Analyses of registry data of patients with anti-GBM and antineutrophil cytoplasmatic antibody-associated (ANCA) vasculitis treated with or without therapeutic apheresis

Therapeutic apheresis (TA) as a treatment for antibody-associated vasculitis (AAV) was questioned by the PEXIVAS although the MEPEX study favored TA. The aim of this study was to evaluate the efficacy of TA to improve renal function in patients consecutively included in the WAA-apheresis registry versus patients not treated with TA.

MATERIALS AND METHODS

Included were 192 patients that suffered from anti-glomerular basement membrane disease (anti-GBM, n = 28) and antineutrophil cytoplasmic antibody-associated vasculitis of MPO or PR3 origin. Of these 119 had performed TA and the other 73 had not performed TA for theses diagnoses (CTRL).

RESULTS

Elderly had an increased risk to die within 12 months (p = 0.002). All 28 anti-GBM had renal involvement, 21 dialysis dependent. At 3 month nine (36 %) did not need dialysis. Baseline data regarding renal function of AAV patients, subtype MPO and PR3, were worse in the TA groups than in CTRL. Recovery out of dialysis was better for the PR3-TA group compared with 1) the controls of MEPEX (RR 0.59, CI 0.43-0.80) and 2) the MPO-TA patients (RR 0.28, CI 0.12-0.68). The MPO-TA recovered similarly as the MEPEX-CTRL. Renal function improved most for TA-patients from baseline during the first 3 months (MPO-TA and PR3-TA) and stabilized thereafter and less for MPO-CTRL and PR3-CTRL.

CONCLUSION

PR3-TA patients seem to have best chances to get out of dialysis. PR3-TA and MPO-TA improved residual renal function better than CTRL. The present study recommends reconsiderations to use TA for AAV especially those with PR3-vasculitis with severe renal vasculitis.

Analysis of extracorporeal photopheresis within the frame of the WAA register

The aim of the study was to investigate safety and if extracorporeal photopheresis (ECP) may change health criteria (HC) and quality of life (QoL).

MATERIAL AND METHOD

560 patients (33 % women) were treated with ECP for a total of 13,871 procedures during a 17-years period. Mean age was 48 years (±18, range 3-81 years). Self-estimation of QoL was graded: 0 (suicidal) up to 10 (best ever) and HC: 0 (Bed ridden, ICU condition) up to 10 (athletic). Adverse events were analyzed. ANOVA and paired comparisons were performed.

RESULTS

Patients were treated due to graft versus host disease (GVHD, n = 317), skin lymphoma (n = 70), solid organ transplants (n = 47), skin diseases (n = 20) and other diseases (n = 106). Adverse events (AEs) were registered in 5.4 % of the first treatments and in 1.2 % of the subsequent procedures. Severe AEs were present in 0.04 % of all procedures. No patient died due to the procedure. Tingling and stitching were the most common AE. For those with GVHD an improvement was noticed within approximately 10 procedures of ECP in the severity stage, QoL (from a mean of 6.1 to 6.8, p < 0.002) and the HC (6.1 -> 6.4, p < 0.014) and improved further with added procedures.

CONCLUSION

Photopheresis is an established therapy with few side effects. The present study of soft variables indicate that GVHD shows benefits upon ECP within approximately 10 procedures in regard to the severity of mainly skin GVHD, and lower baseline levels of HC and QoL.

Uremic Toxicity: Present State of the Art

The uremic syndrome is a complex mixture of organ dysfunctions, which is attributed to the retention of a myriad of compounds that under normal condition are excreted by the healthy kidneys (uremic toxins). In the area of identification and characterization of uremic toxins and in the knowledge of their pathophysiologic importance, major steps forward have been made during recent years. The present article is a review of several of these steps, especially in the area of information about the compounds that could play a role in the development of cardiovascular complications. It is written by those members of the Uremic Toxins Group, which has been created by the European Society for Artificial Organs (ESAO). Each of the 16 authors has written a state of the art in his/her major area of interest.

Plasma Therapies in Thrombotic Syndromes

Background

Plasma therapies are being applied to thombotic syndromes, but there are limited controlled studies.

Objective

To review the evidence and the current practices for plasma therapies in thrombotic syndromes.

Methods

Expert-enhanced evidence-based analysis. Evidence obtained as of Dec 31, 2002 using Pub Med electronic reference library and expert-obtained library for a total of > 3,000 references obtained using the terms plasma therapy or plasma exchange or plasmapheresis or plasmafiltration or sorbents each combined with the words thrombotic syndrome or sepsis or septic shock. The authors screened the abstracts, reviewed the agreed set of papers, and compiled the recommendations.

Results

Plasma therapies, which alter the plasma components in patients, have been applied in thrombotic syndromes worldwide. In these patients, there is a biologic plausibility for plasma therapies since they have molecules that are prothrombotic and/or antifibrinolytic which would put them at risk for microvascular thrombosis and end-organ damage. There are respectively one randomized controlled trial (RCT) in primary thrombotic syndrome, and secondary thrombotic syndrome, which showed an improvement in mortality in applying plasma therapies (plasma exchange by centrifugation). However, there are numerous non-randomized and case series. Plasma exchange is accepted as the standard therapy for primary thrombotic syndrome as in thrombotic thrombocytopenic purpura (TTP). However, no consensus has been reached for plasma exchange in secondary thrombotic syndromes such as in sepsis, hemolytic uremic syndrome (HUS), thrombocytopenia associated multiple organ failure, TTP/HUS, s/p bone marrow or solid organ transplant, HELLP syndrome, immunologic disorders, drug exposure, or pancreatitis.

Conclusions

As we understand more about the pathophysiology of thrombotic syndromes, specific plasma therapies can be applied for the specific need of a particular patient population. There are sufficient preliminary data to recommend a definitive RCT to evaluate the efficacy of the different types of plasma therapies in secondary thrombotic syndromes.

Adverse events in apheresis: An update of the WAA registry data

Apheresis with different procedures and devices are used for a variety of indications that may have different adverse events (AEs). The aim of this study was to clarify the extent and possible reasons of various side effects based on data from a multinational registry. The WAA-apheresis registry data focus on adverse events in a total of 50846 procedures in 7142 patients (42% women). AEs were graded as mild, moderate (need for medication), severe (interruption due to the AE) or death (due to AE). More AEs occurred during the first procedures versus subsequent (8.4 and 5.5%, respectively). AEs were mild in 2.4% (due to access 54%, device 7%, hypotension 15%, tingling 8%), moderate in 3% (tingling 58%, urticaria 15%, hypotension 10%, nausea 3%), and severe in 0.4% of procedures (syncope/hypotension 32%, urticaria 17%, chills/fever 8%, arrhythmia/asystole 4.5%, nausea/vomiting 4%). Hypotension was most common if albumin was used as the replacement fluid, and urticaria when plasma was used. Arrhythmia occurred to similar extents when using plasma or albumin as replacement. In 64% of procedures with bronchospasm, plasma was part of the replacement fluid used. Severe AEs are rare. Although most reactions are mild and moderate, several side effects may be critical for the patient. We present side effects in relation to the procedures and suggest that safety is increased by regular vital sign measurements, cardiac monitoring and by having emergency equipment nearby.

Corrigendum. The influence of body mass index on the accumulation of advanced glycation end products in hemodialysis patients

Correction to: European Journal of Clinical Nutrition (2015) 69, 309–313; doi: 10.1038/ejcn.2014.261; published online 14 January 2015 Since the publication of this article, the authors have noticed that several of the author names were published incorrectly. The correct author names are listed above. The .html and online PDF versions have also been amended. The authors apologise for any inconvenience caused.

The influence of body mass index on the accumulation of advanced glycation end products in hemodialysis patients

BACKGROUND/OBJECTIVES

The level of skin autofluorescence (AF) at a given moment is an independent predictor of mortality in hemodialysis (HD) patients. Skin AF is a measure of the accumulation of advanced glycation end products (AGEs). The aim of the study was to estimate the influence of nutrition on the 1-year increase of skin AF (ΔAF) in HD patients.

SUBJECTS/METHODS

A total of 156 HD patients were enrolled in this study. Skin AF, body mass index (BMI), superoxide dismutase, myeloperoxidase, C-reactive protein, inter-cellular adhesion molecule-1, von Willebrand factor and heart-type fatty acid-binding protein were measured four times at intervals of approximately half a year. Data from the monthly routine blood analysis were also used. Daily calorie, protein and AGE intakes were assessed from food recordings over a period of 1 week.

RESULTS

A J-shaped relation was found between baseline BMI and ΔAF (P=0.01). The lowest point of the J-shaped curve is found for BMI=24.3 kg/m(2). In the univariate analysis of the contributors to the 1-year ΔAF, we found that beside BMI=24.3 kg/m(2), AGE and calorie intakes, as well as myeloperoxidase and HD vintage, had a P <0.10. The sole independent predictor of the 1-year ΔAF was BMI=24.3 kg/m(2) (P=0.01).

CONCLUSIONS

It appears that calorie, protein and AGE intakes hardly influence the 1-year ΔAF in HD patients. BMI of HD patients of around 24 kg/m(2) resulted in a lower 1-year ΔAF.

A decision analysis of long-term lithium treatment and the risk of renal failure

OBJECTIVE

To establish whether lithium or anticonvulsant should be used for maintenance treatment for bipolar affective disorder (BPAD) if the risks of suicide and relapse were traded off against the risk of end-stage renal disease (ESRD).

METHOD

Decision analysis based on a systematic literature review with two main decisions: (1) use of lithium or at treatment initiation and (2) the potential discontinuation of lithium in patients with chronic kidney disease (CKD) after 20 years of lithium treatment. The final endpoint was 30 years of treatment with five outcomes to consider: death from suicide, alive with stable or unstable BPAD, alive with or without ESRD.

RESULTS

At the start of treatment, the model identified lithium as the treatment of choice. The risks of developing CKD or ESRD were not relevant at the starting point. Twenty years into treatment, lithium still remained treatment of choice. If CKD had occurred at this point, stopping lithium would only be an option if the likelihood of progression to ESRD exceeded 41.3% or if anticonvulsants always outperformed lithium regarding relapse prevention.

CONCLUSION

At the current state of knowledge, lithium initiation and continuation even in the presence of long-term adverse renal effects should be recommended in most cases.

Analyses of data of patients with Thrombotic Microangiopathy in the WAA registry

Thrombotic Microangiopathy (TMA) is a histopathological feature of various diseases including thrombotic thrombocytopenic purpura and hemolytic uremic syndrome. The aim of this study was to investigate the outcome and prognostic variables of TMA-patients.

MATERIALS AND METHODS

Data were consecutively retrieved from the WAA-apheresis registry (www.waa-registry.org) during 2003-2009. Included were all 120 patients (1237 procedures) who suffered from various forms of TMA, as registered by the ICD-10 code M31.1. Besides registry data, more extensive information was retrieved from the latest 64 patients. Adverse events of the TMA patients were compared to those of the other patients in the registry.

RESULTS

The mean age was 46 years (range 11-85 years, 57% women). In 72% therapeutic apheresis was due to an acute indication while a long-term indication was present in 28%. Plasma exchange was performed by centrifugation and filtration technique (95% and 4%, respectively), and immunoadsorption in 1% of the patients. Only fresh frozen plasma was used as replacement fluid in 69% of procedures. Adverse events were more frequent than in the general apheresis population (10% versus 5%, RR 1.9, CI 1.6-2.3). No death occurred due to apheresis treatment. Three percent of the procedures were interrupted. Bronchospasm and/or anaphylactic shock were present in two patients and one patient suffered from TRALI. At admission 26% were bedridden and needed to be fed. The risk of dying during the treatment period was significantly higher if the patient also suffered from a compromising disease, such as cancer. There was an inverse correlation between the ADAMTS13 level and the antibody titer (r=-0.47, p=0.034).

CONCLUSIONS

Patients with TMA have an increased risk for moderate and severe AE compared to the general apheresis population. Many patients were severely ill at admission. The prognosis is worse if the patient also has a severe chronic disease. Even slightly increased ADAMTS13-antibody titers seem to have a negative impact on the ADAMTS13 levels.

Large improvements in major cardiovascular risk factors in the population of northern Sweden: the MONICA study 1986-2009

OBJECTIVES

the incidence of cardiovascular disease has declined rapidly in Sweden since the 1980s. We explored changes in major cardiovascular risk factors in northern Sweden between 1986 and 2009.

DESIGN

since 1986, six population surveys have been carried out in northern Sweden using procedures of the World Health Organization MONICA project. The population age range was 25-64 years in 1986 and 1990, and 25-74 years from 1994. Trends were analysed using generalized linear models.

RESULTS

a total of 10586 subjects were included in the surveys. Blood pressure decreased by 4.9/3.9 mmHg in women and 1.8/1.5 mmHg in men aged 25-64 years between 1986 and 2009. In men and women aged 65-74 years, the decrease was 12.6/6.1 mmHg between 1994 and 2009. From 1994, the use of blood pressure-lowering drugs increased, particularly among the older subgroup. The prevalence of smoking halved between 1986 and 2009; 11% of women and 9% of men were smokers in 2009. Cholesterol levels decreased by 0.9 mmol L(-1) in the younger age group (25-64 years), and the use of lipid-lowering agents increased from 1994. Among subjects aged 25-64 years, one in five was obese in 2009, which was twice as many as in 1986, and body mass index (BMI) increased by 1.5 kg m(-2) , corresponding to an increase in weight of 4 kg. There was no further increase in BMI from 2004. The prevalence of diabetes did not change between 1986 and 2009. The proportion that received a university education increased markedly in all age groups, especially in women, during the study period.

CONCLUSIONS

significant improvements were observed in major cardiovascular risk factors in northern Sweden between 1986 and 2009.

A review on sex differences in stroke treatment and outcome

BACKGROUND

Beyond epidemiological differences, it has been controversial whether any important sex differences exist in the treatment of stroke. In this review paper, the following areas are covered: thrombolysis, stroke unit care, secondary prevention, surgical treatment, and rehabilitation. Additionally, symptoms at stroke onset, as well as outcome measures, such as death, dependency, stroke recurrence, quality of life, and depression are reviewed.

METHODS

Search in PubMed, tables-of-contents, review articles, and reference lists after studies that include information about sex differences in stroke care.

RESULTS

Ninety papers are included in this review. Women suffer more from cortical and non-traditional symptoms. Men and women benefit equally from thrombolysis and stroke unit care. Women with cardioembolic strokes may benefit more from anticoagulant therapy. Most studies have not found any tendency towards sexism in the choice of treatment. Post-stroke depression and low quality-of-life seem to be more common among women. Mortality rates are higher among men in some studies, while long-term ADL-dependency seems to be more common among women.

CONCLUSIONS

Sex differences in stroke treatment and outcome are small, with no unequivocal proof of sex discrimination. Women have less favourable functional outcome because of higher age at stroke onset and more severe strokes.

Stroke unit care revisited: who benefits the most? A cohort study of 105,043 patients in Riks-Stroke, the Swedish Stroke Register

BACKGROUND

Treatment at stroke units is superior to treatment at other types of wards. The objective of the present study is to determine the effect size of stroke unit care in subgroups of patients with stroke. This information might be useful in a formal priority setting.

METHODS

All acute strokes reported to the Swedish Stroke Register from 2001 through 2005 were followed until January 2007. The subgroups were age (18-64, 65-74, 75-84, 85+ years and above), sex (male, female), stroke subtype (intracerebral haemorrhage, cerebral infarction and unspecified stroke) and level of consciousness (conscious, reduced, unconscious). Cox proportional hazards and logistic regression analyses were used to estimate the risk for death, institutional living or dependency.

RESULTS

105,043 patients were registered at 86 hospitals. 79,689 patients (76%) were treated in stroke units and 25,354 patients (24%) in other types of wards. Stroke unit care was associated with better long-term survival in all subgroups. The best relative effect was seen among the following subgroups: age 18-64 years (hazard ratio (HR) for death 0.53; 0.49 to 0.58), intracerebral haemorrhage (HR 0.61; 0.58 to 0.65) and unconsciousness (HR 0.70; 0.66 to 0.75). Stroke unit care was also associated with reduced risk for death or institutional living after 3 months.

CONCLUSIONS

Stroke unit care was associated with better long-term survival in all subgroups, but younger patients, patients with intracerebral haemorrhage and patients who were unconscious had the best relative effect and may be given the highest priority to this form of care.

Increased incidence of stroke and impaired prognosis after stroke among patients with seropositive rheumatoid arthritis

OBJECTIVE

To examine the incidence of, and outcome after, a stroke in patients with rheumatoid arthritis (RA) compared with the general population.

METHODS

The northern Sweden MONICA register was used to compare the incidence of stroke in a cohort of RA patients with the general population. Forty RA patients who had also suffered a stroke were identified. For each patient with RA, three controls with a history of stroke but without RA were randomly collected from the same register, and matched for age and sex.

RESULTS

The standardised incidence ratio (SIR) for stroke was 2.7 in RA patients compared with the general population (p<0.05). During the follow-up, RA patients had a higher overall case fatality (CF) following stroke compared with controls (hazard ratio (HR) =1.70, p<0.05).

CONCLUSIONS

Both the incidence of a stroke, and the subsequent CF, were higher among RA patients compared with the general population. The results emphasize the necessity of optimising the prevention of stroke and follow-up care after a stroke in RA.

Diagnostic criteria and quality control of the registration of stroke events in the MONICA project

Stroke events are being registered in 27 of the MONICA collaborating centres. Coding of test cases has shown the greatest discrepancies in coding of the type of stroke (different pathoanatomical diagnoses) and of the diagnostic category (whether a definite stroke has occurred or not), 23% and 14% discrepancies respectively. A check for completeness of stroke registration at the Northern Sweden MONICA Center showed that more than 91% of the events were retrieved by routine registration procedures. Measures to reduce the discrepancies in coding between centres and to check for completeness of data are suggested. In many centres, the number of stroke events below 65 years of age is too small to permit meaningful analyses. By including also stroke events in the 65-74 year age range, the number of fatal events in the Northern Sweden MONICA area increased by 195% and non-fatal events by 149%. Many other MONICA centres have also extended their upper age limit for the registration of stroke events, thus improving the preconditions for statistical evaluations of the long-term changes in stroke incidence.

Hemodialysis dialyzers contribute to contamination of air microemboli that bypass the alarm system in the air trap

BACKGROUND

Previous studies have shown that micrometer-sized air bubbles are introduced into the patient during hemodialysis. The aim of this study was to investigate, in vitro, the influence of dialysis filters on the generation of air bubbles.

METHODS

Three different kind of dialyzers were tested: one high-flux FX80 dry filter (Fresenius Medical Care AG&Co. KGaA, Bad Homburg, Germany), one low-flux F8HPS dry filter (Fresenius Medical Care AG&Co. KGaA, Bad Homburg, Germany) and a wet-stored APS-18u filter (Asahi Kasei Medical, Tokyo, Japan). The F8HPS was tested with pump flow ranging between 100 to 400 ml/min. The three filters were compared using a constant pump flow of 300 ml/min. Measurements were performed using an ultrasound Doppler instrument.

RESULTS

In 90% of the series, bubbles were measured after the outlet line of the air trap without triggering an alarm. There were significantly more bubbles downstream than upstream of the filters F8HPS and FX80, while there was a significant reduction using the APS-18u. There was no reduction in the number of bubbles after passage through the air trap versus before the air trap (after the dialyzer). Increased priming volume reduced the extent of bubbles in the system.

CONCLUSIONS

Data indicate that the air trap does not prevent air microemboli from entering the venous outlet part of the dialysis tubing (entry to the patient). More extended priming of the dialysis circuit may reduce the extent of microemboli that originate from dialysis filters. A wet filter may be favorable instead of dry-steam sterilized filters.

Increased abdominal obesity, adverse psychosocial factors and shorter telomere length in subjects reporting early ageing; the MONICA Northern Sweden Study

BACKGROUND

The rate of biological ageing is individual and represents the steady decrease in physiological and mental functions. Adverse social factors have been shown to influence this process. Self-perceived early ageing (SEA) might be a useful indicator of early biological ageing and increased mortality risk. The aim of this population-based study was to identify markers of SEA, including telomere length.

METHODS

We studied 1502 subjects (744 men, 758 women) from Northern Sweden. These subjects underwent a physical examination, blood sampling (including telomere length) and completed a self-administered questionnaire about their subjective age, social situation, lifestyle, and self-rated health (SRH). Age- and SRH-adjusted statistical analyses were made comparing SEA subjects with same-sex controls.

RESULTS

In all, 7.9% of men and 12.1% of women reported SEA. These subjects had significantly (p<0.0001) wider waist circumference and higher body mass index than controls. SEA men showed higher fasting glucose and SEA women showed higher total cholesterol levels than controls (p=0.020 and p=0.015, respectively). In addition, SEA women more often reported infrequent physical exercise (p=0.006), mental problems (p=0.064) and worse SRH (p=0.001) than controls. In a random sub-sample, telomere length was significantly shorter in SEA subjects (n=139) than controls (n=301; p=0.02), but not after full adjustment for BMI.

CONCLUSIONS

Self-perceived early ageing is not uncommon and is associated with abdominal obesity, poor self-rated health, lower education, and shorter telomere length. This could link adverse social factors with features of the metabolic syndrome as well as with early biological ageing, of importance for targeting preventive programmes.

Polymorphism of genes related to cardiovascular disease in patients with rheumatoid arthritis

OBJECTIVE

To analyze candidate genes, related to cardiovascular disease (CVD) in general, and potentially involved in the inflammatory process, in RA patients from northern Sweden.

METHODS

Four hundred and sixty-seven individuals (345 females; 122 males) with RA (ACR criteria), having a mean age of 61.8 +/- 13.0 years and mean disease duration of 16.2 +/- 12.1 years, were consecutively recruited and followed-up for 3 years. The prevalence of CVD, [(ischemic heart disease (IHD), deep vein thromboses/pulmonary embolism (DVT/PE) and/or stroke/TIA] and hypertension was registered. Candidate genes encoding for Beta-fibrinogen (G-455A), Factor XIIIA (Val34Leu), plasminogen activator inhibitor type-1 (PAI-1 4G/5G), and tumor necrosis factor receptor (TNFR)II (M196R) were analysed. Controls (n = 672) were randomly selected according to age and gender from the Medical Biobank of Northern Sweden. Polymorphisms were genotyped using a TaqMan 9700HT and the 5'nuclease allelic discrimination assay.

RESULTS

The genotypes, carriers and alleles did not differ in distribution between patients and controls. Carriage of the TNFRII R variant was more frequent among patients with hypertension (p = 0.018). The genotype distribution of PAI-1 in patients with IHD differed significantly (p = 0.002) because carriage of 4G was more frequent (p = 0.024). Combined carriage of TNFRII 196R variant and Beta-fibrinogen-455A was a stronger predictor for hypertension than each genotype separately. The distribution of FXIIIA genotypes deviated significantly in RA patients with DVT/PE (p = 0.028) with an increased frequency of the Leu34 variant.

CONCLUSION

The unusual alleles of TNFRII, PAI-1 and FXIIIA were associated with CVD in RA patients. The combination of several of the rare types further increased the predictive values for CVD.

Unexpected effects of donor gender on the storage of liquid plasma

BACKGROUND

Swedish regulations in effect since 2006 allow the storage of plasma for transfusion up to 14 days at 2-6 degrees C and for 3 years at < or = -30 degrees C. In this study, the quality of currently used plasma components was investigated.

MATERIALS AND METHODS

Plasma components, prepared from whole blood or by apheresis, either leucocyte depleted or not leucocyte depleted, were stored at 2-6 degrees C as liquid plasma or as thawed fresh-frozen plasma; 31% were from female donors. Concentration, function and activation markers of the plasma coagulation systems were investigated during storage for up to 42 days.

RESULTS

Cold-induced contact activation was the dominant storage lesion, occurring earlier and at higher frequency in plasma from females. Increased kallikrein-like activity led to changes in activated partial thromboplastin time, prothrombin time, protein C and C1 inhibitor (C1INH). C1INH function dropped to 53% on Day 14 in cold-activated plasma components.

CONCLUSION

Contact activation may be triggered before Day 14, especially in plasma from females, and may progress as a result of the consumption of C1INH. The data suggest that lack of cold-induced contact activation may be an important quality criterion. To achieve this, plasma from male donors could be selected for transfusion and the storage time limited to 7 days.

Lack of aggregation of ischemic stroke subtypes within affected sibling pairs

OBJECTIVE

To establish whether subtypes of ischemic stroke aggregate within ischemic stroke-affected sibling pairs more than expected by chance alone.

METHODS

This retrospective family study was based on a pooled analysis of two cohorts of male and female adult sibling pairs with symptomatic ischemic stroke. One hospital-based cohort of 404 individuals (first proband seen August 30, 1999) was recruited from the United States and Canada, and another population-based cohort of 198 individuals (first proband seen April 17, 1997) was recruited from Umeå, Sweden. Subtype diagnoses were based on Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria.

RESULTS

Agreement for subtype diagnoses within families was poor (mean +/- asymptotic SE kappa = 0.17 +/- 0.04). Occurrence of one ischemic stroke subtype in a proband was not associated with a greater likelihood of that subtype being the qualifying stroke subtype in the sibling. Comparable levels of agreement were seen when restricting the analysis to same-sex sibling pairs (kappa = 0.22 +/- 0.05) to sibling pairs in which the proband's stroke occurred before the age of 65 years (kappa = 0.16 +/- 0.05) or to pairs in which the proband's stroke occurred at or after the age of 65 years (kappa = 0.19 +/- 0.05).

CONCLUSIONS

The subtype of ischemic stroke in a proband was a poor determinant of the subtype of ischemic stroke in the respective sibling. This suggests that many genetic risk factors for ischemic stroke may not be specific for one subtype.

Time trends in population cholesterol levels 1986-2004: influence of lipid-lowering drugs, obesity, smoking and educational level. The northern Sweden MONICA study

Background

Self-Rated Health (SRH) correlates with risk of illness and death. But how are different questions of SRH to be interpreted? Does it matter whether one asks: “How would you assess your general state of health?”(General SRH) or “How would you assess your general state of health compared to persons of your own age?”(Comparative SRH)? Does the context in a questionnaire affect the answers? The aim of this paper is to examine the meaning of two questions on self-rated health, the statistical distribution of the answers, and whether the context of the question in a questionnaire affects the answers.

Methods

Statistical and semantic methodologies were used to analyse the answers of two different SRH questions in a cross-sectional survey, the MONICA-project of northern Sweden.

Results

The answers from 3504 persons were analysed. The statistical distributions of answers differed. The most common answer to the General SRH was “good”, while the most common answer to the Comparative SRH was “similar”. The semantic analysis showed that what is assessed in SRH is not health in a medical and lexical sense but fields of association connected to health, for example health behaviour, functional ability, youth, looks, way of life. The meaning and function of the two questions differ – mainly due to the comparing reference in Comparative SRH. The context in the questionnaire may have affected the statistics.

Conclusions

Health is primarily assessed in terms of its sense-relations (associations) and Comparative SRH and General SRH contain different information on SRH. Comparative SRH is semantically more distinct. The context of the questions in a questionnaire may affect the way self-rated health questions are answered. Comparative SRH should not be eliminated from use in questionnaires. Its usefulness in clinical encounters should be investigated.

Time trends in population cholesterol levels 1986-2004: influence of lipid-lowering drugs, obesity, smoking and educational level. The northern Sweden MONICA study

OBJECTIVES

To explore time trends in population total cholesterol.

DESIGN AND SETTING

Five population-based cross-sectional surveys, 1986-2004 in the northern Sweden MONICA study included 8827 men and women.

RESULTS

Age-adjusted cholesterol level declined in men, 25-64 years old, from 6.38 to 5.78 mmol L(-1) and in women from 6.32 to 5.51 mmol L(-1). Between 1994 and 2004, subjects 65-74 years old were included, and their levels also decreased, in men from 6.35 to 5.76 mmol L(-1) and in women from 7.11 to 6.24 mmol L(-1). The decrease was continuous over surveys and age groups, except in young and middle-aged men where no further decline was found after 1999. Cohorts born 1920-1939 showed decreased cholesterol over the period, whilst no change was noted for those born thereafter. In 2004, one-fourth of men and one-third of women 25-74 years achieved levels below 5.0 mmol L(-1). Subjects with low educational level, body mass index > or =25 or smokers all had higher cholesterol levels which persisted during the 18-year period. In 2004, the 9% who used lipid-lowering drugs are estimated to contribute, at most, to 0.13 mmol L(-1) lower cholesterol in the population.

CONCLUSION

Large decreases in cholesterol levels occurred in the 18-year period. Less smoking may contribute to, and increasing obesity attenuate, this trend whilst lipid-lowering drugs have had little effect until recently. Socio-economic inequalities persist.

Advantages and disadvantages of surgical placement of PD catheters with regard to other methods

Peritoneal dialysis is underused for various reasons. One reason may be problems with insertion of catheters for access. Another reason is the delayed start (break-in period) of about 2 weeks after operation. This review describes various approaches to the insertion of a peritoneal dialysis catheter. The optimal conditions to strive for are given as is an overview of various techniques. This article favours surgical placement while others might prefer other techniques. Described is the use a 3-purse string suture technique that allows immediate start of dialysis after catheter insertion both for acute dialysis indications as well as for acute start in chronic dialysis patients. A key to lesser complications is to establish a team devoted to the insertions rather than to allow various physicians to perform insertions as a training procedure. An optimal access is one of the important life lines for these patients.

Favourable trends in the incidence and outcome of myocardial infarction in nondiabetic, but not in diabetic, subjects: findings from the MONICA myocardial infarction registry in northern Sweden in 1989-2000

BACKGROUND

The aim of this study was to compare time trends in incidence, case fatality and mortality due to myocardial infarction (MI) in patients with or without diabetes.

METHODS

This study was based on the Northern Sweden MONICA Project MI registry with a target population of about 200,000 inhabitants in the age group 35--64 years in the two northernmost counties of Sweden. During 1989--2000, 6254 patients who had had an MI according to MONICA criteria were included in this study: 4569 patients had a first MI and 1685 had a recurrent MI. Sixteen per cent of the men and 20% of the women had had diabetes mellitus diagnosed prior the MI.

RESULTS

Over the 12-year period, there was a declining trend in incidence and case fatality in first MI. Also, the event rates (first ever and recurrent MI) declined in men without diabetes. In women without diabetes favourable time trends were seen in first ever MI, recurrent MI and in case fatality. There were no favourable time trends for any of these outcomes in patients with diabetes.

CONCLUSION

In nondiabetic subjects below the age of 65, the incidence of, and case-fatality in, MI declined. This led to a decreased mortality over the 12-year period. These favourable trends over time were not observed in diabetic subjects.

Systemic antibodies to the leukotoxin of the oral pathogen Actinobacillus actinomycetemcomitans correlate negatively with stroke in women

BACKGROUND

Chronic infections and associated inflammatory markers are suggested risk factors for cardiovascular diseases (CVD) and stroke. The proinflammatory cytokine interleukin (IL)-1beta is suggested to play a role in the regulation of local inflammatory responses in both CVD and periodontitis. The leukotoxin from the periodontal pathogen Actinobacillus actinomycetemcomitans has recently been shown to cause abundant secretion of IL-1beta from macrophages. The aim of the present study was to compare the prevalence of systemic antibodies to A. actinomycetemcomitans leukotoxin in stroke cases (n = 273) and matched controls (n = 546) in an incident case-control study nested within the Northern Sweden MONICA and Vasterbotten Intervention cohorts.

METHODS

Antibodies to A. actinomycetemcomitans leukotoxin were analyzed in a bioassay with HL-60 cells (leukocytes), purified A. actinomycetemcomitans leukotoxin, and plasma. Plasma samples which inhibited lactate dehydrogenase release from leukotoxin-lysed cells by > or =50% were classified as antibody positive.

RESULTS

Antibodies to A. actinomycetemcomitans leukotoxin were detected in 18.8% of the women and 15.2% of the men. Women with those antibodies had a significantly decreased risk for stroke (OR = 0.28, 95% CI: 0.13-0.59), but not men (OR = 0.88, 95% CI: 0.52-1.51).

CONCLUSION

The immunoreactivity to A. actinomycetemcomitans leukotoxin correlates negatively with a future stroke in woman, but not in men. Further studies are needed to explain the underlying mechanisms, as well as the biological relevance of this finding.

Leptin, but not adiponectin, predicts stroke in males

OBJECTIVE

To test whether leptin and adiponectin are risk markers for a first-ever stroke. RESEARCH DESIGN, METHODS AND SUBJECTS: A nested case-referent study identified 276 cases with first-ever stroke (234 cases with ischaemic and 42 with haemorrhagic stroke). Prior to the stroke, they had participated in population-based health surveys in northern Sweden (median time between survey and stroke was 4.9 years). Referents were matched for sex, age, date and type of health survey, and geographical region. Putative risk markers for first-ever stroke, including blood pressure (BP), diabetes, smoking, body mass index (BMI), cholesterol, leptin, and adiponectin, were analysed by conditional logistic regression analysis.

RESULTS

Increased BMI, high cholesterol and fasting glucose levels, diabetes mellitus and hypertension were found in future stroke patients. Whereas leptin levels were higher in male subjects (P = 0.004), adiponectin did not differ between groups. A high leptin level independently predicted stroke in men (OR = 2.46; 95% CI 1.08-5.62) but not in women. Adiponectin levels did not predict stroke. Males with high leptin levels developed stroke faster than males with low leptin levels (P = 0.0009), independently of traditional risk factors.

CONCLUSIONS

Leptin may be an important link to the development of cerebrovascular disease in men, whereas adiponectin does not associate with future stroke.

The influence of smoking and smokeless tobacco use on weight amongst men

OBJECTIVE

To explore the effect of tobacco use (smoking and smokeless tobacco) and cessation on body weight.

DESIGN

Cross-sectional and prospective follow-up study.

SETTING

Northern Sweden.

SUBJECTS

A total of 2993 men aged 25-64 years who participated in the northern Sweden MONICA study in 1986, 1990 or 1994, 1650 of whom were followed up in 1999.

MAIN OUTCOME MEASURES

The prevalence of overweight [body mass index (BMI) >/= 27] amongst tobacco users was compared with nonusers at entry into the study. The average annual percentage weight gain amongst men was also determined according to tobacco use both at entry and at follow-up, and the development of overweight amongst tobacco-use groups was reported using standardized incidence ratios.

RESULTS

Smokers who quit tobacco during the follow-up period gained significantly more weight than smokers who switched to snus (annual gain 0.96% vs. 0.51%, P < 0.05). At entry, ex-smokers had higher prevalence of overweight than nonusers of tobacco [prevalence ratio (PR) = 1.24, 95% confidence interval (CI) = 1.10-1.40]. Snus users had slightly higher prevalence of overweight at entry (PR = 1.20, CI = 1.01-1.42). Snus users who quit gained more weight than nonusers (0.70% vs. 0.44%, P < 0.05) or those who continued to use snus (0.42%).

CONCLUSIONS

Cessation of tobacco, either cigarettes or snus, leads to significantly increased weight gain. However, snus use may play a role in lowering the weight gain following smoking cessation.

Large variations in the use of oral anticoagulants in stroke patients with atrial fibrillation: a Swedish national perspective

OBJECTIVES

To explore nation-wide use of anticoagulation in stroke patients with atrial fibrillation, in routine clinical practice in Sweden.

DESIGN

Cross-sectional cohort study.

SETTING

Patients included in Riks-Stroke, the Swedish national quality register for stroke care, during 2001.

SUBJECTS

Hospitals with incomplete coverage were excluded, leaving 4538 stroke patients with atrial fibrillation amongst 18 276 stroke patients from 75 hospitals in six health care regions.

MAIN OUTCOME MEASURE

Treatment with oral anticoagulants.

RESULTS

At stroke onset, the proportion of patients with atrial fibrillation and first-ever stroke, receiving oral anticoagulants as primary prevention was 11.0% (range 8.4-13.5% between regions and 2.5-24.4% between hospitals). Younger age, male sex and diabetes at stroke onset independently predicted primary prevention with oral anticoagulants. The proportion of stroke patients with atrial fibrillation receiving oral anticoagulants as secondary prevention at discharge was 33.5% (range 29.9-40.6% between regions and 16.4-61.9% between hospitals). Independent predictors for secondary prevention were younger age, male sex and independent activities of daily life (ADL) function before the stroke, being discharged to home, being fully conscious on admission and health care region.

CONCLUSION

There were variations between hospitals and regions that differences in age, sex, functional impairments and comorbidities could not fully explain. This indicates that evidence-based primary and secondary prevention of embolic stroke is insufficiently practised. Local factors seem to determine whether patients with atrial fibrillation gain access to optimal prevention of stroke or not.

Evolving patterns of tobacco use in northern Sweden

BACKGROUND AND OBJECTIVES

Cross-sectional data from northern Sweden suggest that the increased use of Swedish moist snuff (snus) may have contributed to a decline in the prevalence of smoking, especially amongst men. This study describes the evolving patterns of tobacco use in this population over the period 1986-1999.

DESIGN

This is a prospective follow-up study of 1651 men and 1756 women, aged 25-64 years, who were enrolled in the northern Sweden MONICA project (entry in 1986, 1990, 1994) and who were followed-up in 1999. Information on tobacco use at entry and at follow-up was used to describe the stability of tobacco use over a period of 5-13 years ending in 1999.

RESULTS

Snus was the most stable form of tobacco use amongst men (75%); only 2% of users switched to cigarettes and 20% quit tobacco altogether. Smoking was less stable (54%); 27% of smokers were tobacco-free and 12% used snus at follow-up. Combined use (smoking and snus) was the least stable (39%), as 43% switched to snus and 6% switched to cigarettes. Former users of both products were much less stable than former users of either cigarettes or snus. The stability of smoking amongst women was 69%, which was higher than that amongst men (P < 0.05).

CONCLUSIONS

The use of snus played a major role in the decline of smoking rates amongst men in northern Sweden. The evolution from smoking to snus use occurred in the absence of a specific public health policy encouraging such a transition and probably resulted from historical and societal influences.

Impact of smokeless tobacco use on smoking in northern Sweden

BACKGROUND AND OBJECTIVES

For many years Swedish men have had the world's lowest rates of smoking and smoking-related mortality. Despite these facts, a thorough analysis of tobacco use patterns in Sweden has not been performed. The purpose of this study was to examine the prevalence and interaction of cigarette smoking and use of Swedish moist snuff (snus) in the population of northern Sweden.

DESIGN

The study cohort of 2998 men and 3092 women aged 25-64 was derived from the northern Sweden MONICA study, consisting of population-based surveys in 1986, 1990, 1994 and 1999. Detailed information on tobacco use was used to develop prevalence data, and the prevalence ratio was used to compare rates amongst various subgroups.

RESULTS

Amongst men ever-tobacco use was stable in all survey years at about 65%, but the prevalence of smoking declined from 23% in 1986 to 14% in 1999, whilst snus use increased from 22% to 30%. In women the prevalence of smoking was more stable in the first three surveys (approximately 27%) but was 22% in 1999, when snus use was 6%. In all years men showed higher prevalence of ex-smoking than women. A dominant factor was a history of snus (PR = 6.18, CI = 4.96-7.70), which was more prevalent at younger ages.

CONCLUSIONS

The recent transition from smoking to snus use amongst men, and incipiently amongst women, in northern Sweden is remarkable and relevant to the global discussion on strategies to reduce smoking.

No increase in the prevalence of known diabetes between 1986 and 1999 in subjects 25-64 years of age in northern Sweden

AIMS

A global increase in diabetes is predicted due to higher body weight and less physical activity. Over the period 1986-1999, the body mass index (BMI) of the adult population of northern Sweden increased from 25.3 to 26.2 and the prevalence of obesity (BMI > or = 30) from 11% to 15%, although this was more distal than central adiposity. Our hypothesis was that this would lead to a higher prevalence of diabetes.

METHODS

Four population surveys with new and independent cohorts of 2000 invited subjects, 25-64 years old, in 1986, 1990, 1994 and 1999. In the first three surveys an oral glucose tolerance test was carried out in 47%.

RESULTS

Over the time period 1986-1999 there was no increase in the prevalence of known diabetes. No trends were noted in the finding of previously undiagnosed diabetes or impaired glucose tolerance over the period 1986-1994, although the confidence intervals are wide. Fasting, but not post-load, glucose levels increased with 0.040 mmol/year (95% CI 0.026; 0.055) in men and 0.033 mmol/year (0.023; 0.044) in women.

CONCLUSION

In spite of a marked increase in BMI, we found no increased prevalence of known diabetes over a 13-year observation period, although our data cannot exclude minor increases in undiagnosed diabetes. The development of more distal than abdominal obesity, a diet with less saturated fat and lower glycaemic index and fewer regular smokers in the population may contribute to this. The effects of obesity may thus be attenuated by other secular trends in society and highlight potential ways of curbing the worldwide increase in diabetes.

Various clinical approaches to minimise complications in peritoneal dialysis

The main reason for a failure of peritoneal dialysis is due to technical problems or infections. By starting PD immediately after the insertion of a dialysis catheter (instead of starting HD before optimal healing of the PD-catheter) it may be easier to achieve acceptance for PD by the patients. An easy and tight access is achieved when inserting the PD-catheter through the rectus muscle, fixing it with three purse string sutures, two of them fixing the inner cuff between the peritoneal membrane and the inner rectus fascia. Thereby early and late leakage will be rare and good drainage is normally achieved besides a low risk for exit site infections. Using Coloplast adhesive insulin can be injected into the PD bags in a simple way even by patients with bad vision. Using ultraviolet light, as additional exchange device (UV-box), the risk for peritonitis is reduced compared to classic manual connection. Using the Y-set or duo-bag system the risk for peritonitis is further lowered. Malfunction by dislocation of the intraperitoneal part of the catheters can often be corrected without surgery using a bent stylet. A controlled study showed that antibiotic prophylactics could significantly reduce the risk for peritonitis in the follow up after insertion of PD catheters. Additionally the risk for peritonitis is reduced using a special connector for the PET-sampling procedures. X-ray of catheter location in the abdominal cavity can be performed by injection of 20-ml contrast media into 100 ml of PD fluid residing in the PD-bag. After mixing, small portions of this fluid can be infused into the abdomen for X-ray determination of the location. An increased ultrafiltration failure during PD may be due to use of beta-blocker medication. After ceasing this medication recovery may occur. Avoiding pets in the room used for PD-exchange may lower the risk for peritonitis further. A devoted nurse and physician will keep up the patients' spirit and help to convert patients not suitable for PD to HD or the other way round. By such measures the incidence of peritonitis can be reduced to 1 in 40 treatment months or less.

[Stroke--and then? Considerable need of assistance two year after stroke according to a large nation-wide study]

The National Board of Health and Welfare together with Riks-Stroke (the Swedish National Registry for Quality Assessment of Acute Stroke Care) were commissioned by the government to study the circumstances of 4,023 stroke patients, two years after the event. Both physical and psychological impairments together with psychosocial consequences were common. Approximately one fifth of the patients did not receive enough help and support, and the most common reason for this was the high cost. Instead many were dependent upon next-of-kin. This indicates that the long-term care of stroke patients needs to be improved.

Uremic toxicity: present state of the art

The uremic syndrome is a complex mixture of organ dysfunctions, which is attributed to the retention of a myriad of compounds that under normal condition are excreted by the healthy kidneys (uremic toxins). In the area of identification and characterization of uremic toxins and in the knowledge of their pathophysiologic importance, major steps forward have been made during recent years. The present article is a review of several of these steps, especially in the area of information about the compounds that could play a role in the development of cardiovascular complications. It is written by those members of the Uremic Toxins Group, which has been created by the European Society for Artificial Organs (ESAO). Each of the 16 authors has written a state of the art in his/her major area of interest.

Differences in long-term outcome between patients treated in stroke units and in general wards: a 2-year follow-up of stroke patients in sweden

BACKGROUND AND PURPOSE

The long-term beneficial effects of stroke unit care have been proved in several randomized trials. However, there is a question of large-scale applicability in routine clinical practice of interventions used by dedicated investigators in small randomized trials. The objective of this study was to compare, 21/2 years after stroke, patients who had been treated in stroke units and those treated in general wards in routine clinical practice.

METHODS

This is a prospective cohort study based on 8194 patients who were included, during the first 6 months in 1997, in Riks-Stroke, the Swedish National Register for quality assessment of acute stroke. Two years after the event, 5189 patients were still alive and 5104 were followed up with a postal questionnaire to which 4038 responded.

RESULTS

Among the group of patients who were independent in activities of daily living (ADL) functions before the stroke, patients who were treated in stroke units were less often dependent in ADL functions, after adjustment for case mix (OR, 0.79; CI, 0.66 to 0.94). If they also lived at home before the stroke, then they had a lower case-fatality rate 2 years after the stroke (OR, 0.81; CI, 0.72 to 0.92).

CONCLUSIONS

Long-term beneficial effects of treatment in stroke units were shown for patients who were independent in ADL functions before the stroke. No benefits were shown for patients who were dependent on help for primary ADL before the stroke. Further studies on this group of patients with more detailed outcome measures are needed.

Fetal exposure, heredity and risk indicators for cardiovascular disease in a Swedish welfare cohort

BACKGROUND

The overall aim was to test whether low birthweight (LBW) in newborns is associated with the risk indicators for cardiovascular disease in early middle age, even in a welfare society. Further, a possible interaction of LBW and heredity for myocardial infarction or stroke was investigated.

METHODS

Overall, subjects were identified as newborns in a local birth register, and as adult participants, in the Västerbotten Intervention Program (n = 7876). Outcome measures such as systolic (SBP) and diastolic blood pressures (DBP), body mass index (BMI), cholesterol, triglycerides and anthropometrics were investigated (at age 29-41 years) in relation to LBW.

RESULTS

Low birthweight was associated with increased SBP and DBP. Triglycerides were elevated among women with LBW and total cholesterol was elevated in men with LBW. Heredity for myocardial infarction or stroke interacted with LBW, and indicated a synergistic effect on the level of SBP. The BMI did not differ between LBW and normal birthweight subjects.

CONCLUSIONS

Our interpretation is that the 'fetal origins' hypothesis' is valid for middle-age subjects who grow up in a welfare society. The population attributable proportions that result from different exposures to LBW were relatively small overall; from a public health perspective, heredity was more important than LBW for elevated SBP.

Adverse events and problems in therapeutic hemapheresis. A report from the Swedish registry

BACKGROUND

Since 1996 adverse events (AE) in therapeutic apheresis (TA) have been more extensively registered in Sweden. This report analyzes the extent and relation of AEs to procedures and diagnoses.

MATERIALS AND METHODS

Reporting of TA performed in Sweden was centralized. A separate system for the registration of AE in TA was established and the data received were entered into a central database for registration and analyses. Fifteen of all 35 apheresis units reported both TA and AE during 1996-1999. These centers performed 75% of all TA procedures. Adverse events included medical symptoms, vascular access problems, technical and other problems.

RESULTS

More than 14,000 procedures were registered during the observation period. No fatalities occurred. AEs occurred in 3.7% (1996), 4.6% (1997), 4.2% (1998) and 4.4% (1999) of procedures. Interventions during the adverse event were performed in about 65% of the events. Apheresis procedures were interrupted due to an adverse event in about 1%. Adverse events occurred in 5.6% of plasma exchanges, 1.9% of plasma modulations and 6.8% of cytapheresis procedures. Paresthesia was registered in 22% and hypotensive events in 20.5%. Other more frequent symptoms were urticaria (14.4%), shivering (7.4%) and nausea (7.4%). AEs were most frequent in patients with Goodpasture's syndrome (12.5%), TTP/HUS (10.5%) and GuillainBarré syndrome (11.0%).

CONCLUSION

AEs are few, often mild and less common in plasma modulation than plasma exchange. AEs are more frequent during TA of patients with certain diagnoses such as TTP/HUS.

What else adds to hypertension in predicting stroke? An incident case-referent study

OBJECTIVES

To examine to what extent traditional biomedical risk factors and social factors can predict, separately or jointly, first-ever stroke event, and to explore to what extent other risk factors might add to hypertension/elevated blood pressure as a stroke risk factor.

DESIGN

An incident case-referent study.

SETTING

The study was nested within the Västerbotten Intervention Program (VIP) and the Northern Sweden MONICA cohorts.

SUBJECTS

The study involves 129 stroke cases with two randomly selected referents per case from the same study cohorts.

RESULTS

History of diabetes, daily smoking, obesity (body mass index greater than or = 30 kg m(-2)), hypertension and living as an unmarried person were associated with an increased risk in univariate analysis. However, in the multivariate logistic regression analysis, only hypertension, diabetes and single marital status remained significant. There was a statistically significant interaction between hypertension and smoking and stroke. Interaction of possible clinical relevance was also observed between hypertension, history of diabetes and stroke.

CONCLUSIONS

The study both emphasizes the multifactorial nature of stroke and illustrates that knowledge of interactions offers different strategic approaches when preventing stroke in clinical work. It is important, but not enough, to focus on blood pressure control. Diabetes prevention as well as prevention of smoking must also be considered as factors of major importance.

Citalopram pharmacokinetics in patients with chronic renal failure and the effect of haemodialysis

OBJECTIVE

To study the effects of severe renal failure and haemodialysis on the pharmacokinetics of citalopram.

METHODS

Four patients with renal failure undergoing haemodialysis and eight healthy controls were given a single dose of citalopram. The concentrations of citalopram and its metabolites desmethylcitalopram and didesmethylcitalopram were measured in serum and urine. On a different day, the four patients undergoing haemodialysis were given another single dose of citalopram, and the drug concentrations were measured in serum from the artery leading to the dialyser and in the dialysate. In addition, one anuric patient treated with citalopram on a regular basis was included in the study.

RESULTS

There were no significant differences between the two groups in any of the pharmacokinetic parameters with the exception of the renal clearance of citalopram, which was significantly lower in the renal failure group than in the control group (1.70 ml/min versus 66.2 ml/min, P<0.001). Oral clearance of citalopram was almost identical in the two groups (452 ml/min versus 456 ml/min). The process of haemodialysis cleared about 1% of the dose as citalopram and 1% as desmethylcitalopram only.

CONCLUSION

Severe renal failure does not affect the pharmacokinetics of citalopram and modification of the usual citalopram dose does thus not seem to be necessary. The contribution of haemodialysis to the total elimination of citalopram is negligible.