Severe gastrointestinal complications after 1,515 adult kidney transplantations

We studied, retrospectively, the occurrence of severe gastrointestinal (GI) complications after kidney transplantation. After 1,515 consecutive adult kidney transplantations performed on 1,445 patients during 1990–1999 at our centre, 147 (10%) severe post-transplantation GI complications were found. Ten percent of the complications were fatal. The median follow-up time was 6.2 years. The main complications were gastroduodenal ulcers and colon complications. GI malignancy developed in 13 patients (0.9%). The complication rate for the first post-transplantation year was 4.8%. Delayed graft function, high age and polycystic kidney disease were risk factors. Five-year patient survival rate was significantly lower in patients with a first-year complication than in those with later or no GI complications (68% vs 88%). Graft survival with deaths censored was the same in both groups. In conclusion, severe GI complications during the first post-transplantation year remain a high risk factor also for long-term patient survival.     

Activity, functional capacity and well-being in ageing Finnish workers

BACKGROUND: The ageing of the labour force and falling employment rates have forced policy makers in industrialized countries to find means of increasing the well-being of older workers and of lengthening their work careers. AIMS: To longitudinally study the relationship between activity and functional capacity and the well-being of ageing workers. METHODS: Follow-up study to that carried out by the Finnish Institute of Occupational Health in 1981-97 (n = 3817). Activity level was measured using various free-time activities, and functional capacity was measured through daily-life activities. The measure of well-being included items with both positive and negative affects. The associations between activity, functional capacity and well-being were analysed by general linear models with repeated measures. RESULTS: Activity level and functional capacity had a strong positive effect (the effects of one unit increase were 0.32 and 0.30, respectively) on well-being. They were also interdependent. The impact of activity level in maintaining well-being became 31% greater during the follow-up, whereas the effect of functional capacity diminished by 17%. CONCLUSION: The results of the study indicate that both involvement in activities and functional capacity have an important, partly compensatory role in maintaining the well-being of ageing workers.     

Gastroduodenal cytomegalovirus infection is common in kidney transplantation patients

OBJECTIVE: Cytomegalovirus (CMV) infection is known to cause ulcerations, erosion and mucosal haemorrhage in the gastrointestinal tract. The aim of this study was to report the CMV findings in the gastroduodenal mucosa of kidney transplantation patients and immunocompetent controls. MATERIAL AND METHODS: Forty-six kidney transplant patients with upper gastrointestinal symptoms and 43 immunocompetent, dyspeptic patients (controls) prospectively underwent oesophagogastroduodenoscopies (OEGDs), with biopsies from the duodenum and stomach. CMV was demonstrated by immunohistochemistry, both in frozen sections using a monoclonal antibody against CMV-specific antigens (pp65 matrix protein) and in paraffin sections by means of a monoclonal antibody against the delayed early protein (p52). RESULTS: CMV was detected in the gastric mucosa in 30% of the kidney transplant patients and in 9% of the controls (p<0.05) and in the duodenal mucosa in 70% and 35%, respectively (p<0.01). The total frequency of CMV findings was similar in patients who underwent OEGDs <1 year and >1 year after transplantation. CMV inclusions were found only in transplantation patients <1 year after transplantation (n=9). CMV findings, especially inclusions, in the gastric biopsies were associated with nausea and upper gastric pain. Histopathological findings in CMV-positive samples were non-specific, focal inflammation in haematoxylin-eosin-stained preparations, while CMV p52 staining showed inclusions in either the epithelial or endothelial cells. CONCLUSIONS: CMV could be detected in the gastroduodenal mucosa in 74% of kidney transplantation patients and in 40% of immunocompetent controls (p<0.01). CMV diagnostics are always recommended when gastroduodenal biopsies of kidney transplantation patients are performed.     

Diagnosis of acute renal allograft rejection by analyzing whole blood mRNA expression of lymphocyte marker molecules

BACKGROUND: Currently, the diagnosis of acute rejection after kidney transplantation is based on a kidney biopsy taken after clinical rejection suspicion. A robust, noninvasive diagnostic method would allow easier and more frequent monitoring of the patient and the graft. Potentially, a straightforward method would be the analysis of lymphocyte marker molecule expression from whole blood samples. METHODS: Whole blood samples were collected prospectively in a single kidney transplantation center from 50 adult kidney recipients transplanted between 2001 and 2005. The mRNA expression of granzyme B, perforin, FasL, granulysin, CD154, ICOS, CTLA4 and PD-1 were analyzed with real-time quantitative polymerase chain reaction. RESULTS: The expression of ICOS and CD154 were significantly lower in rejection patients than in control patients (P<0.001). Both genes gave statistically significant area under receiver operating characteristic curve (AUC; 0.87, 0.88) with 84% sensitivity and 100% specificity for CD154 and 76% and 86% for ICOS, respectively. In paired rejection and postrejection therapy samples, the expression of both genes significantly increased during rejection therapy (P<0.001). When rejection patients were compared to patients biopsied because of other reasons of graft dysfunction, both CD154 and ICOS were lower in rejection patients but only CD154 was statistically significant (P=0.028, AUC=0.740, sensitivity 52%, specificity 90%). The other studied genes gave no consistent statistically significant results. CONCLUSIONS: The whole blood gene expression quantities of costimulatory molecules CD154 and ICOS reasonably robustly differentiated rejection patients from control patients. The clinical use of the analysis is limited by poor capability to differentiate patients with rejection from patients with other causes of graft dysfunction.     

Lower recurrence risk through mammographic screening reduces breast cancer treatment costs

Mammographic screening is associated with a reduced risk of breast cancer recurrence. The objective of the study was to evaluate treatment costs due to breast cancer recurrence in relation to patients’ use of mammographic screening, consecutively collected in a defined population. The study included 418 women exposed to screening and 109 women unexposed to screening diagnosed with stage I–III breast cancer. During the first eight years after primary diagnosis, 19% (N = 80) of the exposed women and 33% (N = 36) of the unexposed women developed recurrent disease, P = 0.002. In the exposed group, 41% of the 8-year treatment costs were for the treatment of patients who developed recurrent disease, compared with 52% in the unexposed group, P = 0.039. Among the relapsed patients, the mean post-recurrence costs were EUR14,950, accounting for 65% of their total 8-year costs. The mean post-recurrence costs were comparable for both exposure groups irrespective of the detection method.     

Significance of quantitative measurement of heparin‐induced platelet antibodies

Background: Heparin‐induced thrombocytopenia (HIT) is a prothrombotic immune‐mediated adverse drug reaction. Antigen and platelet activation assays are used for detection of antibodies. Quantitative results from platelet factor 4 (PF4)‐dependent immunoassays may lead to inter‐laboratory standardization of measurements. Objectives: The aim was to modify a PF4‐dependent immunoassay to measure PF4/heparin antibodies quantitatively. Methods: Over five consecutive years, 1070 samples from thrombocytopenic, heparin‐treated patients were analyzed by a PF4/heparin ELISA and the heparin‐induced platelet activation assay (HIPA). Results of ELISA assay were expressed as arbitrary units per liter (AU/L). Results: Precision of ELISA at the concentration of 50 AU/L was 3.6%. Of 1070 samples, 117 were positive for antibodies by ELISA and/or HIPA assay. The higher the antibody concentration was, the higher was the proportion of HIPA positive cases (>140 AU/L, 100%, n = 26; 100–140 AU/L, 55%, n = 20; 50–99 AU/L, 38%, n = 29; 30–49 AU/L, 17%, n = 36). Conclusions: The measurement of anti‐PF4/heparin antibody concentration is a new parameter that may improve the diagnosis of HIT. All samples with extremely strong antibody concentration were positive also by HIPA. For accuracy, antibody concentrations must be in the linear range of the assay and an international standard is needed.     

Population-based mammography screening results in substantial savings in treatment costs for fatal breast cancer

SummaryAims The aim was to assess the effect of population-based mammography screening on treatment costs for fatal breast cancer in Turku, Finland.Materials and methods The study included 556 women with invasive breast cancer, diagnosed at the age of 40–74 years in 1987–1993: 427 in the screened group (screen-detected or interval cancer) and 129 in the unscreened group (not yet invited or refused screening). Both groups were followed up for 8 years from diagnosis.Results In the unscreened group, 32 (25%) patients died of breast cancer versus 49 (12%) in the screened group (p < 0.001). The non-discounted mean treatment costs were 2.8-fold for those dying of breast cancer compared to survivors: €26,222 versus €9,434; the difference between means was €16,788 (95% CI 14,915–18,660) (p<0.001). The mean costs for fatal cases were high, irrespective of the way cancer was detected: €23,800 in the unscreened group versus €27,803 in the screened group; the difference between means was €−4,003 (−10,810 to 2802) (p=0.245). In the unscreened group, patients with fatal breast cancer accounted for 41% (€0.76/1.87 million) of the total treatment costs versus 29% (€1.36/4.76 million) in the screened group. It was estimated that about one third of costs for fatal breast cancer were avoided through mammography screening, accounting for 72–81% of the estimated total treatment cost savings achieved by screening. About 31–35% of the screening costs for 1987 to 1993 were offset by savings in treatment costs.Conclusions Treatment costs for fatal breast cancer are high. Mammography screening results in substantial treatment cost savings, in which reduction of fatal disease is the key element.