, had segmental MPGN. This patient presented with urinary abnormalities and, after treatment with prednisone, had improvement in her hematuria. None of these four patients developed chronic renal failure. These observations indicate a variable outcome in patients with HAE and non-SLE GN.

Wegener's granulomatosis. A distinct gingival lesion

A hyperplastic (strawberry) gingivitis is a feature of Wegener's granulomatosis. A further case is described in which the only manifestations to date have been the gingival lesion. The diagnostic value of the ANCA test is discussed for patients who present with an unusual hyperplastic gingivitis.

A comparison between oral ciprofloxacin and intraperitoneal vancomycin and netilmicin in CAPD peritonitis

This report describes a prospective, randomized comparison of oral ciprofloxacin and intraperitoneal vancomycin/netilmicin in the treatment of 50 consecutive episodes of CAPD peritonitis in 35 patients. Successful cure of peritonitis was achieved in 76% of subjects taking oral ciprofloxacin and 72% of those given intraperitoneal antibiotics. Satisfactory concentrations of ciprofloxacin in dialysate were achieved in all patients. Failure of ciprofloxacin was due to persistence of an isolate of intermediate sensitivity (1), to persistence with acquisition of resistance (1), and to relapse/reinfection in the remaining four cases (with resistant or moderately sensitive strains in three cases). Ciprofloxacin was well tolerated in the majority of cases. A significant rise in serum creatinine was noted in almost all patients taking oral ciprofloxacin. The advantages of oral drug administration indicate that oral ciprofloxacin is the preferred first-line treatment of CAPD-associated peritonitis.

Parathyroidectomy in chronic renal failure: a nine-year follow-up study

Seventy-three patients with chronic renal failure who underwent parathyroidectomy between March 1978 and April 1987 were reviewed. Thirty-four patients had undergone sub-total parathyroidectomy, and 39 patients had undergone total parathyroidectomy with parathyroid autograft into the forearm. Eight patients showed persistent hyperparathyroidism requiring a second surgical procedure. In all other patients there was highly statistical improvement in parathyroid hormone, total calcium, ionized calcium, alkaline phosphatase and a significant reduction in calcium x phosphate product. Histological evidence of osteitis fibrosa was present in 21 of 22 patients before surgery. Postoperatively, four showed complete resolution and improvement. Three patients developed histological evidence of osteomalacia during the study period. Only four of the 39 patients who underwent total parathyroidectomy with autograft had true recurrent hyperparathyroidism and only two of the 34 patients who underwent sub-total parathyroidectomy had recurrent disease, indicating that there is little to choose between the two techniques in the control of secondary hyperparathyroidism and its subsequent recurrence. In one patient with recurrence of hyperparathyroidism from a forearm parathyroid graft the histological picture was different from that of normal hyperplastic parathyroid tissue. Although it is probable that abnormal parathyroid tissue had been implanted there was no evidence of invasive growth into the forearm muscle. The most striking feature of long term follow-up was the difference in calcium x phosphate product in patients in whom vascular calcification increased compared to those patients with no change or regression of calcification. Mean calcium phosphate product in those patients with progressive vascular calcification was 4.93 for small and medium size vessels and 5.38 for large vessels compared to 4.10 for small and medium vessels and 4.09 for large vessels. In the former case the serum phosphate was 2.00 and 2.17 as compared to 1.75 or 1.73, suggesting that the aim in patients with end stage renal failure maintained by dialysis should be to control the serum phosphate concentration to 1.8 mmol or less and the calcium x phosphate product to less than 4.2.

Oral hairy leukoplakia in an HIV-negative renal transplant patient

A case of oral hairy leukoplakia presenting in an HIV-negative renal transplant recipient is described. The diagnosis was confirmed by identifying Epstein-Barr viral particles in the upper prickle cell layers of the epithelium by electron microscopy and by in situ DNA hybridisation.

Renal replacement treatment for diabetic patients in Newcastle upon Tyne and the Northern region, 1964-88

OBJECTIVES

To review the experience of renal replacement treatment in diabetic patients treated in Newcastle upon Tyne and the Northern region from 1964 to 1988, and to compare the morbidity and mortality of diabetic patients treated with dialysis or transplantation with those of matched controls of non-diabetic patients.

DESIGN

Retrospective study of clinical case notes.

SETTING

Renal units of the Northern region, particularly that in Newcastle upon Tyne.

PATIENTS

All 65 diabetic patients treated by renal replacement treatment in Newcastle upon Tyne from 1964 to 1987; 42 diabetic patients were matched with 42 non-diabetic patients according to age, sex, year of starting treatment, and type of treatment (dialysis or transplantation).

MAIN OUTCOME MEASURES

Sex, age, renal biopsy findings, blood pressure, history of diabetic treatment, and plasma creatinine concentration at the start of renal replacement treatment. History of renal replacement treatments, suitability for transplantation, history of transplantation, cumulative survival, and cause of death during follow up. Survival of technique, cumulative survival of the first peritoneal catheter and history of peritonitis in patients treated with continuous ambulatory peritoneal dialysis; source of graft, histocompatibility antigens, duration of associated stay in hospital, and graft survival in patients receiving renal or pancreatic transplant.

RESULTS

1259 Patients with chronic renal failure were accepted for renal replacement treatment in Newcastle upon Tyne, of whom 65 (5%) had diabetes. The first was accepted in 1974, and between 1974 and 1980 another 15 were treated (mean age 42 years; 4% of new patients). From 1981 to 1987, 49 diabetic patients (mean age 44; 9% of new patients) were treated. Fifty patients (77%) had insulin dependent diabetes and the remaining 15 (23%) non-insulin dependent diabetes. On average, the patients were aged 25 (range 5-57) when diabetes was first diagnosed and 44 (range 24-70) at the start of renal replacement treatment. The mean age at the start of treatment was 40 for patients with non-insulin dependent diabetes and 58 for patients with non-insulin dependent diabetes. Transplantation was performed in 33 of the diabetic patients, whose mean age was lower than that of those who did not receive a transplant (41 v 48 respectively, p less than 0.05). Comparison between the 42 diabetic patients and matched controls showed that the overall survival at five years was 46% and 77% respectively. The three year survival of the diabetic patients who did not receive a transplant was poor (41% v 79% respectively). Of patients transplanted, survival at five years was 73% in the diabetic patients and 90% in the controls. However, there was no significant difference in the five year graft survival (64% v 46% respectively).

CONCLUSIONS

Diabetes adversely affects morbidity and mortality in patients having renal replacement treatment, but renal transplantation seems to be the best option for treating diabetic patients with end stage renal failure.

Ascorbate-induced hyperoxalaemia has no significant effect on lactate generation or erythrocyte 2,3,diphosphoglycerate in dialysis patients

To examine the possible effects of hyperoxalaemia on anaerobic metabolism and erythrocyte pyruvate kinase activity, we induced a rise in plasma oxalate in 11 dialysis patients by the oral administration of ascorbic acid, 500 mg day-1 for 3 weeks. Blood samples were taken from the same antecubital vein before and after the supplementation period, without venous stasis, after an overnight fast. This protocol allowed patients to be used as their own controls. Five healthy subjects underwent an identical protocol to exclude any effect of ascorbate per se. Mean (SEM) plasma oxalate (mumol l-1) rose from 30.3 (3.5) to 48.4 (6.1) in patients and from 1.4 (0.2) to 6.8 (0.9) in healthy subjects. Whole blood ascorbate (mg l-1) rose from 7.0 (0.7) to 26.6 (2.5) in patients and from 9.3 (1.2) to 17.8 (1.8) in healthy subjects (reference range 7.5-20.0 mg l-1). No changes were observed in either group in plasma creatinine, bicarbonate, haemoglobin, or erythrocyte 2,3,diphosphoglycerate (2,3 DPG) after the 3 week supplementation period. Before supplementation lactate generation (area under curve, mmol min l-1) in the 5 min following a 60 s period of standardized ischaemic forearm exercise was significantly (P = 0.026) greater in patients [69.1 (4.7)] than in healthy subjects [46.9 (6.7)]; no significant change in lactate generation occurred in either group after ascorbate-induced hyperoxalaemia. We conclude that changes in plasma oxalate of the order of 20 mumol l-1 have no significant effect on lactate generation or 2,3,DPG levels in uraemic subjects.

The nutritional/metabolic and hormonal effects of 8 weeks of continuous ambulatory peritoneal dialysis with a 1% amino acid solution

Circulating intermediary metabolites, hormones and plasma amino acids (AA) were measured at intervals over 24 hours in seven non-diabetic patients with chronic renal failure treated by continuous ambulatory peritoneal dialysis (CAPD), before and after an 8-week period during which a 1% amino acid dialysis solution replaced two of the four dextrose exchanges. Mean 24-hour concentrations of plasma total and essential amino acid were higher following the AA dialysate (total pre: 2893 +/- 185; total post: 3357 +/- 244; p less than 0.05; essential pre: 751 +/- 47; essential post: 1064 +/- 57 mumol/l; p less than 0.001). Mean 24-hour concentrations of the branched chain amino acids leucine, isoleucine and valine were higher following the AA dialysate (valine pre: 201 +/- 18; valine post: 321 +/- 19; p less than 0.001; leucine pre: 102 +/- 6; leucine post: 127 +/- 9; p less than 0.01; isoleucine pre: 67 +/- 5; isoleucine post: 85 +/- 7 mumol/l; p less than 0.05). Serum albumin increased with use of the AA dialysate (pre: 36 +/- 1; 2 weeks, 40 +/- 1; 4 weeks, 40 +/- 1; 6 weeks, 41 +/- 1; 8 weeks, 38 +/- 2 g/l). 24-hour profiles and mean 24-hour concentrations of blood glucose, serum insulin, serum triglyceride, plasma non-esterified fatty acids (NEFA), plasma 3-hydroxybutyrate and plasma alanine were unchanged after the AA period. Plasma bicarbonate decreased with use of the amino acid solution (pre: 21 +/- 1; 2 weeks, 18 +/- 1; 4 weeks, 18 +/- 1; 6 weeks, 16 +/- 1; 8 weeks, 16 +/- 1 mmol/l). Use of a 1% amino acid solution over an 8-week period in CAPD patients improves the plasma amino acid profile but results in a metabolic acidosis. The other endocrine and metabolic abnormalities of uremia remain unchanged.

Hepatic and peripheral insulin action in chronic renal failure before and during continuous ambulatory peritoneal dialysis

1. A three-step hyperinsulinaemic euglycaemic clamp was performed in six uraemic patients before dialysis and after 3 months of treatment with continuous ambulatory peritoneal dialysis, and in seven matched normal control subjects. Glucose turnover was assessed basally and during the clamp using [3-3H]glucose as a tracer. 2. The glucose infusion rate required to maintain euglycaemia was insignificantly higher in normal subjects compared with undialysed uraemic subjects at each insulin infusion rate. 3. The isotopically assessed total glucose turnover was also similar in normal and uraemic subjects. Basal hepatic glucose output was again similar in uraemic and control subjects and output was suppressed to a similar degree at each insulin infusion rate. 4. After treatment with continuous ambulatory peritoneal dialysis, the glucose infusion rate and the total glucose turnover during the clamp rose significantly at all three insulin concentrations (P less than 0.05), but remained insignificantly different from normal control values. Hepatic glucose output was unchanged. 5. Peripheral insulin action was improved during continuous ambulatory peritoneal dialysis, but hepatic insulin action was unchanged.

Periosteal new bone formation in chronic renal failure

A retrospective analysis of the skeletal surveys of 47 patients with periosteal new bone formation (PNB) associated with chronic renal failure was performed in order to determine the radiological features of this abnormality. Sequential skeletal surveys identified the time of development of PNB in 11 patients. The aetiology of PNB was investigated by reviewing biochemical and pathological data for these patients during this period. Symmetrical involvement of weight bearing bones was a typical feature of PNB. PNB was often identified at multiple sites. No association of PNB with radiological, biochemical or pathological evidence of aluminium induced osteomalacia was found. Both hyperparathyroidism and osteosclerosis were common in patients with PNB but since hyperparathyroidism is a frequent occurrence in patients with chronic renal failure its relationship to PNB is not necessarily causal.

Oxalate retention in chronic renal failure: tubular vs glomerular diseases

Plasma oxalate concentration was measured using an enzyme/bioluminescent assay in 289 patients (178 males, 111 females) with chronic renal failure (plasma creatinine greater than 200 mumol/l), age (SD) 55.5 (13.8) years. Plasma oxalate ranged between less than 0.8 and 48 mumol/l and showed a positive correlation with plasma creatinine (r = 0.57, p less than 0.0001). The slope of the regression line in 55 patients with glomerulonephritis (GN) was significantly lower than in patients with tubulointerstitial disease (TI); however the intercept was significantly higher in GN than in TI. Analysis of covariance showed no relationship between plasma oxalate concentration and age, duration of renal impairment, or administration of diuretics, vitamin D analogues, or phosphate binders. Longitudinal analysis of plasma oxalate measured 3-monthly in selected patients showed marked variability of oxalate/creatinine and oxalate/urea ratios.

Correction of subclinical ascorbate deficiency in patients receiving dialysis: effects on plasma oxalate, serum cholesterol, and capillary fragility

Whole blood ascorbate, plasma oxalate, serum cholesterol, and capillary fragility were measured at monthly intervals for 3 mth in 7 patients receiving continuous ambulatory peritoneal dialysis and 4 receiving haemodialysis, to whom ascorbate supplements had not been prescribed for at least 12 mth. Ascorbate supplements, 25 mg/day, were prescribed for the first month and 50 mg/day for the second month; in the final month patients received no supplements. Whole blood ascorbate was below normal in 6/11 patients at the start of the study but was normal in 10/11 patients when taking ascorbate 50 mg/day. No significant changes in plasma oxalate were observed with these doses of ascorbate, and correction of ascorbate deficiency had no effect on serum cholesterol, mean cell volume, or the results of capillary fragility tests. In a supplementary study, ascorbic acid 500 mg/day was administered for 3 wk to 11 patients. This resulted in a significant rise in mean plasma oxalate from 30.3 (SEM 3.5) to 48.4 (SEM 20.3) mumol/l.

Effect of pyridoxine supplementation on plasma oxalate concentrations in patients receiving dialysis

Plasma oxalate and erythrocyte glutamic oxaloacetate transaminase activity (EGOT) (an indicator of nutritional status with respect to pyridoxine) were measured in 21 patients maintained on regular continuous ambulatory peritoneal dialysis or haemodialysis before and after a 4-month period of supplementation with pyridoxine, 100 mg day-1. Prior to supplementation 10/21 patients showed subnormal EGOT activity, although the increment in activity on addition of pyridoxal-5-phosphate in vitro was within the normal range in all cases. Mean plasma oxalate was 31.5 mumol l-1 (SEM 2.9) prior to supplementation and did not change significantly with supplementation, despite normalization of EGOT activity in all but 2/21 patients. We conclude that pyridoxine deficiency does not contribute significantly to hyperoxalaemia in patients receiving dialysis and that 100 mg of pyridoxine daily is insufficient to reduce oxalate generation by a pharmacological action on glycine transamination.

The determination of plasma oxalate concentrations using an enzyme/bioluminescent assay. 2. Co-immobilisation of bioluminescent enzymes and studies of in vitro oxalogenesis

An inexpensive, continuous flow assay for the determination of oxalate in plasma is described. The assay is based on the bioluminescent determination of NADH, a product of the degradation of oxalate by oxalate decarboxylase and formate dehydrogenase, using bioluminescent enzymes immobilized on cyanogen bromide-activated sepharose. The detection limit of the assay is 0.8 mumol/l. Intra-batch CV values of 5.2 and 3.8% were obtained at oxalate concentrations of 18 and 60 mumol/l. Recovery of added oxalate averaged 100.7%. Plasma oxalate ranged from less than 0.8 to 2 mumol/l in 14 healthy subjects, and from 6 to 134 mumol/l in 125 patients with renal disease treated by continuous ambulatory peritoneal dialysis. Ascorbic and dehydroascorbic acid did not directly interfere in the assay. In vitro oxalogenesis was observed in blood from 12 healthy subjects, but only after samples had stood at room temperature for more than 6 h. No significant oxalate generation occurred in blood from 24 patients with impaired renal function, even after standing at room temperature for 24 h. Oxalate generation was inhibited by the addition of oxalate to plasma, but the addition of urea and creatinine was without effect.

Zinc deficiency and hyperprolactinaemia are not reversible causes of sexual dysfunction in uraemia

We selected a group of male dialysis patients complaining of sexual dysfunction in whom penile vascular insufficiency and drug-induced impotence had been excluded. Monitoring of nocturnal penile tumescence was used to confirm organic disturbance. Patients with normal serum prolactin concentrations (n = 18) had significantly lower serum zinc values than normal controls (P less than 0.001) and were entered in a 6-month double-blind study comparing oral zinc acetate with placebo. Patients with elevated prolactin concentrations (n = 8) were entered in a 3-month double-blind crossover study comparing oral pergolide mesylate with placebo. In the zinc study, serum zinc concentrations increased (P less than 0.05) in the zinc-treated but not the placebo-treated group. One of nine patients receiving zinc reported improved sexual function, as did two of nine patients receiving placebo. There were no significant changes in sperm counts, nocturnal penile tumescence, testosterone, sex hormone binding globulin or gonadotrophin concentrations in either treatment group. In the pergolide study, serum prolactin values decreased (P less than 0.01) in the pergolide but not in the placebo treatment period. One patient reported improved sexual function during the pergolide treatment period and two during the placebo period. There were no significant changes in sperm counts, nocturnal penile tumescence, testosterone, sex hormone binding globulin or gonadotrophin concentrations after pergolide. These studies show no benefit of zinc or pergolide compared with placebo in the treatment of uraemic impotence.