Albuminuria: marker or target in indigenous populations

BACKGROUND: Australian Aborigines in remote areas are experiencing an epidemic of renal disease, type 2 diabetes, hypertension, and cardiovascular disease. Adult deaths are increased 3- to 6-fold, and renal failure more than 20-fold. Renal disease is marked by albuminuria. We describe its distributions and correlations in two remote communities in the Northern Territory. METHODS: Observations in Community 1 included a screen of 939 adult participants (18+ years, 90% recruitment), a treatment program, and 8 to 11 years of follow-up. In Community 2, a screen of 259 people, or 60% of adults, included HbA1c, homocysteine, C-reactive protein (CRP), CMV serology, and carotid intimal media thickness (CIMT). Albumin/creatinine ratio (ACR) was measured by immunoassay in g/mol on random urine, with microalbuminuria defined as 3.4 to 33, and overt albuminuria as ACR 34+. RESULTS: Dipstick urine protein trace+ correctly classified 76% of people with ACR 3.4+, and dipstick protein 1+ correctly classified 82% of people with ACR 34+. ACR was stable to glucose loading and water diuresis in subsets of people in Community 1. ACR levels rose steeply with age. Rates of micro- and overt albuminuria in Community 1 were 28% and 21%, and in Community B were 31% and 13%. ACR correlated inversely with estimated glomerular filtration rate (GFR). ACR also correlated directly with weight, blood pressure, cholesterol, triglycerides, random glucose, HbA1c, homocysteine, and GGT levels, and inversely with HDL cholesterol. ACR correlated with skin sores, scabies, high titer antibodies to Helicobacter pylori, high-titer CMV antibodies, with CRP over a greatly elevated range and, inversely, with birth weight. Finally, ACR correlated with CIMT. Baseline ACR predicted loss of GFR over time. ACR 3.4+ predicted all-cause and cardiovascular hospitalization, while ACR 34+ predicted all renal failure developing over 11 years and all-cause natural deaths and cardiovascular disease deaths. ACEi treatment for people with ACR 34+ reduced renal failure and natural deaths, but the hierarchical effect of higher ACRs within that group for renal and nonrenal deaths was maintained. CONCLUSION: Random urine ACR is a stable and robust marker of renal disease, which is multideterminant. A broad base of shared risk factors probably explains the simultaneous emergence of the excessive renal and nonrenal chronic disease morbidities from which these populations suffer. Thus, albuminuria is a unifying marker for the harmful effects of the spectrum of chronic disease, and perhaps beyond. Dipstick urine protein is a useful surrogate for ACR when resources are constrained and disease burdens high.     

Motor overflow in schizophrenia

The occurrence of motor dysfunction as a sign of schizophrenia, in addition to being a side effect of medication, has received considerable support in recent years. The current study aimed to systematically investigate both the presence and pattern of one such motor dysfunction, motor overflow. It was hypothesised that patients with schizophrenia would show significantly greater motor overflow than controls, and that the pattern of motor overflow occurrence would also vary significantly between the groups. A finger flexion task was used to examine the presence and pattern of motor overflow. Subjects were asked to maintain target forces, using either their index or small finger, representing 25, 50 or 75% of the maximum strength capacity for whichever finger was performing the task. Patients were found to exhibit significantly greater motor overflow than controls. There were also significant findings with respect to the patterns of motor overflow produced, specifically in regards to fine motor control and performance variability. In summary, patients differed significantly from controls in both the degree and pattern of overflow exhibited.     

beta-Herpesvirus (human cytomegalovirus and human herpesvirus 6) reactivation in at-risk lung transplant recipients and in human immunodeficiency virus-infected patients

Human herpesvirus (HHV)-6 is a beta-herpesvirus-like human cytomegalovirus (HCMV) with the potential to reactivate in immunocompromised persons. HHV-6 and HCMV were assessed in the peripheral blood leukocytes of 26 lung transplant recipients and of 37 human immunodeficiency virus (HIV)-infected patients receiving highly active antiretroviral therapy, to determine the degree of concordance between HHV-6 and HCMV reactivation in different biologic settings. In the lung transplant recipients (145 samples), HHV-6 was not detected, even though 44 (30%) of 145 samples were from 9 HCMV DNA-positive patients (13 episodes of HCMV pneumonitis). Among the HIV-infected patients (172 samples), HCMV DNA was detected in 29 (17%) of 172 samples from 10 patients (4 episodes of HCMV disease). HHV-6 DNA was detected in 2 HIV-infected patients who did not have HCMV detected at that time. These findings suggest that the pathobiologic control mechanisms for these 2 beta-herpesviruses may be significantly different.     

An international survey of indoor air quality,ventilation, and smoking activity in restaurants: a pilot study

During a pilot study of indoor air quality in restaurants, a survey was performed in 34 medium-priced restaurants in six countries in Asia, Europe, and North America using a uniform protocol. The concentration of selected constituents of environmental tobacco smoke (ETS) present in occupied areas was determined during lunch and dinner periods by measuring the levels of four particulate-phase markers and two gas-phase markers. The particulate-phase markers determined were respirable suspended particles, ultraviolet particulate matter, fluorescing particulate matter, and solanesol particulate matter. The gas-phase markers were nicotine and 3-ethenylpyridine (3-EP). Correlation between the markers was investigated to explore an improved monitoring approach. It was concluded that at least one marker in each phase was necessary to describe adequately the ETS load. An assessment was made of the ventilation system in each restaurant, and effective ventilation rates were determined based on CO(2) measurements. Smoking activity was also monitored. These data were used to model nicotine and 3-EP concentrations that resulted in a satisfactory prediction of their levels, especially at the higher concentrations. A total number of 1370 questionnaires were returned by the restaurant patrons in five countries. In some countries, dissatisfaction rates above 20% were observed for draft, freshness of air, and noise. The dissatisfaction rates related to tobacco smoke were less than 20%, which is lower than would be predicted based on measured ETS levels. Based on the results of this international pilot study, recommendations are given for future studies of this type.     

The association between birthweight and current blood pressure: a cross-sectional study in an Australian Aboriginal community

OBJECTIVES: To study the relationship of blood pressure to birthweight and current body mass index in a population with high rates of low birthweight (< 2.5 kg). DESIGN: A cross-sectional population screening program conducted between 1992 and 1998, with retrospective retrieval of birthweights. SETTING: A remote coastal Australian Aboriginal community with a high prevalence of diabetes, cardiovascular and renal disease. PARTICIPANTS: Eighty-two per cent of the community members (1473/1805) were screened. Birthweights were available for 767 (71%) of the screened participants aged 7-43 years. MAIN OUTCOME MEASURES: The association between birthweight and current blood pressure, accounting for current body mass index. RESULTS: Mean birthweights were low, and 18% of children and 35% of adults had been low-birthweight babies. In children (7-17 years), blood pressure was not correlated with birthweight, but in adults there was an inverse correlation - a 1 kg increase in birthweight was associated with a 2.9 mmHg (95% CI, 0.3-5.5 mmHg) decrease in systolic blood pressure, after adjusting for age, sex and current weight. Overweight adults with low birthweight had the highest blood pressures. CONCLUSIONS: Low birthweight is significantly associated with higher blood pressure in adult life, and the effect is amplified by higher current weight. Given the high rates of low birthweight in Aboriginal people in remote areas, and the detrimental effect of higher blood pressures on chronic diseases (currently present in epidemic proportions), interventions should focus on improving birthweights and on weight control in adolescents and adults. Special attention should be paid to children with low birthweight to avoid their becoming overweight in adult life.     

Social disadvantage and variation in the incidence of end-stage renal disease in Australian capital cities

OBJECTIVE: To evaluate variation in the incidence of end-stage renal disease (ESRD) within Australian capital cities. To explore the relation between the incidence of ESRD and socioeconomic disadvantage. METHODS: We obtained data from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) regarding 5,013 patients from capital cities who started ESRD treatment between 1 April 1993 and 31 December 1998. We used the postcode at the start of treatment to calculate the average annual incidence of ESRD for each of 51 capital city regions using 1996 Census counts based on place of usual residence. We calculated standardised incidence ratios with 95% confidence intervals for each region. The standardised incidence ratios were examined in relation to the SEIFA Index of Relative Socio-economic Disadvantage (IRSD), derived from the 1996 Census. Low IRSD values indicate more disadvantaged areas. RESULTS: There is significant variation in the standardised incidence of ESRD within capital cities. There was a significant correlation (r=-0.41, p=0.003) between the standardised incidence ratio for ESRD and the SEIFA IRSD. CONCLUSIONS AND IMPLICATIONS: Capital city areas that are more disadvantaged have a higher incidence of ESRD. Socioeconomic factors may be important determinants of the risk of developing ESRD.