Is Age Associated with the Number or Types of Medications Prescribed to Renal Transplant Recipients?

OBJECTIVES: To determine whether age influences the number or types of medications prescribed to younger (aged 18-64) and elderly (aged > or =65) renal transplant recipients 3 years posttransplant. DESIGN: A cross-sectional study involving renal transplant recipients. SETTING: Medical College of Georgia. PARTICIPANTS: A random sample of 100 elderly and 100 younger renal transplant recipients who received posttransplant care at the Medical College of Georgia, were on stable immunosuppressant therapy regimens, and were at least 3 years posttransplant. MEASUREMENTS: Medical and pharmacy data of recipients were evaluated for demographics; presence of a lipid-lowering agent; number of antihypertensives, immunosuppressants, antidiabetic agents, and total medications; number of rejections; dose per kilogram of immunosuppressant(s); infection-related hospitalizations; and measures of blood pressure, blood glucose, serum creatinine, serum tacrolimus/cyclosporine concentrations, total cholesterol, and triglycerides. RESULTS: Elderly recipients were more likely to have diabetes mellitus before the transplant and to develop diabetes mellitus afterwards (P=.04) and were prescribed more total medications (12.40+/-3.72 vs 10.25+/-4.07, P<.001) and antidiabetic agents (0.89+/-0.93 vs 0.42+/-0.77, P<.001) 3 years posttransplant than younger recipients. Elderly recipients also had fewer chronic rejections, more infection-related hospitalizations, lower diastolic blood pressure, and greater fasting blood glucose levels 3 years posttransplant (P<.05) than younger recipients. CONCLUSION: Future investigation should focus on deciphering the implications of the greater numbers of medications prescribed to elderly renal transplant recipients in terms of maximizing desired health outcomes (e.g., graft survival) and minimizing adverse drug-related experiences (e.g., infection).     

Induction of Remission with Intravenous Immunoglobulin and Cyclophosphamide in Steroid-Resistant Evans’ Syndrome Associated with Dermatomyositis

Evans’ syndrome is characterised by the simultaneous or sequential occurrence of Coombs’-positive haemolytic anaemia (AIHA) and immune thrombocytopenia without underlying aetiology. It has been found to be associated with collagen vascular diseases, especially systemic lupus erythematosus (SLE) and scleroderma. However, Evans’ syndrome with dermatomyositis is very rare. A 59-year-old woman, who had been taking high-dose prednisolone for a month and cyclosporin for 10 days for dermatomyositis, developed purpura on the left popliteal fossa. The platelet and haemoglobin levels decreased to 77.000/mm³ and 9.8 g/dl, respectively. Antiplatelet antibody was positive. Thrombocytopenia responded to intravenous immunoglobulin (IVIG) for a short time, but further decreased in a week. Her blood film showed features of haemolytic anaemia. Laboratory findings showed reticulocytosis and a positive direct Coombs’ test. Bone marrow examination showed a mild hyperplasia of erythroid precursors and megakaryocytes. The patient was successfully treated with cyclophosphamide in addition to oral prednisolone. AIHA in connective tissue disease may develop gradually and show a benign clinical course in most patients. Therefore, we suggest that patients with dermatomyositis and anaemia should always be checked for haemolysis if there is no other explanation. Received: 22 December 1999 / Accepted: 7 July 2000     

Factors Associated with Completion of Pre–Kidney Transplant Evaluations

This study sought to examine various factors that may prevent transplant candidates from completing their transplant workup prior to listing. We reviewed the records of 170 subjects (cases = 100, controls 70) who were either on dialysis or had less than 20 mL/min creatinine clearance and were therefore candidates for preemptive transplantation. Approximately, 56% of preemptive patients completed their workup, while only 36% of patients on dialysis completed their workup. Our data revealed that factors contributing toward completion of workup included intrinsic motivation (four times more likely), lack of specific medical comorbidities (three times more likely), and preemptive status (two times more likely). Among patients on dialysis, intrinsic motivation (five times more likely) and absence of cardiovascular complications (four times more likely) were associated with completion. When comparing patients on dialysis to patients not on dialysis, there were significant differences between the two groups in distance from home to the transplant center, level of education, and presence of medical comorbidities. We believe that targeted interventions such as timely referral, providing appropriate educational resources, and development of adequate support systems, have the potential to improve workup compliance of patients with advanced chronic kidney disease, including those on dialysis.     

Skin Score Decrease in Systemic Sclerosis Patients Treated with Intravenous Immunoglobulin – A Preliminary Report

The aim of the study was to determine for the first time the response of systemic sclerosis (SSc) patients to treatment with intravenous immunoglobulin (IVIg). Three patients with progressive and rapidly deteriorating disease (mainly affecting the skin) were planned to receive six monthly courses of high-dose IVIg (2g/kg). All had a thorough physical examination, clinical evaluation by the modified Rodnan total skin thickness score, and measurement of the titres of PM-Scl antibodies before and after the treatment, and before and after each treatment course. Two of the three patients received six IVIg courses as planned and no adverse effects or disease progression occurred during the therapy. The third patient received three courses, after which he developed renal failure and later died of sepsis. All three patients had a large decrease in their skin score after the treatment compared to that before the treatment. No modification of PM-Scl antibody titres was noted in any patient. Intravenous immunoglobulin (IVIg) may have a role in the treatment of SSc patients with rapidly deteriorating skin disease. The specific indications, as well as the safety of this treatment, should be further researched. Received: 25 August 1999 / Accepted: 1 December 1999     

Mineral Metabolism in European Children Living with a Renal Transplant: A European Society for Paediatric Nephrology/European Renal Association–European Dialysis and Transplant Association Registry Study

Background and objectives

Data on mineral metabolism in pediatric renal transplant recipients largely arise from small single-center studies. In adult patients, abnormal mineral levels are related to a higher risk of graft failure. This study used data from the European Society for Paediatric Nephrology/European Renal Association–European Dialysis and Transplant Association Registry to study the prevalence and potential determinants of mineral abnormalities, as well as the predictive value of a disturbed mineral level on graft survival in a large cohort of European pediatric renal transplant recipients.

Design, setting, participants, & measurements

This study included 1237 children (0–17 years) from 10 European countries, who had serum calcium, phosphorus, and parathyroid hormone measurements from 2000 onward. Abnormalities of mineral metabolism were defined according to European guidelines on prevention and treatment of renal osteodystrophy in children on chronic renal failure.

Results

Abnormal serum phosphorus levels were observed in 25% (14% hypophosphatemia and 11% hyperphosphatemia), altered serum calcium in 30% (19% hypocalcemia, 11% hypercalcemia), and hyperparathyroidism in 41% of the patients. A longer time since transplantation was associated with a lower risk of having mineral levels above target range. Serum phosphorus levels were inversely associated with eGFR, and levels above the recommended targets were associated with a higher risk of graft failure independently of eGFR.

Conclusions

Abnormalities in mineral metabolism are common after pediatric renal transplantation in Europe and are associated with graft dysfunction.     

Post-Discharge Worsening Renal Function in Patients with Type 2 Diabetes and Recent Acute Coronary Syndrome

Background

Worsening renal function during hospitalization for an acute coronary syndrome is strongly predictive of in-hospital and long-term outcome. However, the role of post-discharge worsening renal function has never been investigated in this setting.

Chronic Rejection After Intestinal Transplant: Where Are We in Order to Avert It?

Chronic rejection affects the long-term survival of all solid organ transplants and, among intestinal allografts, occurs in up to 10% of the recipients. The insidious clinical evolution of the chronic allograft enteropathy, the absence of noninvasive biomarkers, and the late endoscopic findings delay its diagnosis. No pharmacological approach has been proven effective, and allograft removal nowadays still represents the only available therapy. The inclusion of the liver in the visceral allograft appears to be the only intervention affecting the development of chronic rejection, as revealed by large-center studies and registry reports. A significant body of evidence emerged from the experimental setting and provided essential knowledge on the complex mechanisms behind the development of chronic allograft enteropathy. More recently, donor-specific antibodies have been suggested as an early, key element in the natural history of chronic allograft enteropathy and several novel approaches, tackling the antibody-mediated graft injury, have gained acceptance in clinical settings and are believed to impact on chronic rejection. The inclusion of a liver allograft is advocated when re-transplanting a sensitized recipient, due to its protective effect against humoral immunity. Multicenter trials are required to understand and tackle chronic rejection, and find the therapeutic answer to this clinical dilemma.     

Are Neighborhood-Level Characteristics Associated with Indoor Allergens in the Household?

Background: Individual home characteristics have been associated with indoor allergen exposure; however, the influence of neighborhood-level characteristics has not been well studied. We defined neighborhoods as community districts determined by the New York City Department of City Planning. Objective: We examined the relationship between neighborhood-level characteristics and the presence of dust mite (Der f 1), cat (Fel d 1), cockroach (Bla g 2), and mouse (MUP) allergens in the household. Methods: Using data from the Puerto Rican Asthma Project, a birth cohort of Puerto Rican children at risk of allergic sensitization (n = 261), we examined associations between neighborhood characteristics (percent tree canopy, asthma hospitalizations per 1,000 children, roadway length within 100 meters of buildings, serious housing code violations per 1000 rental units, poverty rates, and felony crime rates), and the presence of indoor allergens. Allergen cutpoints were used for categorical analyses and defined as follows: dust mite: >0.25 μg/g; cat: >1 μg/g; cockroach: >1 U/g; mouse: >1.6 μg/g. Results: Serious housing code violations were statistically significantly positively associated with dust mite, cat, and mouse allergens (continuous variables), adjusting for mother's income and education, and all neighborhood-level characteristics. In multivariable logistic regression analyses, medium levels of housing code violations were associated with higher dust mite and cat allergens (1.81, 95%CI: 1.08, 3.03 and 3.10, 95%CI: 1.22, 7.92, respectively). A high level of serious housing code violations was associated with higher mouse allergen (2.04, 95%CI: 1.15, 3.62). A medium level of housing code violations was associated with higher cockroach allergen (3.30, 95%CI: 1.11, 9.78). Conclusions: Neighborhood-level characteristics, specifically housing code violations, appear to be related to indoor allergens, which may have implications for future research explorations and policy decisions.     

Epstein–Barr Virus Antibody Titers Are Not Associated with Gastric Cancer Risk in East Asia

Digestive Diseases and Sciences - Epstein–Barr virus (EBV)-positive gastric cancers represent a distinct subtype of gastric cancers and account for nearly 10% of the gastric cancer burden,...     

Severe Pulmonary Hemorrhage in Patients With End-Stage Renal Disease in Antineutrophil Cytoplasmic Autoantibody–Associated Vasculitis

BackgroundIt has been reported that after patients with antineutrophil cytoplasmic autoantibody (ANCA)–associated vasculitis (AAV) progress to end-stage renal disease (ESRD), they are less likely to experience relapse of vasculitis. However, we encountered a few patients with ESRD suffering severe pulmonary hemorrhage caused by relapse of AAV. The current study presents our observation on these patients.MethodsOf 198 consecutive patients with AAV with follow-up data in our center, 66 progressed to ESRD during follow-up. Clinical and laboratory data were collected and retrospectively analyzed.ResultsAmong the 66 patients with ESRD, 5 experienced severe pulmonary hemorrhage. They had positive serum perinuclear ANCA and myeloperoxidase ANCA and were diagnosed as microscopic polyangiitis. All 5 patients achieved remission after initial induction therapy. The average duration of follow-up was 47.0 (range 8.0–98.0) months. After progressing to ESRD and starting hemodialysis, these patients experienced severe pulmonary hemorrhage within 9.0 (range 2.0–23.0) months. After immunosuppressive therapy, pulmonary hemorrhage ceased in 4 patients, and the other died of respiratory failure.ConclusionsSevere pulmonary hemorrhage can occur in ESRD patients with AAV. Disease activity and relapses of AAV should be monitored even after patients progress to ESRD.     

Is Chronic Nonmalignant Pain Associated with Decreased Appetite in Older Adults? Preliminary Evidence

OBJECTIVES: To examine the association between self-reported appetite impairment and pain intensity in community-dwelling older adults with chronic nonmalignant pain. DESIGN: Cross-sectional survey. SETTING: An outpatient pain clinic at the University of Pittsburgh. PARTICIPANTS: A convenience sample of 65 older adults with chronic nonmalignant pain. MEASUREMENTS: Demographics, pain intensity (short-form McGill Pain Questionnaire), self-reported appetite impairment using a newly developed instrument, mood (30-item Geriatric Depression Scale, (GDS)), cognitive status (Folstein Mini-Mental State Examination), dependence in feeding, dependence in grocery shopping and meal preparation, and comorbidities (Cumulative Illness Rating Scale). Medication information was classified as total number of medications, number of analgesics, number of opioids, and number of potential appetite-impairing side effects. RESULTS: Univariate analyses revealed that those who reported pain-related appetite impairment had higher pain intensity than those who reported no appetite impairment (P<.001). Comparison of subjects with and without pain-related appetite impairment revealed a significant difference in GDS scores (P=.027), number of analgesics (P=.015), and number of opioids (P=.014). None of the other variables was statistically significant. The relationship between pain intensity and perceived pain-related appetite impairment was maintained in an analysis of covariance that controlled for GDS score, number of analgesics, and presence of opioids (P=.004). CONCLUSION: Chronic pain is associated with self-reported appetite impairment in older adults, but examination of the influence of reduction in pain intensity on appetite improvement is needed to establish a causal relationship between chronic pain and diminished appetite.     

TLR9 Polymorphisms Are Associated with Altered IFN-�� Levels in Children with Cerebral Malaria

Toll-like receptor (TLR) polymorphisms have been associated with disease severity in malaria infection, but mechanisms for this association have not been characterized. The TLR2, 4, and 9 single nucleotide polymorphism (SNP) frequencies and serum interferon-γ (IFN-γ) and tumor necrosis factor-α (TNF-α) levels were assessed in Ugandan children with cerebral malaria (CM, N = 65) and uncomplicated malaria (UM, N = 52). The TLR9 C allele at −1237 and G allele at 1174 were strongly linked, and among children with CM, those with the C allele at −1237 or the G allele at 1174 had higher levels of IFN-γ than those without these alleles (P = 0.03 and 0.008, respectively). The TLR9 SNPs were not associated with altered IFN-γ levels in children with UM or altered TNF-α levels in either group. We present the first human data that TLR SNPs are associated with altered cytokine production in parasitic infection.     

Increased Urinary Liver-Type Fatty Acid–Binding Protein Level Predicts Worsening Renal Function in Patients With Acute Heart Failure

Background

Urinary liver-type fatty acid–binding protein (L-FABP) is a potential biomarker for acute kidney injury, and it in turn increases cardiovascular mortality. We tested whether the urinary L-FABP level predicted short- and mid-term outcomes in patients with acute heart failure.

–374 T/A Polymorphism in RAGE Gene is Associated with Onset of Diabetes Mellitus,Atherosclerosis, and Renal Dysfunction in Patients with Hypertension

Receptor of advanced glycation end products (RAGE) is reportedly linked with chronic inflammatory diseases due to aging or diabetes. The aim of this study was to show how ?374 T/A RAGE has an impact on systemic vascular damage and renal function. The study subjects were a total of 468 essential hypertension patients from the Non-Invasive Atherosclerotic Evaluation in Hypertension (NOAH) study cohort. We prospectively examined the association of ?374 T/A RAGE with their prognoses and investigated the correlation between ?374 T/A RAGE and multiple clinical parameters. Kaplan–Meier analysis did not show a significant association of ?374 T/A RAGE with total mortality or the prevalence of cardiovascular events. Carriers of the A allele showed a significantly higher prevalence of diabetes mellitus (DM) and lower estimated glomerular filtration rate (eGFR) than subjects without this allele. In subjects with DM, carriers of the A allele showed a significantly lower eGFR. These significant correlations were only seen in male subjects. Carriers of the A allele of ?374 T/A RAGE show an independent risk of atherosclerosis and reduced renal function in male hypertensive patients with DM.