Old donors for kidney transplantation: how old?

The widening gap between transplant demand and supply has prompted the expansion of selection criteria for kidney donation to increase the available donor pool. Using kidneys from older donors has increased transplant activity, but has also resulted in reduced graft survival, possibly as a consequence of the imbalance between the number of viable nephrons supplied and the metabolic demand of the recipient. To fill this imbalance and improve graft outcomes, the transplant of 2 older kidneys in the same recipient has been proposed. This procedure, however, does not always confer the same benefit of single transplants from young donors. To optimize allocation of these organs, a panel of pathologists defined a scoring system of pretransplant graft biopsies to help guide the decision between single versus dual kidney transplantation. The survival of kidneys obtained from donors older than 60 years and allocated to single or dual transplantation on the basis of this pretransplant biopsy score was similar to that of single grafts from younger donors and substantially better than that of single grafts from older donors not evaluated histologically before grafting. This strategy has provided excellent outcomes even when kidneys from donors older than 70 years have been used. Thus, biopsy-based allocation algorithm of older grafts may allow extending selection criteria of donors to increase the number of available transplants without increasing the risk of premature graft failure.     

Old or frail: what tells us more?

BACKGROUND: Selecting elderly persons who need geriatric interventions and making accurate treatment decisions are recurring challenges in geriatrics. Chronological age, although often used, does not seem to be the best selection criterion. Instead, the concept of frailty, which indicates several concurrent losses in resources, can be used. METHODS: The predictive values of chronological age and frailty were investigated in a large community sample of persons aged 65 years and older, randomly drawn from the register of six municipalities in the northern regions of the Netherlands (45% of the original addressees). The participants' generative capacity to sustain well-being (i.e., self-management abilities) was used as the main outcome measure. RESULTS: When using chronological age instead of frailty, both too many and too few persons were selected. Furthermore, frailty related more strongly (with beta values ranging from -.25 to -.39) to a decline in the participants' self-management abilities than did chronological age (with beta values ranging from -.06 to -.14). Chronological age added very little to the explained variances of all outcomes once frailty was included. CONCLUSIONS: Using frailty as the criterion to select older persons at risk for interventions may be better than selecting persons based only on their chronological age.     

Left Bundle Branch Block,an Old–New Entity

Left bundle branch block (LBBB) is generally associated with a poorer prognosis in comparison to normal intraventricular conduction, but also in comparison to right bundle branch block which is generally considered to be benign in the absence of an underlying cardiac disorder like congenital heart disease. LBBB may be the first manifestation of a more diffuse myocardial disease. The typical surface ECG feature of LBBB is a prolongation of QRS above 0.11 s in combination with a delay of the intrinsic deflection in leads V5 and V6 of more than 60 ms and no septal q waves in leads I, V5, and V6 due to the abnormal septal activation from right to left. LBBB may induce abnormalities in left ventricular performance due to abnormal asynchronous contraction patterns which can be compensated by biventricular pacing (resynchronization therapy). Asynchronous electrical activation of the ventricles causes regional differences in workload which may lead to asymmetric hypertrophy and left ventricular dilatation, especially due to increased wall mass in late-activated regions, which may aggravate preexisting left ventricular pumping performance or even induce it. Of special interest are patients with LBBB and normal left ventricular dimensions and normal ejection fraction at rest but who may present with an abnormal increase in pulmonary artery pressure during exercise, production of lactate during high-rate pacing, signs of ischemia on myocardial scintigrams (but no coronary artery narrowing), and abnormal ultrastructural findings on myocardial biopsy. For this entity, the term latent cardiomyopathy had been suggested previously.     

Old and new tests: where will it end?

Testing has improved the safety of the blood supply. We have excellent serologic tests in place now and are implementing nucleic acid based tests to identify asymptomatic carriers of viruses during the infectious part of the pre-seroconversion (window) period. However, the blood supply was already quite safe after a variety of other mechanisms had been put into place besides testing to screen out individuals at risk of carrying the most important transfusion transmissible agents. An important safety factor is the use of volunteer, unpaid (unremunerated) blood donors. The best alternative to implementing yet more tests to reduce, but not eliminate, the minute residual risks of transfusion transmission of such agents as HIV, HBV and HCV is the application of microbial inactivation technology to blood and blood components. Such microbially inactivated, cellular blood components should not have the risk of transmitting infectious agents, but may have other, different risks, since nothing has yet been shown to be one hundred percent safe (i.e., risk free). The use of a test to detect carriers of spongiform encephalopathies to prevent their theoretical transmission by transfusion may cause harm to donors and might increase risk for recipients by decreasing the available blood supply.     

Too Old for Freedom? Not Too Late to Try

The physical, psychological and social aspects of care for older adults in nursing homes has been the subject of research internationally for more than 50 years. Numerous guidelines, models and principles of care have been published, yet in many facilities the lack of care which is “person-focused” remains concerning. Potentially, a return to a basic set of simple principles guiding care, ones which are intrinsically focused on the person, would be of use. Despite the plethora of models within the human care literature, looking outside of this frame might be useful not only for those in aged care at the end of life, but for older individuals more broadly. The argument for examining the “Five Freedoms” for animal welfare, which are recognized and applied internationally, is made, and suggestions for adapting this for human care, consistent within a One Health framework, are offered.     

Hemophagocytic Lymphohistiocytosis in a 19 Year Old Critically Ill Patient

Haemophagocytic lymphohistiocytosis (HLH) describes a clinical syndrome of hyperinflammation resulting in an uncontrolled and ineffective immune response. It presents with a clinical picture of likely sepsis, i.e., fever, laboratory evidence of inflammatory response, coagulopathy and thrombocytopaenia should be appropriately investigated and managed for sepsis, but the possible diagnosis of HLH should be borne in mind. Awareness of the clinical symptoms and of diagnostic criteria for HLH is crucial to starting immunosuppressive/immunomodulatory and cytotoxic drugs in time. We present a case of HLH in a 19 year old male who presented with fever, neurological symptoms, cytopaenias, laboratory markers of inflammation and bone marrow aspirate showed hemophagocytosis.     

Is Being a Grandmother Being Old? Cross-Ethnic Perspectives from New Zealand

This paper draws on a study of social aging among women in urban New Zealand for a comparative analysis of grandmother as a marker of being socially old. The paper features the views and perspectives of the women themselves and examines ethnic group identification as a source of variation. Data collected in a series of indepth interviews with women representing four ethnic groups indicate similar patterns regarding prevalence of transition to the role and recognition of grandmother as one of the roles treated by others as primary in definition of old, but differences regarding how the role is treated in self definitions. In the women's own definitions, being a grandmother is treated as one among a configuration of markers of old age and its significance rests on how the role connects with the other markers. Six other markers were implicated: a shorter future, social generativity, social status, seniority, social renewal, and social integration. Ethnic variation in how the grandmother role connects is evident in respect to all six and relatively strong in the case of social status, seniority, social renewal, and social integration. Indicated for further study is the influence of ethnic culture and also the interaction of ethnicity with other sources of variation such as age in years and marital status.     

A new era for oral anticoagulation? Old and new anticoagulant drugs

The expanding demand for long-term antithrombotic therapy and the major limitations of the vitamin-K antagonists, namely their narrow therapeutic range, numerous drug interactions and need for laboratory monitoring, have stimulated the development of new antithrombotic agents. Direct thrombin inhibitors and factor Xa inhibitors are the new classes of orally available anticoagulants that are most advanced in development. Large clinical trials evaluate several compounds both in the primary and secondary prevention of venous thromboembolism and in the prevention of cardioembolism in patients with atrial fibrillation.     

Echocardiographic Contrast in Two-Dimensional Echocardiography: New Applications for an Old Technique?

Although Gramiak and Shah first introduced the technique of using contrast enhanced two-dimensional echocardiography in 1968, it has seen a resurgence of new and varied applications. Three of the areas of interest are in the use of microbubble enhanced contrast agents to evaluate: (1) regional myocardial blood flow; (2) regional myocardial function; and (3) myocardial ischemic areas and infarct size. Whether these new approaches will have applications and value in the clinical laboratory is still a matter of conjecture. The objective of this review is to briefly summarize the potential uses and the advantages and disadvantages of each application.     

Corticosteroid Use for Diabetic Macular Edema: Old Fad or New Trend?

Diabetic retinopathy is the leading cause of blindness in working age individuals in developed countries. Most cases of diabetes related vision loss result from breakdown of the blood-retinal barrier with resultant diabetic macular edema (DME). For over 30 years, laser photocoagulation has been the standard therapy for DME, but most eyes do not experience significant improvements in visual acuity. Intravitreal injections of drugs that inhibit the action of vascular endothelial growth factor (VEGF) lead to gains in vision, but can be expensive and need to be repeated frequently. In addition to VEGF-mediated breakdown of the blood-retinal barrier, recent evidence suggests that inflammation plays an important role in the development of DME. Recognizing this, physicians have injected steroids into the vitreous and developers have created sustained release implants. Intravitreal injections of triamcinolone acetonide lead to rapid resolution of macular edema and significant short-term improvements in visual acuity, but unfortunately, visual acuities diminish when treatment is continued through 2 years. However, intravitreal triamcinolone remains an attractive treatment option for eyes that are pseudophakic, scheduled to undergo cataract surgery, resistant to laser photocoagulation, or require urgent panretinal photocoagulation for proliferative retinopathy. In controlled trials, intraocular implants that slowly release dexamethasone and fluocinolone show promise in reducing macular edema and improving visual acuity. The high incidences of drug related cataracts and glaucoma, however, require that corticosteroids be used cautiously and that patients be selected carefully. The increasing number of patients with DME, the burgeoning cost of medical care and the continuing development of intravitreal steroids suggest that the use of these agents will likely increase in coming years.