Changing acute renal failure treatment from intermittent hemodialysis to continuous hemofiltration: impact on azotemic control.

BACKGROUND: Continuous renal replacement therapy is increasingly used in the management of acute renal failure in critically ill patients. The advantages of continuous renal replacement therapy (CRRT) over intermittent hemodialysis (IHD), however, are not yet fully documented. In particular, it is unknown whether continuous veno-venous hemodiafiltration (CVVHDF) provides better control of azotemia than IHD. OBJECTIVES: To study the effect on azotemic control of changing acute renal failure treatment from IHD to CVVHDF. SETTINGS: Tertiary intensive care unit. PATIENTS: Forty seven consecutive critically ill patients with multiorgan failure and acute renal failure treated with IHD and 47 similar patients treated with CVVHDF. METHODS: Analysis of daily morning urea and creatinine concentrations over the period of renal replacement therapy in the ICU. Statistical comparison of data. RESULTS: The two groups of patients were comparable for mean age (55 years for IHD vs. 60 years for CVVHDF; NS) and number of failing organs prior to therapy (mean of 4.2 for IHD vs. 3.7 for CVVHDF; NS). Severity of illness at admission as assessed by APACHE II score, however, was greater for patients receiving CVVHDF (29.4 vs 25.7; p<0.003). CVVHDF was associated with a significantly lower plasma urea (p < 0.0001) and serum creatinine (p < 0.01) level at 24 hours of treatment despite similar levels at the start of therapy Throughout the duration of therapy, mean urea levels (35.0 mmol/L for IHD vs 23.4 mmol/L for CVVHDF) and mean serum creatinine levels (513 micromoles/L for IHD and 263 micromoles/L for CVVHDF) showed significantly (p <0.0001) better control of uremia with CRRT. CONCLUSIONS: Changing the form of renal replacement therapy from intermittent hemodialysis to continuous hemofiltration is associated with improved control of azotemia. The superior adequacy of small solute clearance achieved during CVVHDF provides additional support for its preferential use in the management of acute renal failure in the ICU.     

Anionic Synthesis of Epoxy End‐Capped Polymers

The reaction of living anions of polystyrene (PS) or poly(methyl methacrylate) (PMMA) with epibromohydrin for the synthesis of well‐defined epoxy end‐functionalized polymers is reported. Polyanions were reacted with an excess of epibromohydrin in tetrahydrofuran (THF) at ?78 °C. The functionalities of the resulting polymers were analyzed by matrix‐assisted laser desorption ionization time‐of‐flight mass spectrometry (MALDI‐TOF MS), NMR, and size exclusion chromatography (SEC). The epoxy end groups were reacted with 1,1‐diphenyl‐ hexyllithium, and MALDI‐TOF MS and NMR before and after this chemical modification were used to determine the presence of the epoxy end groups. The presence of the epoxy end group was confirmed by anionically polymerizing ethylene oxide from these epoxy end group. The formation of a block copolymer due to the epoxy end groups was proved by SEC analysis. The combined MALDI‐TOF MS, ¹H NMR, and SEC results indicate that epoxy end‐capped PS was obtained in quantitative yield. The method was extended to the synthesis of epoxy end‐capped PMMA. With this polymer the extent of end‐functionalization was high but not quantitative, with non‐dimeric byproducts detected by MALDI‐TOF MS.

     

COVID-19 in Kidney Transplant Patients From a Large UK Transplant Center: Exploring Risk Factors for Disease Severity

BackgroundThe novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has raised concern for the health of immunocompromised individuals, who are potentially at higher risk of more severe infection and poorer outcomes. As a large London transplant center serving a diverse patient population, we report the outcomes of SARS-CoV-2 infection in our cohort of 2848 kidney and/or pancreas transplant patients.MethodsData were obtained retrospectively for all transplant patients who attended hospital during the peak of the pandemic and had a positive nasopharyngeal SARS-CoV-2 test.ResultsSixty-six patients were found to be positive for SARS-CoV-2. Twenty percent were treated as outpatients, 59% were admitted to the general ward, and 21% required intensive care. Treatment consisted of reduced immunosuppression, antibiotics for pneumonia or sepsis, and other supportive treatments. Within our cohort, 12 patients died (18%), with an overall mortality of 0.4%. Predictive risk factors for COVID-19 severity were explored.ConclusionsSevere disease was associated with lower hemoglobin prior to COVID-19 diagnosis and lower lymphocyte count at the time of diagnosis but not age, sex, ethnicity, or preexisting comorbidities. Lower glomerular filtration rate and higher C-reactive protein were associated with more severe disease. Despite no use of hydroxychloroquine, azithromycin, antiviral, or immunomodulatory medications, our mortality rate (kidney and pancreas transplant patients) is similar to current international rates.     

Standardized physician preparation of death certificates

One method for determining cause of death in a clinical trial is to use standard nosological coding of death certificates. In order to look at an alternative approach, the Hypertension Detection and Follow-up Program (HDFP) assessed underlying causes of death through the use of three physicians. These physicians were trained and standardized in the proper recording of cause of death on death certificates. Each physician completed a death certificate for each of the 768 deaths in the HDFP, utilizing all available information, including HDFP records, plus any additional hospital and autopsy records. The new standardized death certificates were then transmitted to a panel of three nosologists who coded the cause of death. The physician preparation procedure was compared with a procedure wherein a panel of three nosologists coded the original death certificate for the underlying cause of death. The procedures agreed on the three-digit International Classification of Disease, Adapted code in 60.1% of the cases. The agreement rate improved to 72.5% when disease codes were collapsed into broad disease categories utilized in the HDFP.     

Enterobacter asburiae sp. nov., a new species found in clinical specimens, and reassignment of Erwinia dissolvens and Erwinia nimipressuralis to the genus Enterobacter as Enterobacter dissolvens comb. nov. and Enterobacter nimipressuralis comb. nov.

Enterobacter asburiae sp. nov. is a new species that was formerly referred to as Enteric Group 17 and that consists of 71 strains, 70 of which were isolated from humans. Enterobacter asburiae sp. nov. strains gave positive reactions in tests for methyl red, citrate utilization (Simmons and Christensen's), urea hydrolysis, L-ornithine decarboxylase, growth in KCN, acid and gas production from D-glucose, and acid production from L-arabinose, cellobiose, glycerol (negative in 1 to 2 days, positive in 3 to 7 days), lactose, D-mannitol, alpha-methyl-D-glucoside, salicin, D-sorbitol, sucrose, trehalose, and D-xylose. They gave negative reactions in the Voges-Proskauer test and in tests for indole, H2S production, phenylalanine, L-lysine decarboxylase, motility, gelatin, utilization of malonate, lipase, DNase, tyrosine clearing, acid production from adonitol, D-arabitol, dulcitol, erythritol, i(myo)-inositol, melibiose, and L-rhamnose. They gave variable reactions in tests for L-arginine dihydrolase (25% positive after 2 days) and acid production from raffinose (69% positive after 2 days). Thirty-four Enterobacter asburiae sp. nov. strains were tested for DNA relatedness by the hydroxyapatite method with 32PO4-labeled DNA from the designated type strain (1497-78, ATCC 35953). The strains were 69 to 100% related in 60 degrees C reactions and 63 to 100% related in 75 degrees C reactions. Divergence within related sequences was 0 to 2.5%. Relatedness of Enterobacter asburiae sp. nov. to 84 strains of members of the Enterobacteriaceae was 5 to 63%, with closest relatedness to strains of Enterobacter cloacae, Erwinia dissolvens, Enterobacter taylorae, Enterobacter agglomerans, Erwinia nimipressuralis, and Enterobacter gergoviae. All strains tested were susceptible to gentamicin and sulfdiazine, and most were susceptible to chloramphenicol, colistin, kanamycin, nalidixic acid, carbenicillin and streptomycin. All strains were resistant to ampicillan, cephalothin, and penicillin, and most were resistant or moderately resistant to tetracycline. Enterobacter asburiae sp. nov strains were isolated from a variety of human sources, most prevalent of which were urine (16 strains), respiratory sources (15 strains), stools (12 strains), wounds (11 strains), and blood (7 strains). The clinical significance of Enterobacter aburiae is not known. As a result of this and previous studies, proposals are made to transfer Erwinia dissolvens and Erwinia nimipressuralis to the genus Enterobacter as Enterobacter dissolvens comb. nov. and Enterobacter nimipressuralis comb. nov., respectively.     

Chromosome 17p deletions and p53 gene mutations associated with the formation of malignant neurofibrosarcomas in von Recklinghausen neurofibromatosis.

von Recklinghausen neurofibromatosis (NF1) is a common hereditary disorder characterized by neural crest-derived tumors, particularly benign neurofibromas whose malignant transformation to neurofibrosarcomas can be fatal. The NF1 gene has been mapped to a small region of chromosome 17q, but neither the nature of the primary defect nor the mechanisms involved in tumor progression are understood. We have tested whether NF1 might be caused by the inactivation of a tumor suppressor gene on 17q, analogous to that on chromosome 22 in NF2, by searching for deletions of chromosome 17 in NF1-derived tumor specimens. Both neurofibrosarcomas from patients with "atypical" NF and 5 of 6 neurofibrosarcomas from NF1 patients displayed loss of alleles for polymorphic DNA markers on chromosome 17. However, the common region of deletion was on 17p and did not include the NF1 region of 17q. Since no loss of markers on chromosome 17 was observed in any of 30 benign tumors from NF1 patients, the 17p deletions seen in neurofibrosarcomas are probably associated with tumor progression and/or malignancy. This region contains a candidate gene for tumor progression, p53, which has recently been implicated in the progression of a broad array of human cancers. In a preliminary search for p53 aberrations by direct sequencing of polymerase chain reaction-amplified DNA from 7 neurofibrosarcomas, 2 tumors that contained point mutations in exon 4 of the p53 gene were found, suggesting a role for this gene in at least some neurofibrosarcomas. Thus the formation of malignant neurofibrosarcomas may result from several independent genetic events including mutation of the NF1 gene, whose mechanism of tumorigenesis remains uncertain, and subsequent loss of a "tumor suppressor" gene on 17p, most likely p53.     

Trophoblast interaction with fibrin matrix. Epithelialization of perivillous fibrin deposits as a mechanism for villous repair in the human placenta.

The authors have used morphometric, immunocytochemical, and electron optical techniques to study fibrin deposits associated with villi from 14 normal term placentas, and have examined the response of cultured cellular trophoblast to fibrin matrix in vitro. Morphometric analysis of 3477 villous profiles showed that 5.5% of villi examined had fibrin deposition at sites of syncytial denudation and that fibrin deposition was highly associated with villous epithelial denudation, as evidenced by loss of cytokeratin staining. The perivillous fibrin deposits were strongly immunoreactive for the B beta chain of fibrin II, consistent with local thrombolytic cleavage of fibrinogen to fibrin. Deposits were frequently surfaced by a discontinuous layer of cytokeratin-positive trophoblastic cells that showed type IV basement membrane collagen immunoreactivity at the interface between trophoblast and fibrin. Ultrastructurally, damage to the syncytial trophoblast was apparent at the edge of some deposits, where syncytial denudation was accompanied by a fibrin coating of residual cellular trophoblast and the trophoblastic basal lamina. Other deposits were surfaced by syncytial trophoblast with underlying cellular trophoblast and a new basal lamina external to the basal lamina of the villous core. Cultured cellular trophoblast grown on a fibrin matrix, but not on uncoated plastic, showed morphologic differentiation into a trophoblast layer like that on term villi. The authors suggest that epithelialization of perivillous fibrin deposits is a form of villous repair and that trophoblast-fibrin interactions can modulate trophoblastic differentiation.