Effect of Hemodiafiltration on the Progression of Neuropathy with Kidney Failure: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Neuropathy is a common complication of kidney disease that lacks proven disease-modifying treatments. Hemodiafiltration improves clearance of uremic toxins and is associated with better nerve function than hemodialysis. We aimed to determine whether hemodiafiltration reduces the progression of neuropathy in people receiving hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The Filtration in the Neuropathy of End-Stage Kidney Disease Symptom Evolution (FINESSE) study was an open-label, blinded end point assessment, controlled trial that randomized maintenance hemodialysis recipients to hemodiafiltration or high-flux hemodialysis for 48 months or until death or cessation of dialysis at four study centers. The primary outcome was the mean change in the yearly modified total neuropathy score from baseline, with time points weighted equally.

RESULTS

A total of 124 participants were randomized and followed for a mean of 41 months. At baseline, neuropathy was present in 91 (73%) participants (modified total neuropathy score greater than or equal to two), and 38 (31%) had moderate to severe neuropathy (modified total neuropathy score 9-28). Convection volume in the hemodiafiltration arm was a median of 24.7 (interquartile range, 22.4-26.5) L. The mean modified total neuropathy score (SEM) worsened by 1.7 (0.4)/28 and 1.2 (0.4)/28 in the hemodiafiltration and hemodialysis groups, respectively, with a mean difference of 0.5 (95% confidence interval, -0.7 to 1.7; P=0.37). There was no difference in survival (hazard ratio, 1.24; 95% confidence interval, 0.61 to 2.51; log rank P=0.55) or any of the prespecified adverse events. There was no difference between groups in the number of participants who suffered an adverse event adjusted by follow-up time (relative risk, 1.05; 95% confidence interval, 0.83 to 1.32; P=0.68).

CONCLUSIONS

Neuropathy is still a common complication of kidney disease without disease-altering therapy. Hemodiafiltration did not affect neuropathy progression compared with hemodialysis.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

Filtration in the Neuropathy of End-Stage Kidney Disease Symptom Evolution (FINESSE), ACTRN12609000615280.

Randomised controlled trial of the impact of haemodiafiltration on uraemic neuropathy: FINESSE study protocol

INTRODUCTION

The majority of patients undergoing haemodialysis (HD) show evidence of uraemic neuropathy, a condition with no known disease-modifying treatments. The pathogenesis of uraemic neuropathy is poorly understood, but may be related to cumulative exposure to middle molecules or other solutes such as potassium. It is not known whether haemodiafiltration (HDF) reduces the progression of uraemic neuropathy.

METHODS AND ANALYSIS

Filtration In the Neuropathy of End-Stage kidney disease Symptom Evolution (FINESSE) is a multicentre, randomised, open-label, blinded endpoint assessment, controlled trial designed to assess the impact of HDF versus HD on uraemic neuropathy. Maintenance HD patients will be randomised in a 1:1 ratio to receive HDF or HD with high-flux membranes for 4 years. The primary endpoint is the difference in the mean change in Total Neuropathy Score (TNS)-a measure of peripheral neuropathy combining symptoms, signs and nerve conduction velocity-over the study period. Secondary outcomes include change at annual timepoints in the TNS and the Neuropathy Symptom Score; and in morbidity, mortality and safety events.

ETHICS AND DISSEMINATION

The FINESSE trial has been approved by the Ethics Review Committee of the Sydney South West Area Health Service (HREC/09/RPAH/268) and of Adventist HealthCare Limited (2012-027). When published in a peer-reviewed journal, it will be the largest and longest reported randomised trial aimed at reducing the incidence and severity of uraemic neuropathy. It will advance the understanding of the natural history of uraemic neuropathy and the influence of convective therapies on both neurophysiological and clinical outcomes. It will also allow refinement of current hypotheses surrounding the pathogenesis of uraemic neuropathy and, most importantly, may lead to improvements in the lives of the many patients affected by this debilitating condition.

TRIAL REGISTRATION NUMBER

ACTRN12609000615280.

Human leucocyte antigen polymorphisms in nut-allergic patients in South Wales

BACKGROUND

Peanuts and tree nuts are among the most common foods provoking severe allergic reactions including fatal anaphylaxis. However, little is known of the underlying genetic and immunological mechanisms involved.

OBJECTIVE

Based on findings in other allergic diseases, we have investigated whether specific human leucocyte antigens (HLA) are associated with nut allergy.

METHOD

Eighty-four patients presenting at the allergy clinic with symptoms of nut allergy were typed for the HLA Class I (HLA-A and B) and Class II (HLA-DRB1 and DQB1) loci by PCR using sequence-specific primers. Carriage frequencies were compared with 82 atopic non-nut-allergic subjects and 1798 random blood donors.

RESULTS

The frequency of HLA-B(*)07 (28.57%) and DRB1(*)11 (15.48%) was increased in the nut-allergic patients compared to the atopic controls (12.20% and 3.66%, respectively) but not when compared to the blood donors (28.86% and 10.12%). DRB1(*)13 and DQB1(*)06 were both increased in frequency in the nut allergy patients over both the atopic and blood donor controls. However, none of these increased frequencies were significant when corrected for the number of comparisons undertaken.

CONCLUSION

At HLA '2-digit resolution' and with undifferentiated patients with nut allergy, there are no major disturbances in the frequency of HLA-A, B, DRB1 or DQB1 types. However, the difference in frequency of HLA-DRB1(*)11 between the nut allergy patients and the atopic controls merits further investigation as this may represent an important phenotypic relationship.

Salmonella enterica serotype Javiana infections associated with amphibian contact, Mississippi, 2001

Salmonella Javiana is a Salmonella serotype that is restricted geographically in the United States to the Southeast. During the summer of 2001, the number of reported S. Javiana infections in Mississippi increased sevenfold. To identify sources of infection, we conducted a case-control study, defining a case as an infection with S. Javiana between August and September in a Mississippi resident. We enrolled 55 cases and 109 controls. Thirty (55%) case patients reported exposure to amphibians, defined as owning, touching, or seeing an amphibian on one's property, compared with 30 (29%) controls (matched odds ratio 2.8, P=0.006). Contact with amphibians and their environments may be a risk factor for human infection with S. Javiana. The geographic pattern of S. Javiana infections in the United States mimics the distribution of certain amphibian species in the Southeast. Public health officials should consider amphibians as potential sources of salmonellosis, and promote hand washing after contact with amphibians.

Outpatient intensive chemotherapy for small cell lung cancer: five years experience of modified 'ICE' ifosfamide carboplatin and etoposide

INTRODUCTION

Small Cell Lung Cancer (SCLC) is increasingly being treated in the district general hospital setting. The search for an active regimen which can be given with the least toxicity and best outcomes led us to use a modified ICE (Ifosfamide, Carboplatin and Etoposide) regimen and modify it further by using oral mesna instead of intravenous mesna.

METHOD

All patients selected to receive the modified ICE regime over a 5-year period were included in our study. All patients were assessed for performance status and prognostic factors. Only those with WHO performance status 0-1 and Manchester prognostic score 0-3 were considered for ICE chemotherapy. All patients were followed up for 1 year after recruitment was completed.

RESULTS

Median survival for all 32 patients was 18.4 months (CI 12.2-24.6) and for the 28 patients with limited disease the median survival was 19.9 months (CI 8.2-31.6). Toxicity levels were low with no neutropenic deaths. One patient died three days after treatment was started due to disease progression. A total of 6 patients remained alive one year after recruitment was completed. Five out of the 6 were followed up for at least 2 years.

CONCLUSION

Using this out-patient modified ICE regime we have achieved a median survival comparable to other active chemotherapy regimes for SCLC with no significant increase in toxicity.

Controlled trial of three weeks nicotine replacement treatment in hospital patients also given advice and support

BACKGROUND

Smoking is a major public health issue, estimated as causing 120 000 deaths in the UK per year. Smoking cessation is an important aspect of the treatment of many diseases. Nicotine replacement therapy (NRT) has been shown to increase cessation rates among healthy volunteers and in general practice, but it is not clear whether it has an effect in hospital patients.

METHODS

Patients referred by their hospital doctor to the smoking cessation counsellor and who agreed to participate in the study were randomised to receive either NRT given as a nicotine patch daily and a nicotine inhalator on an as needed basis plus advice and support (AS+NRT), or to receive just advice and support (AS). Claims of smoking cessation were validated at 1 week, 3 months, 6 months, and 1 year by carbon monoxide (CO) breath testing.

RESULTS

A total of 245 patients were randomised, 136 AS+NRT and 109 AS. There were no significant demographic differences between the two groups at baseline. At 1 year 35 (14%) had sustained cessation confirmed by a CO breath test, 20/136 (15%) AS+NRT and 15/109 (14%) AS, p=0.857. One hundred and ten patients gave up smoking for at least 1 week, 54% AS+NRT and 33% AS (p<0.001). By 6 months there was no significant difference between the two groups (22/136 (16%) AS+NRT and 15/109 (14%) AS).

CONCLUSION

In hospital patients NRT, given as regular daily patches plus an inhalator to be used as needed, did not add to the smoking cessation rate achieved at 1 year by regular advice and support, despite significantly increasing the cessation rate at 1 week.

Polymorphism in the STAT6 gene encodes risk for nut allergy

Nut allergy is an important and potentially life threatening food allergy with a prevalence of one in 150 children in the UK population. STAT6 (signal transducer and activator of transcription) is an important molecule in the induction and regulation of an allergic response, which maps to chromosome 12q in a region previously linked with total serum IgE concentration and atopy in different populations. We have examined the frequency of a single nucleotide polymorphism (SNP) in the 3'UTR region of STAT6 gene in 71 UK Caucasoid patients diagnosed with nut allergy and 45 atopic patients without nut allergy using PCR-RFLP and compared these with 184 UK healthy controls. The STAT6 G allele frequency was significantly increased in nut allergy patients compared with blood donor controls (P < 0.0001, OR = 2.9, 95% CI: 1.7-4.9), which was under a recessive model (GG vs GA+AA, P = 0.0001, OR = 3.2, 95% CI: 1.7-5.8) but not in atopic patients without nut allergy. The G allele was most frequent in the severe cases and GG homozygosity was associated with the increased risk of severe reaction (OR = 3.9, 95% CI: 1.9-8.3). We conclude that STAT6 3'UTR polymorphism is associated with susceptibility and severity in nut allergic patients in our population.

Radioprotection of human endothelial cells with amifostine

MATERIALS AND METHODS

We studied the effect of amifostine on radiation sensitivity of human endothelial cells and several tumor cell lines (HeLa, MIA PaCa-2 and BxPC-3). The cells were incubated in medium with a concentration of 1 microgram/microliter amifostine and after 1 hour irradiated with 10 or 20 Gy single dose. Proliferation index was measured by BrdU assay after another 8 and 24 hours.

RESULTS

The results show a higher proliferation rate of endothelial cells following radiation plus amifostine, compared with radiation alone. Amifostine induced an increase of proliferation in the control/non-irradiated human endothelial cells. After irradiation with 10 Gy single dose the proliferation of amifostine treated human endothelial cells was still higher. Amifostine exerts no apparent proliferative effect on the tumor cells.

CONCLUSIONS

The results presented indicate that amifostine acts as an activation of proliferation of the human endothelial cells in a simple in-vitro system and indicate that amifostine supplementation prior to radiation therapy might exert a radioprotective effect to healthy tissue without spurring tumor growth.

Staphylococcus aureus bloodstream infections among patients undergoing electroconvulsive therapy traced to breaks in infection control and possible extrinsic contamination by propofol

Infectious complications associated with electroconvulsive therapy (ECT) are extremely unusual. When five of nine patients undergoing ECT at one facility on June 20, 1996 developed Staphylococcus aureus bloodstream infection (BSI), an investigation was initiated. A retrospective cohort study, a procedure review, and observational and microbiologic studies were performed. A case was defined as any patient who had ECT at Facility A from June 1, 1995 through June 20, 1996 and developed S. aureus BSI <30 days after ECT. The post-ECT S. aureus BSI rate was significantly greater on the epidemic day than the pre-epidemic period, (i.e., June 1, 1995 through June 19, 1996) (5 of 9 vs 0 of 54 patients, P < 0.001). All patients during the study period received propofol before ECT. Case patients were more likely than noncase patients to have higher maximum temperature after ECT (median 103.9 degrees F vs 100.0 degrees F, P < 0.03) and a greater time from preparation of intravenous medications to infusion (median 2.1 vs 1.1 h, P = 0.01). All case-patient S. aureus isolates were indistinguishable by pulsed field gel electrophoresis. Our investigation suggests that the ECT-associated S. aureus BSIs were associated with infection control breaks, which possibly led to the extrinsic contamination of propofol. Prevention of propofol-associated infectious complications requires aseptic preparation and use immediately before infusion.

The contribution of nitrate respiration to the energy budget of the symbiont-containing clam Lucinoma aequizonata: a calorimetric study

Heat production and nitrate respiration rates were measured simultaneously in the gill tissue of Lucinoma aequizonata. This marine bivalve contains chemoautotrophic, intracellular, bacterial symbionts in its gill tissue. The symbionts show constitutive anaerobic respiration, using nitrate instead of oxygen as a terminal electron acceptor. An immediate increase in heat production was observed after the addition of nitrate to the perfusion medium of the calorimeter and this was accompanied by the appearance of nitrite in the effluent sea water. The nitrate-stimulated heat output was similar under aerobic and anaerobic conditions, which is consistent with the constitutive nature of nitrate respiration. The amount of heat released was dependent on the concentration of nitrate in the perfusion medium. At nitrate concentrations between 0.5 and 5 mmol l-1, the total heat production was increased over twofold relative to unstimulated baseline values. A mean (&plusmn;s.e.m.) experimental enthalpy of -130&plusmn;22.6 kJ mol-1 nitrite (N=13) was measured for this concentration range.

Reactivation of ubiquitination in Artemia franciscana embryos during recovery from anoxia-induced quiescence

Encysted gastrulae of Artemia franciscana are known to enter a reversible state of quiescence promoted by anoxia, during which the half-life of cytochrome oxidase is prolonged up to 77-fold. This observation suggests that proteolytic pathways within mitochondria are inhibited, and indeed the suppression of the initial step in ubiquitin-mediated proteolysis under anoxia has been reported. Given that active embryos require efficient degradation of macromolecules, we investigated the reactivation of ubiquitination during recovery from anoxia and aerobic acidosis (elevated CO2 levels under aerobic conditions). During 6 h of recovery from anoxia, the levels of ubiquitin-conjugated proteins rose 6.5-fold, reaching 78 % of the pre-anoxia (control) values. Concomitant with the elevation in ubiquitin conjugates was a sharp decline in AMP level, a rise in ATP level and an alkalization of intracellular pH. Our results suggest that the reinitiation of ubiquitin conjugation is partially dependent on decreasing AMP and/or increasing ATP levels. However, when anoxic embryos were transferred to aerobic acidosis, which promotes a return to control (aerobic) levels of adenylates yet maintains the acidic intracellular pH, 71 % of the total suppression of ubiquitination still remained. This observation reveals a predominant role of intracellular alkalization in the reactivation of ubiquitination during recovery. We suggest that the rapid reversibility of the factors regulating ubiquitin conjugation allows Artemia embryos readily to reinitiate the degradation of proteins via the ubiquitin-mediated pathway during recovery.

Generation of immunostimulatory dendritic cells from human CD34+ hematopoietic progenitor cells of the bone marrow and peripheral blood

Dendritic antigen-presenting cells are considered to be the most effective stimulators of T cell immunity. The use of dendritic cells has been proposed to generate therapeutic T cell responses to tumor antigens in cancer patients. One limitation is that the number of dendritic cells in peripheral blood is exceedingly low. Dendritic cells originate from CD34+ hematopoietic progenitor cells (HPC) which are present in the bone marrow and in small numbers in peripheral blood. CD34+ HPC can be mobilized into the peripheral blood by in vivo administration of granulocyte-colony-stimulating factor. The aim of the current study was to determine whether functional dendritic cells could be elicited and grown in vitro from CD34+ HPC derived from bone marrow or granulocyte-colony-stimulating factor-mobilized peripheral blood. Culture of CD34+ HPC with granulocyte-macrophage-colony-stimulating factor and tumor necrosis factor alpha yielded a heterogeneous cell population containing cells with typical dendritic morphology. Phenotypic studies demonstrated a loss of the CD34 molecule over 1 week and an increase in cells expressing surface markers associated with dendritic cells, CD1a, CD80 (B7/BB1), CD4, CD14, HLA-DR, and CD64 (Fc gamma RI). Function was validated in experiments showing that cultured cells could stimulate proliferation of allogeneic CD4+ and CD8+ T lymphocytes. Antigen-presenting capacity was further confirmed in experiments showing that cultured cells could effectively stimulate tetanus toxoid-specific responses and HER-2/neu peptide-specific responses. The derivation and expansion of dendritic cells from cultured bone marrow or granulocyte-colony-stimulating factor-mobilized CD34+ HPC may provide adequate numbers for testing of dendritic cells in clinical studies, such as vaccine and T cell therapy trials.

A MICROCALORIMETRIC STUDY OF TURTLE CORTICAL SLICES: INSIGHTS INTO BRAIN METABOLIC DEPRESSION

In previous papers, we have examined turtle cortical neurons in vitro for mechanisms of anoxic metabolic depression ('channel arrest' and changes in electrical parameters). Negative results prompted the current study with the aim of examining more closely the energy profile and metabolism of turtle cortical slices. Calorimetry is used to measure heat dissipation during normoxia and nitrogen perfusion (120 min) and the results are converted into an ATP utilization rate. These indicate that the control rate of ATP utilization (1.72 &micro;mol ATP g-1 min-1) agrees closely with in vivo whole-brain metabolic measurements. Both nitrogen perfusion and pharmacologically induced anoxic (cyanide+N2) groups depressed heat dissipation considerably compared with the control value (nitrogen 37 %; pharmacological anoxia 49 %). The resulting ATP utilization estimates indicate metabolic depressions of 30 % (nitrogen) and 42 % (pharmacological anoxia). The slice preparation did not exhibit a change in any measured adenylate parameter for up to 120 min of anoxia or pharmacological anoxia. Significant changes did occur in [ADP], ATP/ADP ratio and energy charge after 240 min of exposure to anoxic conditions. These results support the idea that the turtle cortical slice preparation has a profound resistance to anoxia, with both nitrogen perfusion and pharmacological anoxia causing a rapid decline in heat dissipation and metabolism.

Morphological Variation in the Dentition and Skull of the Australian Ghost Bat, Macroderma-Gigas (Microchiroptera, Megadermatidae)

Morphological variation in the dentition and some cranial characters of the Australian ghost bat, Macroderma gigas, is reviewed by means of univariate and multivariate analyses. Specimens examined are drawn from existing populations across northern Australia; also included for parts of this study are mummified remains from southern central South Australia and late Pleistocene subfossil specimens from south-western Western Australia. No clear-cut geographic pattern in morphological variation in M. gigas is indicated by multivariate anlysis (i.e. principal components analysis), although there is some evidence for clinal variation from univariate analysis (i.e. Scheffe's multiple-comparions procedure). Northern Australian ghost bats (with the exception of north-eastern Australian indiv~duals) tend to be smaller than their southern counterparts. Sexual dimorphism appears to be low. Independent patterns of covariation among characters are extracted by principal components analysis: cheek tooth widths cluster separately from lengths; lengths and widths of the same teeth cluster separately from those of occluding teeth; and cranial measurements cluster separately from tooth measurements. Patterns in the data suggest that the number of characters needed to be examined in future morphometric studies of the vulnerable ghost bat can be significantly reduced.

Insulin-like effects of vanadate in isolated rat adipocytes

Vanadate has been shown to have a number of insulin-like effects in various cells, including isolated rat adipocytes. In the present study we compared the activities of vanadate and insulin in isolated fat cells using a number of different assays of insulin-like activity. Both insulin and vanadate stimulated [2-3H]glucose incorporation into fat cell lipid in a dose-dependent manner, but the maximal effect of vanadate was markedly greater than that of insulin. At 10(-2) M vanadate the effect was 3-4 times as great as the maximal effect of insulin. This effect was dependent on specific glucose transport. Combinations of insulin and vanadate were not more effective than vanadate alone. Vanadate also produced antilipolysis with an effect somewhat greater than that of insulin. Using [U-14C]glucose both vanadate and insulin stimulated 14CO2 production and [14C]glucose incorporation into lipid, and again the effect of vanadate was greater than that of insulin. Vanadate had a greater effect on 14CO2 production than on [14C]glucose incorporation into lipid. When [1-14C]glucose was used vanadate again had a significantly greater effect on 14CO2 production than did insulin, but when [6-14C]glucose was used the effects of vanadate and insulin were equal. These results demonstrate that vanadate has insulin-like effects in isolated fat cells, but it selectively stimulates certain pathways to a greater extent than does insulin. The greater effect of vanadate than insulin appears to be primarily on the pentose phosphate shunt, suggesting that this agent may be useful for examination of this intracellular pathway in fat cells.

A New Order of Tertiary Zalambdodont Marsupials

Yalkaparidon coheni and Yalkaparidon jonesi are described here as the first-known members of the marsupial family Yalkaparidontidae and order Yalkaparidontia. Before discovery of these zalambdodont marsupials in unnamed Tertiary sediments from northwestern Queensland, only five orders of australidelphian marsupials were known. Dental and basicranial morphology suggest that notoryctids and yalkaparidontids, which both have highly specialized zalambdodont molars, are dentally convergent. Yalkaparidontids lived in lowland rainforests of northern Australia and appear to have vanished, with the rainforests, sometime in the middle to late Tertiary. Discovery of yalkaparidontids demonstrates a significantly greater breadth of diversity for Australian marsupials.

Preface

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