Risk of dementia among older patients with lymphoma: A Danish nationwide matched cohort study

INTRODUCTION

Treatment of lymphoma can be associated with cognitive challenges, and some patients may fear development of dementia as long-term complication. Studies report a lower risk of dementia after cancer. Some believe this difference to be a protective mechanism of cancer, others believe it to be driven by bias. The risk of developing dementia after lymphoma has not been investigated in a population-based setting. The aim of this study was to identify the risk of being diagnosed with dementia after lymphoma treatment.

MATERIALS AND METHODS

This Danish nationwide matched cohort study included patients aged ≥65 years with a first-time diagnosis of a non-central nervous system lymphoma between 2005 and 2018 in complete remission after treatment with chemotherapy. Patients diagnosed with dementia or treated with dementia medication before lymphoma diagnosis were excluded. Each patient was matched 1:5 on sex, year of birth, and a modified Charlson comorbidity index. Patients and matched comparators were followed from the corresponding patient's date of complete remission. The risk of developing dementia was calculated using cause-specific hazard ratios (HR), and the cumulative risk was estimated by Aalen-Johansen with death as the competing risk.

RESULTS

A total of 3,244 patients and 16,220 matched comparators were included in the study. There was no difference in risk of all-cause dementia among patients with lymphoma compared to matched comparators with cause-specific HR of 0.85 (95% confidence interval [CI]: 0.70;1.04). The risk of both Alzheimer's disease and non-Alzheimer's dementia was equal among patients and comparators: HR 0.89 (95% CI: 0.66;1.21) and 0.82 (95% CI: 0.63;1.07), respectively. Stratified by lymphoma subtype, age, or year of diagnosis, the risk of all-cause dementia remained equal among patients and matched comparators. The cumulative risk of all-cause dementia was significantly lower among patients with lymphoma compared to matched comparators (Gray's test p < 0.001), probably reflecting higher mortality in patients with lymphoma.

DISCUSSION

The risk of all-cause dementia, Alzheimer's disease, and non-Alzheimer's dementia was equal among older patients with lymphoma compared to matched comparators. Our data suggests that risk of developing dementia is not changed after lymphoma treatment.

Prognostic indices in diffuse large B-cell lymphoma: a population-based comparison and validation study of multiple models

Currently, the International Prognostic Index (IPI) is the most used and reported model for prognostication in patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL). IPI-like variations have been proposed, but only a few have been validated in different populations (e.g., revised IPI (R-IPI), National Comprehensive Cancer Network IPI (NCCN-IPI)). We aimed to validate and compare different IPI-like variations to identify the model with the highest predictive accuracy for survival in newly diagnosed DLBCL patients. We included 5126 DLBCL patients treated with immunochemotherapy with available data required by 13 different prognostic models. All models could predict survival, but NCCN-IPI consistently provided high levels of accuracy. Moreover, we found similar 5-year overall survivals in the high-risk group (33.4%) compared to the original validation study of NCCN-IPI. Additionally, only one model incorporating albumin performed similarly well but did not outperform NCCN-IPI regarding discrimination (c-index 0.693). Poor fit, discrimination, and calibration were observed in models with only three risk groups and without age as a risk factor. In this extensive retrospective registry-based study comparing 13 prognostic models, we suggest that NCCN-IPI should be reported as the reference model along with IPI in newly diagnosed DLBCL patients until more accurate validated prognostic models for DLBCL become available.

Geographical and ecological analyses of multiple myeloma in Denmark: Identification of potential hotspot areas and impact of urbanisation

BACKGROUND

The aetiology of multiple myeloma (MM) is unknown but various environmental exposures are suspected as risk factors. We present the first paper analysing the geographical distribution of MM in Denmark at the municipal level to investigate variations that could be explained by environmental exposures.

METHODS

Patients diagnosed with MM in Denmark during 2005-2020 were identified from nationwide registries and grouped into the 98 Danish municipalities based on residence. The age- and sex-standardised incidence rate (SIR) of each municipality was compared to the national incidence in a funnel plot with 95% control limits. Differences in SIRs of rural, suburban, and urban areas were evaluated with incidence rate ratios.

RESULTS

In total, 5243 MM patients were included. Overall, we found a heterogeneous geographical distribution of MM and a potential hotspot in southern Denmark. This hotspot contains three municipalities with SIRs above the 95% control limit assuming considerably higher rate of MM compared to the national incidence rate. A significant higher SIR was found in rural areas compared to urban areas.

CONCLUSION

The geographical distribution of MM in Denmark indicates that the risk of developing MM depends on place of residence probably due to environmental factors.

Work Disability and Return to Work After Lymphoma: A Danish Nationwide Cohort Study

Purpose

Many patients diagnosed with lymphoma are of working age. Cancer patients are known to have a higher risk of sick leave and disability pension, but this has only been delineated for certain subtypes of lymphoma. Therefore, this study aimed at investigating the overall risk of disability pension for all lymphoma subtypes and at quantifying return to work for patients with lymphoma in work before diagnosis.

Patients and Methods

Patients aged 18-60 years with lymphoma in complete remission (CR) diagnosed between 2000 and 2019 were included in the study. Using national registers, each patient was matched with five comparators from the general population with same sex, birth year, and level of Charlson Comorbidity Index. Risk of disability pension was calculated from 90 days after CR or end of treatment with competing events (death, retirement pension, early retirement pension, relapse for patients, or lymphoma diagnosis for comparators). Return to work for patients was calculated annually until 5 years after diagnosis for patients employed before diagnosis.

Results

In total, 4072 patients and 20,360 comparators were included. There was a significant increased risk of disability pension for patients with all types of lymphoma compared to the general population (5-year risk difference: 5.3 (95% confidence interval (CI): 4.4;6.2)). Patients with non-Hodgkin lymphoma were more likely to get disability pension than patients with Hodgkin lymphoma (sex- and age-adjusted 10-year risk difference: 2.9 (95% CI: 0.3;5.5)). One year after diagnosis, 24.5% of the relapse-free patients were on sick leave. Return to work was highest 2 years after diagnosis (82.1%).

Conclusion

Patients with lymphoma across all subtypes have a significantly higher risk of disability pension. Return to work peaks at 2 years after diagnosis.

Mental health among patients with non-Hodgkin lymphoma: A Danish nationwide study of psychotropic drug use in 8750 patients and 43 750 matched comparators

Psychological distress following cancer diagnosis may lead to mental health complications including depression and anxiety. Non-Hodgkin lymphomas (NHLs) include indolent and aggressive subtypes for which treatment and prognosis differ widely. Incident use of psychotropic drugs (PDs-antidepressants, antipsychotics, and anxiolytics) and its correlation to lymphoma types can give insights into the psychological distress these patients endure. In this prospective matched cohort study, we used nationwide population-based registries to investigate the cumulative risk of PD use in NHL patients compared to a sex- and age-matched cohort from the Danish background population. In addition, contact patterns to psychiatric departments and incident intentional self-harm or completed suicide were explored. In total, 8750 NHL patients and 43 750 matched comparators were included (median age 68; male:female ratio 1.6). Median follow-up was 7.1 years. Two-year cumulative risk of PD use was higher in NHL patients (16.4%) as compared to the matched comparators (5.1%, p < .01); patients with aggressive NHL subtypes had the highest incidence. Prescription rates were higher in the first years after diagnosis but approached the rate of the matched population 5 years into survivorship in aggressive NHLs, whereas patients with indolent subtypes continued to be at higher risk. NHL patients had a slightly higher two-year risk of suicide/intentional self-harm (0.3%) as compared to the matched comparators (0.2%, p = .01). These results demonstrate that mental health complications among NHL patients are frequent. Routine assessment for symptoms of depression and anxiety should be consider as part of standard follow-up of NHL patients.

Depth of neutrophil nadir after first cycle of R-CHOP predicts outcome in diffuse large B-cell lymphoma - a nationwide population-based cohort study

We investigated if survival was predicted by nadir neutrophil counts after the first cycle of R-CHOP in patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL). Neutrophil counts (10⁹/L) were categorized in four grades in the nadir time frame. Prognostic indices and comorbidity levels were calculated and used to adjust the Cox regression model. Kaplan-Meier and Cox regression methods were used to estimate and compare survival. We identified 965 patients. Grade 4 neutropenia was present in 432 (45%). Grade 0 patients had a 5-year overall survival of 67%, grade 1-2: 78%, grade 3: 64%, and grade 4: 57%. Compared with grade 0 adjusted hazard ratios (HR) for death were: 0.77 (95% CI 0.49-1.21) for grade 1-2, 1.18 (95% CI 0.82-1.71) for grade 3, and 1.33 (95% CI 1.02-1.73) for grade 4. Grade 4 neutropenia after the 1st cycle of chemotherapy predicted inferior outcome compared with grade 0 and 1-2. Grade 1-2 neutropenia seemed to have superior outcome.

The impact of comorbidity on mortality in multiple myeloma: a Danish nationwide population-based study

To describe the prevalence of comorbidity and its impact on survival in newly diagnosed multiple myeloma patients compared with population controls. Cases of newly diagnosed symptomatic multiple myeloma during the 2005–2012 period were identified in the Danish National Multiple Myeloma Registry. For each myeloma patient, 10 members of the general population matched by age and sex were chosen from the national Civil Registration System. Data on comorbidity in the myeloma patients and the general population comparison cohort were collected by linkage to the Danish National Patient Registry (DNPR). Cox proportional hazards regression models were used to evaluate the prognostic significance of comorbidity. The study included 2190 cases of multiple myeloma and 21,900 population controls. The comorbidity was increased in multiple myeloma patients compared with population controls, odds ratio (OR) 1.4 (1.1–1.7). The registration of comorbidity was highly increased within the year preceding diagnosis of multiple myeloma (OR 3.0 [2.5–3.5]), which was attributable to an increased registration of various diseases, in particular, renal disease with OR 11.0 (8.1–14.9). The median follow‐up time from diagnosis of multiple myeloma for patients alive was 4.3 years (interquartile range 2.4–6.3). Patients with registered comorbidity had increased mortality compared with patients without comorbidity, hazard ratio 1.6 (1.5–1.8). Multiple myeloma patients have increased comorbidity compared with the background population, in particular during the year preceding the diagnosis of myeloma.

The Danish National Chronic Lymphocytic Leukemia Registry

AIM

In 2008, the Danish National Chronic Lymphocytic Leukemia Registry was founded within the Danish National Hematology Database. The primary aim of the registry is to assure quality of diagnosis and care of patients with chronic lymphocytic leukemia (CLL) in Denmark. Secondarily, to evaluate adherence to national guidelines and to provide source data for research purposes.

STUDY POPULATION

All patients diagnosed with CLL in Denmark from 2008 onward are included in the registry. Patients are followed in one of nine hematology centers. All centers participate in the registry and are all obliged to collect data.

MAIN VARIABLES

Predefined data are collected at the time of diagnosis, and follow-up at the time of significant events: treatment, progression, transplantation, and death. Parameters included in the International Workshop on Chronic Lymphocytic Leukaemia criteria for diagnosis, and for decision on treatment initiation as well as characteristics included in the CLL International Prognostic Index are collected.

DESCRIPTIVE DATA

To ensure full coverage of Danish CLL patients in the registry, both continuous queries in case of missing data, and cross-referencing with the Danish National Patient Registry are performed. Data from the registry are published in an annual report summarizing the collected data, the overall survival for yearly cohorts, and the degree of data coverage. Per year approximately 450 new patients with CLL are registered in the registry, cumulative as of July 1, 2015, 3,082 patients have been registered.

CONCLUSION

The Danish National CLL Registry is based within the Danish National Hematology Database. The registry covers a cohort of all patients diagnosed with CLL in Denmark since 2008. It forms the basis for quality assessment of CLL treatment in Denmark and offers a unique opportunity for population-based research.

The Danish National Multiple Myeloma Registry

AIM

The Danish National Multiple Myeloma Registry (DMMR) is a population-based clinical quality database established in January 2005. The primary aim of the database is to ensure that diagnosis and treatment of plasma cell dyscrasia are of uniform quality throughout the country. Another aim is to support research. Patients are registered with their unique Danish personal identification number, and the combined use of DMMR, other Danish National registries, and the Danish National Cancer Biobank offers a unique platform for population-based translational research.

STUDY POPULATION

All newly diagnosed patients with multiple myeloma (MM), smoldering MM, solitary plasmacytomas, and plasma cell leukemia in Denmark are registered annually; ~350 patients. Amyloid light-chain amyloidosis, POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes syndrome), monoclonal gammopathy of undetermined significance and monoclonal gammopathy of undetermined significance with polyneuropathy have been registered since 2014.

MAIN VARIABLES

The main registered variables at diagnosis are patient demographics, baseline disease characteristics, myeloma-defining events, clinical complications, prognostics, first- and second-line treatments, treatment responses, progression free, and overall survival.

DESCRIPTIVE DATA

Up to June 2015, 2,907 newly diagnosed patients with MM, 485 patients with smoldering MM, 64 patients with plasma cell leukemia, and 191 patients with solitary plasmacytomas were registered. Registration completeness of new patients is ~100%. A data validation study performed in 2013-2014 by the Danish Myeloma Study Group showed >95% data correctness.

CONCLUSION

The DMMR is a population-based data validated database eligible for clinical, epidemiological, and translational research.

The Danish National Acute Leukemia Registry

Aim of database

The main aim of the Danish National Acute Leukemia Registry (DNLR) was to obtain information about the epidemiology of the hematologic cancers acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), and myelodysplastic syndrome (MDS).

Study population

The registry was established in January 2000 by the Danish Acute Leukemia Group and has been expanded over the years. It includes adult AML patients diagnosed in Denmark since 2000, ALL patients diagnosed since 2005, and MDS patients diagnosed since 2010. The coverage of leukemia patients exceeds 99%, and the coverage of MDS patients is currently 90%.

Main variables and descriptive data

Approximately, 250 AML patients, 25 ALL patients, and 230 MDS patients are registered in the DNLR every year. In January 2015, the registry included detailed patient characteristics, disease characteristics, treatment characteristics, and outcome data on more than 3,500 AML, 300 ALL, and 1,100 MDS patients. Many of the included prognostic variables have been found to be of high quality including positive predictive values and completeness exceeding 90%. These variables have been used in prognostic observational studies in the last few years. To ensure this high coverage, completeness, and quality of data, linkage to the Danish Civil Registration System and the Danish National Registry of Patients, and several programmed data entry checks are used.

Conclusion

The completeness and positive predictive values of the leukemia data have been found to be high. In recent years, the DNLR has shown to be an important high-quality resource for clinical prognostic research.

Thallium intoxication treated with long-term hemodialysis, forced diuresis and Prussian blue

A 56-year-old woman, who ingested 2 g of thallium sulfate, was successfully treated with long-term hemodialysis for 200 hours during ten days, combined with forced diuresis and Prussian blue. The effect of the artificial kidney dialysis was determined by repeated analysis of the thallium concentration in the dialysis bath and in blood samples. During the first 120 hours of hemodialysis, 143 mg of thallium was eliminated via the artificial kidney and 110 mg via the urinary tract. The present case of acute thallium intoxication is the first in which long-term hemodialysis has been used in the acute phase together with forced diuresis and Prussian blue. The data obtained are compared to those obtained from cases treated with hemodialysis in the past. It is concluded that treatment with hemodialysis should be considered as an important supplement to treatment with forced diuresis and Prussian blue in cases of thallium intoxication.

Paroxetine, a cytochrome P450 2D6 inhibitor, diminishes the stereoselective -demethylation and reduces the hypoalgesic effect of tramadol

OBJECTIVE

Tramadol hydrochloride (INN, tramadol) exerts its antinociceptive action through a monoaminergic effect mediated by the parent compound and an opioid effect mediated mainly by the O-demethylated metabolite (+)-M1. O-demethylation is catalyzed by cytochrome P450 (CYP) 2D6. Paroxetine is a very potent inhibitor of CYP2D6. The objective of this study was to investigate the influence of paroxetine pretreatment on the biotransformation and the hypoalgesic effect of tramadol.

METHODS

With and without paroxetine pretreatment (20 mg daily for 3 consecutive days), the formation of M1 and the analgesic effect of 150 mg of tramadol were studied in 16 healthy extensive metabolizers of sparteine in a randomized, double-blind, placebo-controlled, 4-way crossover study by use of experimental pain models.

RESULTS

With paroxetine pretreatment, the area under the plasma concentration-time curve (AUC) of (+)- and (-)-tramadol was increased (37% [P = .001] and 32% [P = .002], respectively), and the corresponding AUCs of(+)- and (-)-M1 were decreased (67% [P = .0004] and 40% [P = .0008], respectively). (+)-M1 and (-)-M1 could be determined in all subjects throughout the study period regardless of paroxetine pretreatment. The sums of differences between postmedication and premedication values of pain measures differed between the placebo/tramadol and the placebo/placebo combination, with median values as follows: pressure pain tolerance threshold, 390 kPa (95% confidence interval [CI], 211 to 637 kPa) versus -84 kPa (95% CI, - 492 to -32 kPa) (P = .001); single sural nerve stimulation pain tolerance threshold, 25.8 mA (95% CI, 15.3 to 29.8 mA) versus 9.0 mA (95% CI, 1.5 to 14.8 mA) (P = .005); pain summation threshold, 10.7 mA (95% CI, 5.2 to 17.6 mA) versus 5.0 mA (95% CI, 2.8 to 11.2 mA) (P = .066); cold pressor pain, -4.2 cm x s (95% CI, -6.8 to -1.9 cm x s) versus -0.4 cm x s (-1.4 to 1.4 cm x s) (P = .002); and discomfort, -4.7 cm (95% CI, -10.6 to -2.8 cm) versus 0.5 cm (-0.1 to 1.4 cm) (P = .002). The sums of differences of the paroxetine/tramadol combination also differed from placebo/tramadol for some of the measures, with median values as follows: cold pressor pain, -2.2 cm x s (95% CI, -3.7 to -0.4 cm x s) (P = .036, compared with placebo/tramadol); and discomfort, -2.0 cm (95% CI, -5.6 to -1.2 cm) (P = .056). For the other measures, the hypoalgesic effect was retained on the paroxetine/tramadol combination, with median values as follows: pressure pain tolerance threshold, 389 kPa (95% CI, 141 to 715 kPa) (P = .278, compared with placebo/tramadol); single sural nerve stimulation pain tolerance threshold, 12.5 mA (95% CI, 6.2 to 28.3 mA) (P = .278); and pain summation threshold, 8.2 mA (95% CI, 4.4 to 14.6 mA) (P = .179). Paroxetine in combination with placebo showed no analgesic effect.

CONCLUSIONS

It is concluded that paroxetine at a dosage of 20 mg once daily for 3 consecutive days significantly inhibits the metabolism of tramadol to its active metabolite M1 and reduces but does not abolish the hypoalgesic effect of tramadol in human experimental pain models, particularly in opioid-sensitive tests.

Effect of an acute oral lithium intake on urinary Aquaporin-2 in healthy humans with and without simultaneous stimulation with hypertonic saline infusion

OBJECTIVE

Animal experiments have shown that lithium interferes with the formation of Aquaporin-2 in the distal renal tubuli. The effect of lithium on formation of renal water channels has not been studied in healthy humans. The aim of this study was to test the hypotheses that a single oral dose of lithium will reduce the formation of water channels both with and without stimulation with hypertonic saline infusion, and that this effect can be detected by measurement of urinary excretion of Aquaporin-2 (u-AQP2).

METHODS

In healthy subjects, Study 1 (n = 11) and Study 2 (n = 12), urine was collected in 6 and 7 periods between 08.00 and 14.00, respectively, and blood samples were drawn at 30- to 60-min intervals. The study medication was given at 09.00; u-AQP2 was determined by radioimmunoassay.

RESULTS

In Study 1 neither u-AQP2 nor urinary output were significantly changed by lithium. In Study 2, u-AQP2 was increased by hypertonic saline infusion in parallel with an increase in arginine vasopressin. At the end of the study, u-AQP2 was increased by 30% with placebo but only by 13% with the 600 mg lithium dose, and urinary output was significantly higher after 600 mg lithium than after placebo and 300 mg lithium.

CONCLUSIONS

U-AQP2 was not significantly changed after a single oral dose of lithium. The antidiuretic response to hypertonic saline infusion was reduced when lithium was given. It is suggested that lithium increases urinary output by inhibiting trafficking of renal water channels in healthy humans.

Influence of training habits on exercise-induced changes in plasma atrial and brain natriuretic peptide and urinary excretion of aquaporin-2 in healthy man

The purpose of this study was to quantify the influence of training habits on the changes in plasma atrial natriuretic peptide (ANP), plasma brain natriuretic peptide (BNP) and urine aquaporin-2 (u-AQP2) during exercise by studying trained and untrained healthy subjects. Eleven trained subjects (7 males, 4 females) and 10 untrained subjects (8 males, 2 females) performed a maximal aerobic exercise test. ANP and BNP were determined every 3 min and at maximum exercise by radioimmunoassay (RIA), and u-AQP2 was determined before and after the exercise test by RIA. The absolute increase in ANP during exercise was higher in the trained subjects (trained subjects: 5.6 pmol/L; untrained subjects: 2.4 pmol/L, p < 0.05) and was positively correlated to ANP at rest (p < 0.03). The maximum absolute increase in BNP during exercise was the same in the two groups (trained subjects: 0.5 pmol/L; untrained subjects: 0.6 pmol/L, NS) and tended to correlate positively with resting BNP in the trained subjects (p = 0.07). Exercise did not change u-AQP2 excretion in either trained subjects (rest: 372 ng/mmol creatinine; exercise: 314 ng/mmol creatinine, NS) or untrained subjects (rest: 263 ng/mmol creatinine; exercise: 338 ng/mmol creatinine, NS). The absolute increase in ANP during exercise was higher in trained subjects than in untrained subjects and was positively correlated to ANP at rest. This might reflect the normal cardiovascular adaptation to exercise. The increase in BNP during exercise was unrelated to training habits. Training habits did not affect the u-AQP2 excretion during exercise.

Chlamydia pneumoniae DNA in peripheral blood mononuclear cells in dialysis patients, renal transplant recipients and healthy controls

It has been suggested that infection with Chlamydia pneumoniae plays a role in the development and maintenance of atherosclerosis based on differences in the prevalence of antibodies against Chlamydia pneumoniae in patients with and without atherosclerotic lesions and on the presence of bacteria in atherosclerotic lesions. It is well known that patients undergoing chronic dialysis treatment and renal transplant recipients have a considerably increased risk of cardiovascular disease. In this study it is hypothesized that patients with these conditions have a higher prevalence of Chlamydia pneumoniae DNA in the white cells of the peripheral blood. Blood samples from 196 dialysis patients, 114 renal transplant recipients and 342 healthy controls were analysed with an in-house nested polymerase chain reaction (nPCR) and tested for the presence of Chlamydia pneumoniae DNA. The prevalence of Chlamydia pneumoniae DNA was significantly higher in dialysis patients (16.3%) than in healthy controls (8.5%, p < 0.01), whereas no significant difference was found between the prevalence in renal transplant recipients (9.6%) and healthy controls. The prevalence was not related to gender or age in either group, and it was the same in diabetics and non-diabetics. Dialysis patients have a higher prevalence of Chlamydia pneumoniae DNA than healthy controls. The lower prevalence of Chlamydia pneumoniae DNA in renal transplant recipients than in dialysis patients may be due to selection of dialysis patients with few or no cardiovascular complications for renal transplantation. Our results are consistent with the hypothesis that Chlamydia pneumoniae is associated with the pathogenesis of atherosclerosis.

Effect of an acute oral ibuprofen intake on urinary aquaporin-2 excretion in healthy humans

Non-steroidal anti-inflammatory drugs (NSAIDs) inhibit the enzyme cyclooxygenase and thereby block the prostaglandin (PG) synthesis in the kidneys. In animals, PG interferes with the formation of aquaporin 2 in the distal renal tubules. The purpose was to measure the effect of ibuprofen on urinary excretion of aquaporin-2 (u-AQP2), urinary output, urinary osmolality (u-osm) and plasma concentration of vasopressin (AVP) in a dose-response study using placebo and ibuprofen 600mg and 1200mg. In 12 healthy subjects, urine was collected in 6 periods between 07.00 h and 13.00 h, and blood samples were drawn at 60-min intervals. The study medication was given 10 h and 1 h before the study. U-AQP2 and AVP were determined by radioimmunoassays. U-AQP2 decreased 33% in the placebo group and increased 47% in the ibuprofen groups. There was a highly significant difference between the placebo group, on the one hand, and the ibuprofen groups, on the other. There was a small but significant increase in AVP in the placebo group and the 600 mg ibuprofen group, but not in the 1200 mg ibuprofen group. Urinary output was at maximum after 2 h, with a 394%, 1020% and 714% increase for placebo, 600 mg ibuprofen and 1200 mg ibuprofen, respectively. U-osm decreased during the experiment in all three groups. Inhibition of renal prostaglandin synthesis by ibuprofen affects the distal part of the nephron by increasing u-AQP2. This increase was not related to changes in AVP, urinary output or urinary osmolality. We suggest that the increased excretion of AQP2 can be explained by an increase in the ratio of AQP2 that is shed into the urine because the endocytic retrieval of AQP2 from the apical membrane is impaired. This could not be revealed by changes in the osmoregulatory system by the low doses of ibuprofen used in the present study.

Effect of water deprivation and hypertonic saline infusion on urinary AQP2 excretion in healthy humans

Arginine vasopressin (AVP) mediates water transport in the renal collecting ducts by forming water channels of aquaporin-2 (AQP2) in the apical plasma membrane. AQP2 is excreted in human urine. We wanted to test the hypothesis that urinary excretion of AQP2 (u-AQP2) reflects the effect of AVP on the renal collecting ducts during water deprivation and hypertonic saline infusion in healthy subjects. Fifteen healthy subjects underwent a 24-h period of fluid restriction. Urine and blood samples were collected at timed intervals. Fifteen healthy subjects were given 7 ml/kg 3% hypertonic saline infusion for 30 min. Urine and blood samples were collected at timed intervals. During fluid restriction, the u-AQP2 rate increased from 3.9 (25th percentile: 3.1; 75th percentile: 5.2) to 7.6 (5.9-9.1; P < 0.001) ng/min, and the plasma AVP (p-AVP) level increased from 0.5 (0.4-0.6) to 3 (1.7-3.3) pmol/l. There was a positive correlation between the maximum change in u-AQP2 rate and the maximum change in p-AVP (r = 0.57, P < 0.03). During the infusion study, u-AQP2 rate was at maximum 90 min after the infusion [baseline: 4.5 ng/min (3.5-4.8); 90 min: 5 ng/min (4.5-6.0) P < 0.02]. p-AVP increased from 1.0 (0.9-1.1) to 1.5 (1.2-1.8; P < 0.002) pmol/l. There was a positive correlation between the maximum change in u-AQP2 rate and the maximum change in p-AVP (r = 0.83; P < 0.0001). It can be concluded that p-AVP and u-AQP2 are increased during thirst and hypertonic saline infusion and that u-AQP2 reflects the action of AVP on the collecting ducts.

Randomized placebo-controlled trial of perindopril in normotensive, normoalbuminuric patients with type 1 diabetes mellitus

Diabetic nephropathy is one of the leading causes of end-stage renal disease. We examined whether ACE inhibitor treatment may have a nephroprotective effect in normotensive insulin-dependent diabetic patients without microalbuminuria and with normal glomerular filtration rate (GFR), and whether any effect was associated with the ACE genotype. In a prospective double-blind randomized study, normotensive patients with type 1 diabetes mellitus with normal serum creatinine and no microalbuminuria were treated with either placebo or perindopril, an ACE inhibitor. Urine albumine/creatinine ratio (ACR), mean blood pressure (MBP) and index of glomerular filtration rate (GFR) based on S-creatinine were determined. ACE genotype was determined by electrophoresis. ACR was higher in the placebo group than in the perindopril group after 4 months, and continued to increase during the study period. After 36 months of observation, ACR in the placebo group was 1.7+/-1.1 mg/mmol, and 0.6+/-0.2 mg/mmol in the ACE-inhibitor-treated group (p<0.001, Mann-Whitney test). During treatment, a significant increase in ACR in the placebo group (p=0.007), Wilcoxon matched paired test) was observed. There were no differences between the groups regarding MBP or GFR. The nephroprotective effects of ACE inhibitor treatment was not associated with the ACE genotype (II, ID, DD).

Staphylococcus aureus carriage in adult peritoneal dialysis patients and their spouses

OBJECTIVE

We hypothesized that carriage of Staphylococcus aureus among continuous ambulatory peritoneal dialysis (CAPD) patients was influenced by their spouses. Furthermore, this carrier status was compared to previous Staph. aureus peritonitis episodes in order to identify the influence of Staph. aureus carriage on peritonitis rate.

DESIGN

A combined prospective surveillance study (Staph. aureus carriage) and retrospective chart review (Staph. aureus peritonitis).

SETTING

A single peritoneal dialysis unit in a county hospital.

PATIENTS AND METHODS

Cultures from patients (n = 32) and spouses (n = 16) were obtained twice, with a 1-month interval, from the anterior nares, the umbilical, and one groin area. All positive cultures were phage typed. Retrospective chart review of all episodes of Staph. aureus peritonitis among the patients was carried out.

RESULTS

Twelve of 32 patients (37.5%) and 5 of 16 spouses (31%) evaluated were carriers. Half of the spouses of patients who were Staph. aureus carriers, were also carriers, as opposed to 20% of spouses of noncarrier patients (p = 0.30). Patients and spouses always shared the same phage type. Among patients, Staph. aureus was found in the nose only (n = 9), in all three regions (n = 2), and extranasally only (n = 1). If only one nasal culture was used to establish carriage, the sensitivity and negative predictive value would be 92% and 95%, respectively. A trend toward a higher incidence (p = 0.062) of Staph. aureus peritonitis was found among carriers (patients), 0.37 versus 0.28 peritonitis episode/dialysis-year.

CONCLUSIONS

Only one positive nasal culture was necessary when carriage of Staph. aureus was to be established. Staph. aureus carriage was found more often in patients who had previously suffered from Staph. aureus peritonitis. The phage types isolated remained fairly constant, and the patients and spouses often had the same carrier state and shared the same phage types, although transmission does not always take place.

Etoposide: more effective and less bone-marrow toxic than standard immunosuppressive therapy in systemic vasculitis?

In two patients suffering from ANCA-positive systemic vasculitis (one from Wegener's granulomatosis, the other from microscopic polyangiitis), who were both resistant to or could not tolerate standard immunosuppressive therapy, complete clinical and biochemical remission was obtained within few months, treating with cyclic etoposide. Etoposide therapy was found to be significantly less bone marrow toxic than standard immunosuppressive therapy.

Continuous venovenous haemodialysis: a three-pump system

A simple three-pump-based system for the performance of continuous venovenous haemodialysis is described. The method employs access to the circulation via a double-lumen catheter, and by means of a standard extracorporeal peristaltic pump the blood is circulated through a haemofiltration filter. Standard solutions for peritoneal dialysis are administered in a single-pass manner countercurrent to the blood flow. To control the dialysate flow through the filter, two separate pumps designed for intravenous infusion are used. Anticoagulation is achieved by means of continuous heparin infusion. This three-pump system is effective in controlling the fluid balance and the level of azotemia. Furthermore, this system makes haemodialysis possible in spite of severe haemodynamic instability. The system is easy to use and inexpensive. 3 patients participated in the study.

Long-term prognosis in idiopathic membranoproliferative glomerulonephritis

The following results were obtained in a long-term follow-up investigation including 37 patients who suffered from idiopathic membranoproliferative glomerulonephritis. The mean follow-up period was 51 months (median 32 months). 1) Renal survival was 35% at 5 years and 16% at 10 years. 2) Univariate analysis indicated significant (p < or = 0.10) association between poor prognosis and the two following parameters a) high age b) elevated blood pressure. 3) Using a Cox-analysis including a) gender b) age at kidney biopsy c) square of age (age age) at biopsy d) presence of nephrotic syndrome e) presence of elevated blood pressure, the following p-values were found: 0.56; 0.02; 0.04; 0.50; 0.09. Thus at the 10% level age, the square of age and elevated blood pressure were significant and independently associated with poor prognosis.

[Peritonitis among patients treated with continuous ambulatory peritoneal dialysis]

A retrospective study of 51 consecutive patients treated with continuous ambulatory peritoneal dialysis (CAPD) during a total of 736 months is presented. Forty-one episodes of peritonitis were found. Thirty-three patients did not experience peritonitis. One patient had six episodes of peritonitis. The time to first and second episode of peritonitis was 487 days (16.2 months) and 1005 days (33.5 months) respectively. The incidence of peritonitis was 0.67 episodes per patient-year, and was not influenced by either sex, diabetes or previous abdominal surgery. The time to the first episode of peritonitis was equal in patients suffering from one vs two or more episodes of peritonitis. Two patients suffered from tunnel infection. Initial treatment with vancomysin and gentamycin (before knowing the results of microbiological culturing) was adequate in 90% of the peritonitis episodes. Sterile peritonitis was found in 12% of the cases. No relapse of peritonitis was observed. Six patients suffered from eleven cases of reinfection. An optimal surgical strategy as well as vancomycin plus gentamicin treatment of peritonitis are advised when a reduction in infection rates is required

Ultrasound-guided renal biopsy with biopsy gun technique--efficacy and complications

One hundred and thirty-one ultrasound-guided renal biopsies performed in 127 patients with automated spring-loaded biopsy technique were evaluated. Adequate tissue for histologic diagnosis was obtained in 92% of the procedures (94% of the patients). The mean glomerular yield was 16.8 glomeruli. Complications were seen in 21% of the patients, 18% having minor and 3% having major complications. Patients with severe hypertension had significantly more complications than the rest of the patients. The rate of complications in patients who had 3 or 4 biopsy passes was not increased compared to patients who had one or 2 biopsy passes. Thus, this study indicates that the risk of complications and the safety of the procedure is not influenced by increasing the number of biopsy passes in order to obtain representative specimens.

[Short and long term prognosis of acute renal failure requiring dialysis. An analysis of 419 consecutive patients]

To describe the relationship between morbidity, mortality, and year of admission we studied 419 patients with acute dialysis-requiring renal failure. Effects of various follow-up periods and stratification on main prognostic factors were evaluated. There was a significantly higher (p < 0.001) number of organ failures/patient during the second six-year period compared with the first six-year period. Early (day 90) mortality was 46% and unchanged during the period. Estimated five year survival rate (95% confidence limits) was 52% (44-60) in patients with a medical etiology, and 28% (20-36) in patients with a surgical etiology. Prognosis was dependent on the severity and progression of the underlying disease process. Changed censoring time and stratification were important tools for enhancing the yield of information from the study. Time(s) and method(s) of risk scoring, stratification(s) of patients, time(s) of censorship, and method of statistical analysis should be identical when comparing results of treatment for acute renal failure from different centres.

Henoch-Schönlein purpura associated with Campylobacter jejuni enteritis. Case report

After an episode of enteritis caused by C. jejuni a 15-year-old boy developed Schönlein-Henoch purpura. Because of continuous proteinuria a renal biopsy was performed. Light microscopy revealed focal proliferative glomerulonephritis. IgA was the dominant immunoglobulin. A causal relationship between enteritis caused by C. jejuni and Schönlein-Henoch purpura complicated with focal proliferative glomerulonephritis is suggested.

Short and long term outcome in a consecutive series of 419 patients with acute dialysis-requiring renal failure

This analysis was done in a consecutive series of 419 patients with potentially reversible acute renal failure (ARF) requiring dialysis treated during the 12 year period January 1977 to December 1988. The aims were to describe the relationship between morbidity, mortality, and the year of admission, to evaluate the effects of various follow-up periods and stratification on main prognostic factors, and to report long term survival.

RESULTS

1) There was a significantly higher (p < 0.001) number of organ failures/patient in the last 6 year period compared with the first 6 year period. 2) Early (day 90) mortality was 46% and did not change significantly during the 12 year period. 3) Etiology, age of the patient, and the severity and the progression of the underlying disease were the most important factors determining outcome. 4) Time of censorship and stratification of the patients influenced prediction models. 5) Estimated 5 year survival rate was 52% (95% confidence limits 44-60%) in patients with a medical etiology, and 28% (95% confidence limits 20-36%) in patients with a surgical etiology.

CONCLUSIONS

1) Prognosis did not change significantly during the 12 year study period, and was almost solely dependent on the severity and progression of the underlying disease process. 2) Changed censoring time and stratification were important tools for enhancing the yield of information from the study. 3) The time(s) and method(s) of risk scoring, stratification(s) of patients, the time(s) of censorship on vital status, and the method for statistical analysis have to be identical if results of treatment for ARF from different centers should be compared.

Prognosis in septicemia complicated by acute renal failure requiring dialysis

During a 12-year period 419 patients were admitted because of acute renal failure requiring dialysis. Fifty (12%) had septicemia verified by blood culture. In a retrospective study age, sex, focus of infection, blood culture results, kidney function, mode of dialysis treatment, numbers and durations of complicating organ failures, presence of gastrointestinal bleeding, and secondary complicating events of septicemia were recorded for the purpose of establishing a prognostic index based on clinical criteria. Respiratory failure was present in 34 patients, circulatory failure in 31 patients, failure of coagulation system in 25 patients, and hepatic failure in 10 patients. Overall mortality was 46%. Highest death-rates were found during the first days of dialysis. In patients with multiple organ failures, in elderly and in patients suffering from staphylococcus aureus septicemia, a non-significant trend towards higher mortality was found. The mode of dialysis treatment did not influence patient survival. Our intention of establishing a prognostic index based on bedside clinical criteria has not been fulfilled. Even though mortality-rate increases in patients with acute renal failure complicated by failure of one or more vital organs, survival-rate in patients with four or more organ failures was 30%.

Prognosis and risk factors in acute, dialysis-requiring renal failure after open-heart surgery

Of 1988 patients who underwent open-heart surgery from 1980 through 1988, 68 (3.4%) developed postoperative acute renal failure requiring dialysis (2.5% of adult and 8.3% of pediatric patients). Isolated aortocoronary bypass grafting was the operation with lowest incidence of this complication (0.6%). Acute renal failure usually appeared during the first 3 postoperative days. It carried a mortality rate of 63%, with half of the deaths occurring during the first few postoperative days, due to low cardiac output and progressive multiple organ failure. Logistic regression analysis in cases of aortic valve replacement demonstrated that significant independent preoperative risk factors for acute renal failure were renal insufficiency (serum creatinine greater than 110 mumol/l in greater than or equal to 2 samples) and increased cardiothoracic index/left ventricular end-diastolic dimension. Data from the literature indicated no time-related trend towards reduction of acute renal failure incidence or mortality. Prevention of low cardiac output is of major importance in these respects. Operative intervention before development of advanced disease with left ventricular dilatation and secondary kidney failure is advocated.

Hemodialysis does not always protect against recurrence of Wegener's granulomatosis

Hemodialysis may protect against disease activity in Wegener's granulomatosis. We report here a 41-year-old woman with Wegener's granulomatosis, in whom renal transplantation was performed after a 10-month period of hemodialysis during which no signs of disease activity were detected. Recurrence of disease did, however, take place 2 years after renal allograft transplantation despite immunosuppressive therapy with cyclosporine A and prednisone. Reinstitution of hemodialysis and graftectomy did not improve the patient's condition but plasmapheresis and treatment with cyclophosphamide and prednisone eliminated all signs of disease within a fortnight. A proposal for better maintenance of these patients is made.

[18 children with slight glomerular proteinuria demonstrated incidentally]

Out of 61 children with idiopathic chronic glomerulonephritis confirmed by biopsy or minimal lesion diagnosed during the period 1964-1987, 18 were found in whom the first sign of renal disease was slight proteinuria demonstrated at routine examination of the urine. Five of these children were referred directly to a nephrological department with the object of further elucidation of the diagnosis. In six of the remaining 13 children, the first referral to hospital took place after an average of 5.9 years and after signs of renal disease were apparent for the first time. In ten of these 13 patients, an average period of 3.9 years elapsed before renal biopsy was carried out and the nature of the disease elucidated. 29 and 73% of these patients, respectively, had developed terminal uraemia five and ten years after establishing the diagnosis. It is recommended that children in whom persistent proteinuria is demonstrated, regardless of the magnitude, should be referred directly to a nephrological department or a paediatric department with special interests. Renal biopsy may be indicated. Life-long systematic follow-up control is indicated.

[Extracorporeal treatment of poisoning. An analysis of 72 consecutive cases from the period 1977-1988]

During a period of 12 years, extracorporeal treatment of 72 cases of poisoning in the form af dialysis and/or haemoperfusion was undertaken in Medical Department C of Arhus Municipal Hospital. Where 54 patients were concerned, the causes of poisoning were medicinal. Eleven cases were caused by ethyl alcohol, six were caused by technical poisons and one by cantharidine which is employed in veterinary medicine. In 50 cases the primary indication for extracorporeal treatment was elimination of the drug or other poison. In the remaining 22 cases the indication was acute renal failure. The total mortality was 4%.

Acute renal failure caused by polymyxin B containing ointment

A case is presented in which a 67-year-old man suffering from non-insulin-dependent diabetes mellitus, after being treated with polymyxin B containing ointment for leg ulcers, developed acute renal failure. After a period of 13 days during which the patient was treated with peritoneal dialysis 5 times, renal function returned. At discharge creatinine-clearance was 12 ml/min. Treating large ulcers with polymyxin B may be dangerous.