The influence of age on changes in health-related quality of life over three years in a cohort undergoing hemodialysis

OBJECTIVES: To assess the extent to which persons aged 70 and older undergoing hemodialysis (HD) had greater changes in health‐related quality of life (HRQOL) over 3 years than younger patients undergoing HD. DESIGN: Longitudinal. SETTING: The Hemodialysis Study (HEMO Study) was a randomized, clinical trial of the effects of HD dose and membrane flux on mortality and morbidity in patients undergoing chronic dialysis. PARTICIPANTS: Secondary analysis of the HEMO Study. MEASUREMENTS: Participants completed the Index of Well‐Being (IWB) and the Kidney Disease Quality of Life—Long Form (KDQOL‐LF), which also includes the Medical Outcomes Study 36‐item Short Form Questionnaire (SF‐36) annually. Changes in subjects those aged 70 and older were compared with changes in subjects aged 55 to 69 and 18 to 54. RESULTS: At baseline, 1,813 (98%) of HEMO participants completed HRQOL surveys. Their mean age was 58, 56% were female, 64% were black, and mean duration of dialysis was 3.8 years. In subjects with HRQOL data at the first three annual assessments, there were no substantial mean declines in the SF‐36 Physical or Mental Component Summary scales over 3 years. In models incorporating effects of attrition, the differences in average change over 3 years between patients undergoing HD aged 70 and older and the younger cohorts were small in magnitude. There were high rates of adverse HRQOL events in all age groups and significantly higher composite event rates of death or clinically significant decline in HRQOL over 3 years was found in subjects aged 70 and older. CONCLUSION: Although HRQOL was impaired in the population undergoing HD, HRQOL scores at baseline reflect a better‐preserved multidimensional quality of life in respondents in the HEMO Study aged 70 and older than in younger patients undergoing HD. There was no substantial relationship between age and average decline in HRQOL score over 3 years in participants in the HEMO Study.     

Persistence of recipient plasma cells and anti-donor isohaemagglutinins in patients with delayed donor erythropoiesis after major ABO incompatible non-myeloablative haematopoietic cell transplantation

Delayed donor erythropoiesis and pure red-cell aplasia (PRCA) complicate major-ABO mismatched non-myeloablative allogeneic stem-cell transplantation. To characterize these events, we analysed red-cell serology and chimaerism in lymphohaematopoietic lineages, including plasma cells and B cells, in 12 consecutive major-ABO incompatible transplants following cyclophosphamide/fludarabine-based conditioning. Donor erythropoiesis was delayed to more than 100 days in nine (75%) patients including six (50%) who developed PRCA. During PRCA, all patients had persistent anti-donor isohaemagglutinins and recipient plasma cells (5-42%), while myeloid and T cells were completely donor in origin. In contrast, B-cell chimaerism was frequently full-donor when significant anti-donor isohaemagglutinins persisted. Four patients with early mixed haematopoietic chimaerism and the prolonged presence of anti-donor isohaemagglutinins and recipient plasma cells developed delayed-onset (>100 days post-transplant) red cell transfusion dependence and PRCA after myeloid chimaerism converted from mixed to full donor. These findings confirm that donor-erythropoiesis is impacted by temporal disparities in donor immune-mediated eradication of recipient lymphohaematopoietic cells during major-ABO incompatibility and suggest that plasma cells are relatively resistant to graft-versus-host haematopoietic effects.     

The clinical and morphologic spectrum of renal cryoglobulinemia

We review the clinical and histologic features of 17 patients with cryoglobulinemia and renal disease. Most cases were associated with evidence of hepatitis C virus (HCV), although a significant minority had no evidence of HCV. The most common histologic pattern for renal involvement was membranoproliferative glomerulonephritis, which was seen in both HCV-positive and HVC-negative patients. Clinical presentation was variable, including nephrotic syndrome, unexplained elevations of serum creatinine, acute renal failure, or extrarenal manifestations. All patients had type II or type III cryoglobulins and all had low serum complements at presentation. Liver function abnormalities in HCV-positive patients were mild. No clinical or laboratory features beyond hepatitis serologies were helpful in distinguishing between HCV-positive and HCV-negative patients. All but 1 HCV-positive patient were treated with interferon (IFN) in either standard or high dosage, and this treatment was largely ineffective. Five of 11 HCV-positive patients progressed to renal failure. HCV patients treated with cyclophosphamide did not develop active liver disease. In all HCV-negative patients, renal function stabilized or improved, and 5 of 6 were treated with cyclophosphamide. In our series, there is limited experience with IFN-ribavirin therapy, which was not well tolerated. Renal cryoglobulinemia is an uncommon illness of diverse etiologies and clinical presentations. Morphologic presentation is also varied. IFN alone is often inadequate therapy for HCV-associated cryoglobulinemia. Experience with IFN-ribavirin in this entity is limited, but has shown promise in hepatic disease and has shown efficacy in HCV-associated cryoglobulinemia. Cyclophosphamide is the treatment of choice for HCV-negative patients and can be used safely in most HCV-positive patients if they fail IFN or IFN-ribavirin therapy, or if they require more aggressive therapy during periods of rapid clinical progression.     

Icicle sign: autoimmune pancreatitis

Abdominal Radiology -     

Two cases of nocardiosis diagnosed by fine‐needle aspiration cytology: Role of special stains

Nocardiosis, a suppurative disease caused by aerobic actinomycetes, is a common opportunistic infection in immunocompromised patients. Unless, the infection is suspected, the diagnosis of Nocardia is tedious and difficult, as these are thin filamentous bacilli, which stain negatively on routine cytological stains. We present two such cases diagnosed on fine‐needle aspiration cytology and discuss the importance of performing the modified Ziehl–Neelsen stain in such cases. Diagn. Cytopathol. 2011. © 2010 Wiley‐Liss, Inc.