Optimising care and the patient experience for people living with dementia: The perceptions of radiography practitioners

INTRODUCTION

Despite abundant literature on the diagnosis of dementia, limited research has explored the lived experiences by radiography practitioners when delivering care to people living with dementia (PLWD). This study explored the perceptions and compatibility of current professional guidance by both radiography practitioners and key stakeholders involved in developing the Society and College of Radiographers clinical practice guideline document for caring for people with dementia.

METHODS

This was a two-stage qualitative multi-method study. Fifteen diagnostic and two therapeutic radiography practitioners from across the UK participated with three asynchronous online discussion forums. One core member and three members from the key stakeholder group participated with individual semi-structured interviews. Data analysis included narrative and thematic analysis.

RESULTS

Participants from both stages identified enablers and barriers to providing person-centred care (PCC) to PLWD. Three superordinate themes were identified linked to (1) Challenges in delivering person-centred care to people living with dementia, (2) The need for role specific education and training, and (3) Partnership working with carers. Challenges in delivering care included time and resource pressures. The lack of dementia specific education compounded these difficulties. Care partners were seen as an asset to providing care.

CONCLUSION

Providing PCC to meet the individual needs of PLWD can be challenging in practice. This is often due to time and resource implications. There were also issues with the identification of PLWD prior to their attendance in the department. Carers could help to alleviate some challenges. There is a need for profession specific education and dementia awareness training to support the provision of PCC to PLWD.

IMPLICATIONS FOR PRACTICE

Dementia training needs to be specifically tailored for radiography practitioners to bridge the gap between guidelines and clinical practice rather than being generalised from other disciplines.

Treatment of bleeding episodes with recombinant factor VIII Fc fusion protein in A-LONG study subjects with severe haemophilia A

INTRODUCTION

The Phase 3 A-LONG study demonstrated the safety and efficacy of rFVIIIFc for the control and prevention of bleeding episodes in severe haemophilia A.

AIM

To describe the treatment of bleeding episodes with rFVIIIFc in the A-LONG study.

METHODS

A-LONG subjects (<1 IU dL^-1 endogenous FVIII) were treated with individualized prophylaxis (Arm 1), weekly prophylaxis (Arm 2) or episodic treatment (Arm 3). Information recorded for each bleeding episode included type, location and dose to treat the episode.

RESULTS

During A-LONG, 757 bleeding episodes occurred during the efficacy period; the majority [456 (60%)] occurred in Arm 3 (episodic treatment). Of 93 subjects in the prophylaxis arms who entered the study with target joints, 43 (60%) in Arm 1 and 11 (52%) in Arm 2 did not experience a target joint bleed. Overall, 98% of bleeding episodes (and 98% of bleeds involving a target joint) resolved with one or two infusions; the median dose per infusion to treat a bleed was 27 IU kg^-1 (27 IU kg^-1 for target joints). Using population pharmacokinetic simulations, FVIII activity levels were predicted to be below the upper limit of normal (150 IU dL^-1 ) in most patients in the event that rFVIIIFc is used to treat a bleeding episode in close proximity to a prophylactic dose.

CONCLUSIONS

These findings demonstrate the efficacy of rFVIIIFc for the treatment of acute bleeding episodes in subjects with severe haemophilia A, regardless of treatment regimen.

Dementia knowledge transfer project in a rural area

INTRODUCTION

Rural Scotland has an ageing population. There has been an increase in the number of people with dementia and as the proportion of people aged over 75 years continues to rise, this will increase still further. The Scottish Government has produced a dementia strategy and implementing this will be a challenge for rural Scotland.

METHODS

Transferring academic knowledge into practice is challenging. A Knowledge Transfer Partnership was formed between NHS Highland and the University of Stirling. A literature review was undertaken of the rural dementia literature; local services were surveyed and described; and interviews were undertaken with people with dementia and carers. Work was conducted on training, diagnostic service provision and local policy. Throughout the project, a collaborative approach was used, which aimed at the joint production of knowledge.

RESULTS

Involving University staff in local service development had a substantial impact. Reviewing existing research knowledge and setting it in the context of local services, and of experience of service use, allowed the relevant priorities to be identified. As well as identifying training needs and providing training, the work influenced local decisions on diagnostic service design and standards, and on policy.

CONCLUSION

This embedded engagement model appeared to produce more rapid change than traditional models of use of academic knowledge.

Vascular access type and risk of mortality in a national prospective cohort of haemodialysis patients

BACKGROUND

Central venous catheters (CVC) are a potential source of bacteraemia and have been associated with increased mortality in haemodialysis patients. We aimed to investigate the relationships between haemodialysis vascular access, taking into account changes in vascular access type during patients' lives, and cause specific mortality risk in a national cohort of dialysis patients.

METHODS

Prospective cohort study including all patients receiving haemodialysis in Scotland at annual cross sectional surveys in 2009, 2010 and 2011. Data were collected through the Scottish Renal Registry and by a structured review of case records following death. Cox proportional hazards regression and multivariable logistic regression were used to model survival and risk of death from septicaemia respectively.

RESULTS

Of a cohort of 2666 patients, 873 (32%) died during follow-up. After case-mix adjustment, patients using only tunnelled CVC during follow-up had a higher risk of all cause mortality across all strata of prior renal replacement therapy exposure [adjusted hazard ratio (HR): 1.83-2.08]. Case-mix adjusted risks of cardiovascular death (adjusted HR: 2.20-2.95) and infection-related death (adjusted HR: 3.10-3.63) were also higher in this group. Patients using tunnelled CVCs during follow-up and prior to death had 6.9-fold higher odds of death from septicaemia compared with those using only arteriovenous fistulae or grafts.

CONCLUSION

Compared with an arteriovenous fistula or graft, sustained use of tunnelled CVCs for vascular access is associated with higher risks of all-cause, cardiovascular and infection-related mortality.

Efficacy and safety of certolizumab pegol monotherapy every 4 weeks in patients with rheumatoid arthritis failing previous disease-modifying antirheumatic therapy: the FAST4WARD study

Background:

Tumour necrosis factor α (TNFα) is a proinflammatory cytokine involved in the pathogenesis of rheumatoid arthritis (RA). Treatment with TNFα inhibitors reduces disease activity and improves outcomes for patients with RA. This study evaluated the efficacy and safety of certolizumab pegol 400 mg, a novel, poly-(ethylene glycol) (PEG)ylated, Fc-free TNFα inhibitor, as monotherapy in patients with active RA.

Methods:

In this 24-week, multicentre, randomised, double-blind, placebo-controlled study, 220 patients previously failing ⩾1 disease-modifying antirheumatic drug (DMARD) were randomised 1:1 to receive subcutaneous certolizumab pegol 400 mg (n = 111) or placebo (n = 109) every 4 weeks. The primary endpoint was 20% improvement according to the American College of Rheumatology criteria (ACR20) at week 24. Secondary endpoints included ACR50/70 response, ACR component scores, 28-joint Disease Activity Score Erythrocyte Sedimentation Rate 3 (DAS28(ESR)3), patient-reported outcomes (including physical function, health-related quality of life (HRQoL), pain and fatigue) and safety.

Results:

At week 24, the ACR20 response rates were 45.5% for certolizumab pegol 400 mg every 4 weeks vs 9.3% for placebo (p<0.001). Differences for certolizumab pegol vs placebo in the ACR20 response were statistically significant as early as week 1 through to week 24 (p<0.001). Significant improvements in ACR50, ACR components, DAS28(ESR)3 and all patient-reported outcomes were also observed early with certolizumab pegol and were sustained throughout the study. Most adverse events were mild or moderate and no deaths or cases of tuberculosis were reported.

Conclusions:

Treatment with certolizumab pegol 400 mg monotherapy every 4 weeks effectively reduced the signs and symptoms of active RA in patients previously failing ⩾1 DMARD compared with placebo, and demonstrated an acceptable safety profile.

Trial registration number:

NCT00548834.

"Benign" hypertensive nephrosclerosis

BACKGROUND

Whether benign hypertensive nephrosclerosis (BHN) causes end-stage renal failure (ESRF) is controversial. One reason for this is the lack of biopsy evidence confirming the clinical diagnosis in most cases.

AIM

To investigate whether biopsy-proven BHN leads to ESRF.

DESIGN

Retrospective analysis.

METHODS

We analysed all cases of biopsy-proven BHN from a single centre over a period of 20 years (n = 60), followed-up for a mean +/- SD 6.7 +/- 5.5 years.

RESULTS

Patients were divided into those with stable renal function (n = 17) and those with declining function (n = 43). Mean eGFR at the time of biopsy was lower in the declining function group (29 +/- 3 vs. 44 +/- 4 ml/min/1.73 m(2), serum creatinine 280 +/- 165 vs. 161 +/- 89 mumol/l, p < 0.001), of whom 72% progressed to ESRF. Median renal survival for the whole group was 6.8 years, with 5- and 10-year survivals of 56% and 35%, respectively. Renal survival was significantly affected by initial serum creatinine, and mean systolic and diastolic blood pressures during follow-up period. Mean protein excretion was higher in the declining group, but not significantly so. On multivariate analysis, only diastolic blood pressure during follow-up predicted renal survival (p = 0.017). Median patient survival for the whole group was 9.95 years post renal biopsy, with 5- and 10-year survivals of 70% and 49% respectively. Survival was affected by initial serum creatinine, initial serum albumin and mean systolic blood pressure during follow-up. On multivariate analysis, only initial serum creatinine was significantly correlated with survival (p = 0.017).

DISCUSSION

Biopsy-proven BHN led to ESRF in a high percentage of our patients, and was associated with significant mortality.

Breath condensate ammonium is lower in children with chronic asthma

Exhaled breath condensate pH and ammonium reflect asthmatic status and acute exacerbations in adults. The aim of this study was to assess whether pH and ammonium could reflect asthma and its severity in children. The current study comprised two parts: 1) a cross-section of 74 children with asthma (median age 10.5 yrs) compared with 47 healthy controls (median age 10 yrs); and 2) longitudinal assessment of eight children (mean age 8.5 yrs) admitted with asthma exacerbation. Condensate pH and ammonium were compared with clinical observations. In the cross-sectional part of the study, lower per cent forced expiratory volume in one second was associated with more symptoms and treatment. There was no significant difference between median pH in children with stable asthma (6.05) compared with controls (5.90). Ammonium was significantly lower in children with asthma (median 258 microM) compared with controls (median 428 microM). No association was found between ammonium or pH and lung function or symptom-free days. In the longitudinal study, significant improvements in oxygen saturation and respiratory rate with treatment of an acute exacerbation were not reflected by changes in pH or ammonium. In conclusion, pH does not appear to reflect disease or severity in children with asthma. Ammonium was significantly lower in children with asthma when compared with controls.

Chronic kidney disease: evolving strategies for detection and management of impaired renal function

Nephrologists have long been concerned about late referral of patients with severe kidney disease, and resultant poor outcomes on dialysis. But there is an increasing realisation that mild to moderate chronic kidney disease is far more common than previously appreciated. Furthermore, the main consequence of chronic kidney disease is not progression to dialysis, but increased risk of cardiovascular disease. Chronic kidney disease is at least as common and important a risk factor for cardiovascular disease as diabetes mellitus. The MDRD formula is a well-validated formula to estimate glomerular filtration rate, which is now being widely implemented by clinical chemistry laboratories, and should increase the recognition of chronic kidney disease. The K/DOQI classification of chronic kidney disease has gained international acceptance and provides the structure to guide referral and management. This classification, and associated guidelines, also focus attention on areas where evidence is lacking, and which urgently require research. These current developments will substantially change and improve how chronic kidney disease is identified and managed.

CDP571, a humanized monoclonal antibody to tumour necrosis factor-alpha, for steroid-dependent Crohn's disease: a randomized, double-blind, placebo-controlled trial

BACKGROUND

More than 50% of patients with Crohn's disease become either steroid resistant or dependent. Accordingly, development of new treatments for steroid-dependent Crohn's disease is a research priority.

AIM

To evaluate CDP571, a humanized antibody to tumour necrosis factor-alpha, for the treatment of steroid-dependent Crohn's disease.

METHODS

Patients with steroid-dependent Crohn's disease (n = 271) were enrolled in a 36-week, double-blind, placebo-controlled trial. Steroid dependence was defined as use of prednisolone or prednisone (15-40 mg/day) or budesonide (9 mg/day) for > or =8 weeks, a previous failed attempt to decrease or discontinue steroids within 8 weeks of screening, and a Crohn's Disease Activity Index score of < or =150 points. Patients were randomized to receive intravenous CDP571 10 mg/kg or placebo 8-weekly through to week 32. Steroids were then tapered using a defined schedule. The primary efficacy endpoint was the percentage of patients with steroid sparing, defined as discontinuation of steroid therapy without a disease flare (Crohn's Disease Activity Index score > or =220 points) at week 36.

RESULTS

Steroid sparing occurred in 53 of 181 (29.3%) CDP571 patients and 33 of 90 (36.7%) placebo patients (P = 0.24). Adverse events occurred at similar frequencies in both treatment groups.

CONCLUSIONS

CDP571 was ineffective for sparing steroids in patients with steroid-dependent Crohn's disease. CDP571 was well tolerated.

Lemierre's syndrome: the link between a simple sore throat, sore neck and pleuritic chest pain

An unusual case of tonsillitis which showed progression to this rare syndrome despite treatment with intravenous antibiotics. Lemierre's syndrome is a rare condition characterised by a triad of: sepsis, thrombophlebitis of the internal jugular vein along with pleuropulmonary and/or distant metastatic abscesses. Diagnosis rests on a high index of suspicion and is confirmed by culture of Fusobacterium spp. from blood or infected sites. Radiological investigations are established aids for confirmation of diagnosis. Treatment is with appropriate antibiotics for at least 6 weeks and surgical drainage of abscesses if required. This case has been presented to highlight the mode of presentation, diagnostic tools employed and the management of the complications that featured in this condition.

Dementia care provision in rural Scotland: service users' and carers' experiences

There has been global neglect of service users' and carers' experiences of dementia care provision in rural areas. The present paper draws on a qualitative study of service provision for people with dementia and their carers in remote and rural Scotland. It draws on interviews with 15 people with dementia and 16 carers to explore their views about health and social dementia care service provision in rural Scotland. A further 14 carers of people with dementia participated in one of three focus groups. The paper discusses perceived gaps in services as well as positive aspects of dementia service provision which service users attribute to living in a rural area. The important issues this raises for the development of dementia care provision in rural areas are briefly discussed.

Intravenous CDP870, a PEGylated Fab' fragment of a humanized antitumour necrosis factor antibody, in patients with moderate-to-severe Crohn's disease: an exploratory study

BACKGROUND

CDP870 is a PEGylated Fab' fragment of a humanized monoclonal antibody that neutralizes tumour necrosis factor-alpha.

AIM

To evaluate the safety and efficacy of a single intravenous dose of CDP870 or placebo over a 12-week period in patients with moderate-to-severe Crohn's disease.

METHODS

Ninety-two adult patients with Crohn's disease (Crohn's Disease Activity Index: 220-450 points) were randomized to receive CDP870 [1.25 (n = 2), 5 (n =26), 10 (n = 17) or 20 mg/kg (n = 23)] or placebo (n = 24). Crohn's Disease Activity Index scores were determined at weeks 0, 2, 4, 8 and 12. The primary end-point was the percentage of patients achieving clinical response [i.e. a decrease in Crohn's Disease Activity Index score > or = 100 points or remission (Crohn's Disease Activity Index score: < or =150 points)] at week 4 in the intent-to-treat population.

RESULTS

The percentage of patients achieving the primary end-point was comparable across all treatment groups (56.0%, 60.0%, 58.8% and 47.8% for placebo, CDP870 5, 10 and 20 mg/kg, respectively). The remission rate at week 2 was 47.1% with CDP870 10 mg/kg vs. 16.0% for placebo (P = 0.041). All treatments were well-tolerated: adverse events, reported by 43 patients treated with CDP870 and 15 patients treated with placebo, were mainly mild-to-moderate in intensity. There were no infusion reactions.

CONCLUSIONS

A single intravenous dose of CDP870 was well-tolerated by patients with Crohn's disease. While no statistically significant difference in clinical response rates between CDP870 and placebo was observed, clinical benefit in terms of remission was demonstrated.

CDP571, a humanised monoclonal antibody to tumour necrosis factor alpha, for moderate to severe Crohn's disease: a randomised, double blind, placebo controlled trial

BACKGROUND

Targeting tumour necrosis factor alpha (TNF-alpha) has demonstrated efficacy in Crohn's disease.

AIM

To evaluate CDP571, a humanised antibody to TNF-alpha, for treating active Crohn's disease.

PATIENTS

A total of 396 patients with moderate to severe Crohn's disease.

METHODS

In a 28 week, randomised, double blind, placebo controlled trial, patients received intravenous CDP571 (10 mg/kg) or placebo every eight weeks to week 24. The primary outcome measure was clinical response (a decrease in the Crohn's disease activity index (CDAI) to > or =100 points or remission (CDAI score < or =150 points)) at week 28. A secondary outcome measure was clinical response (using the same definition) at week 2.

RESULTS

Clinical response occurred at week 28 in 80/263 (30.4%) CDP571 patients and 31/132 (23.5%) placebo patients (p = 0.102). Clinical response at week 2 occurred in 90/263 (34.2%) CDP571 patients and 28/132 (21.2%) placebo patients (p = 0.011). Post hoc exploratory subgroup analysis of 159 patients with baseline C reactive protein (CRP) > or =10 mg/l demonstrated significant differences between CDP571 and placebo in clinical response rates at weeks 2 (CDP571, 50/101 (49.5%); placebo, 9/58 (15.5%); p<0.001) and 28 (CDP571, 29/101 (28.7%); placebo, 7/58 (12.1%); p = 0.018). Adverse events occurred at similar frequencies in both treatment groups.

CONCLUSIONS

CDP571 is modestly effective for short but not long term treatment of unselected patients with moderate to severe Crohn's disease. The clinical relevance of this short term effect is unclear. Post hoc analysis suggests both short and long term efficacy of CDP571 in patients with elevated baseline CRP (> or =10 mg/l). CDP571 is well tolerated.

Measuring the well-being of people with dementia living in formal care settings: the use of Dementia Care Mapping

Over the years there have been advances in the quality of care provision for people with dementia. How to measure the impact of care on the person with dementia has challenged researchers as, until recently, no evaluation tool offered a comprehensive overview of the behaviour patterns and well-being of persons with dementia. Dementia Care Mapping (DCM) is a tool used by care practitioners and researchers to capture both the process (behaviours) and outcome (well-being) of care and is therefore of use as a tool to evaluate quality of care. This study aims to assess, through DCM, the experience of dementia care provision in residential and nursing homes in two voluntary organizations in England. The data illustrates similarities in the well-being and behaviour patterns of 76 persons with dementia living in six care settings throughout England. Examples of instances when people with dementia were "put down" and when well-being was enhanced, are outlined. The homes in the study were meeting the physical care but not the broader psychosocial care needs of the observed residents. The action taken by the organizations as a result of the DCM evaluations is summarized.

Influenza vaccination in asthma: a primary care experience

BACKGROUND

Despite the recommendation of the Department of Health that patients with asthma receive annual vaccination against influenza, uptake remains unsatisfactory with many patients suspicious that vaccination is harmful.

AIM

To examine the effect of influenza vaccination on asthmatic patients typical of a general practice setting.

METHOD

A multicentre study with 56 patients participating from 14 practices in England and Scotland. Patients completed peak expiratory flow rate (PEFR) and symptom diaries for two weeks before and two weeks after influenza vaccination.

RESULTS

A non-significant fall in baseline PEFR of 10.5 l/min, from an average of 431.5 l/min, was observed after influenza vaccination, representing a 2% change from baseline. A significant increase in night time reliever use of 0.17 puffs per night (P < 0.01) was found. Non-significant increases in number of nights per week with sleep disturbed due to asthma, severity of night-time and day-time symptoms, and day-time reliever use were also noted.

CONCLUSION

Influenza is an important cause of morbidity and mortality in asthmatics. This study confirms the safety of influenza vaccination in patients with asthma typical of those seen in primary care. General practitioners need not hesitate in recommending this valuable intervention to their asthmatic patients and should consider ways in which uptake can be improved.

The effect of long, slow haemodialysis on patient survival

BACKGROUND

Long, slow haemodialysis (24 h/week) has been associated with excellent patient survival and reduced cardiovascular mortality. Comparisons of patient survival have only been possible with registry data and other published series which do not control for individual patient characteristics. This retrospective study compares actuarial patient survival between a unit using long, slow haemodialysis (Tassin) and one employing 'conventional' haemodialysis (Nottingham).

METHODS

All patients undergoing haemodialysis at each centre since 1980 were included (Tassin, 452 patients; Nottingham, 282 patients). Actuarial curves of patient survival were calculated by the life-table method and log rank test was used to compare data. Patients were grouped as follows: standard (SRD) and non-standard (NSRD) renal diseases; diabetics and non-diabetics; patients with and without cardiovascular antecedents; risk stratification based on age and comorbidity.

RESULTS

Overall survival was significantly better in Tassin. This difference was also noted for patients with SRD and non-diabetics (both P < 0.001) and for those with (P = 0.007) and without (P < 0.001) cardiovascular antecedents. Survival did not differ significantly for NSRD and diabetics. Survival was better in Tassin in low-risk (P < 0.001) and medium-risk (P < 0.001) groups, but not for high-risk (risk stratification).

CONCLUSIONS

Overall survival is increased on long, slow haemodialysis. Although the benefits are seen in the most favourable prognostic categories, they are also present in patients with comorbid illness (medium-risk group) and pre-existing cardiovascular disease.

Renal cell carcinoma presenting as nephrotic syndrome

A 64-year-old woman presenting with a history of increasing oedema was found to have nephrotic syndrome with a 24-hour urinary protein excretion of 20.7 g and renal impairment with an initial serum creatinine level of 197 mumol/l (2.16 mg/dl). A renal tumour was demonstrated by ultrasound scanning and subsequent nephrectomy revealed a renal carcinoma extending as far as the resected end of the renal vein. Histology of the kidney not involved by the tumour showed normal light microscopic appearances, with electron microscopy demonstrating foot process fusion, suggesting a diagnosis of minimal-change nephropathy. Nephrotic syndrome is a rare complication of renal cell carcinomas, and it is particularly uncommon for minimal change nephropathy to be associated with solid tumours.

Intensive treatment of renal failure in patients with myeloma

We have reviewed our experience in the management of myeloma patients who present with features of severe renal impairment, to examine the role of intensive treatment of the renal failure, and to assess the role of renal biopsy. Between March 1983 and August 1991, 16 patients, who were subsequently diagnosed as having myeloma, presented to the Department of Renal Medicine for investigation of renal failure; nine with symptoms of uraemia and seven with pneumonia, bone pain, emphysema, or ischaemic heart disease. Renal biopsy was performed on 14 patients. Eleven patients had myeloma cast nephropathy, two of whom had concurrent hypertensive nephropathy, two patients had light chain deposition disease, and one patient had interstitial nephritis. Renal function improved in six patients with aggressive rehydration, but three of them subsequently required dialysis. In all 11 patients required dialysis, two short-term and nine long-term. Seven patients were given conventional melphalan and prednisolone and nine patients received VAMP as induction cytotoxic chemotherapy. Five of the VAMP sub-group received interferon alpha 2b as maintenance therapy. The median renal survival was five months (range 0-36 months) and median overall survival was 20 months (range 1-54 months). We conclude that intensive treatment, including dialysis, in myeloma patients with renal failure may result in survival durations approaching those of unselected myeloma patients, and a significant proportion will enjoy a reasonable quality of life.

Complement activation by cellulosic dialysis membranes

AIMS

To assess the effect of cellulosic dialysis membranes on the production of complement degradation products to determine to the role of the classical pathway.

METHOD

Complement activation was studied in 33 patients during a single haemodialysis session using cellulosic membranes. Pre- and post-dialysis plasma EDTA valves of C3, C4, C3dg, C4d and C reactive protein (CRP) were measured. Statistical analysis was done using the Wilcoxon signed rank test.

RESULTS

Post-dialysis C4 (p = 0.0003), C3dg (p < 0.0001), and C4d (p = 0.003) concentrations were increased compared with pre-dialysis values. There was no significant change in C3 (p = 0.095) and CRP (p = 0.13) values. Post-dialysis C3dg and C4d concentrations correlated significantly (p = 0.007). IgG, an undialysed molecule, was quantified and post-dialysis valves were significantly higher than those before dialysis (p = 0.0002), indicating a degree of haemoconcentration. To remove this effect, the C3:IgG, C4:IgG, C3dg:IgG, C4d:IgG and CRP:IgG ratios were calculated. Compared with pre-dialysis values, post-dialysis C3dg:IgG and C4d:IgG ratios were increased and C3:IgG decreased significantly. No change was observed in C4:IgG and CRP:IgG ratios.

CONCLUSION

This study confirms that significant complement activation takes place following dialysis with cellulosic membranes. This is denoted by an increase in C3dg. This was paralleled by a rise in C4d, implying a contributory role for the classical pathway. Concomitant post-dialysis increases in IgG and C4 indicate a degree of haemoconcentration; but removal of this effect shows that C3dg and C4d are increased following dialysis--suggesting classical, in addition to alternative, pathway activation.

Clinical features of benign hypertensive nephrosclerosis at time of renal biopsy

Although hypertension accounts for approximately 15-20% of end-stage renal disease and renal impairment occurs in 15% of patients with essential hypertension, there are few data available on the clinical features of patients with benign hypertensive nephrosclerosis, the histological consequence of hypertension on the kidney. To determine its prevalence on renal biopsy and its clinical features (including proteinuria and renal function), we used the U.K. MRC Glomerulonephritis Registry of 7339 biopsies from 20 centres to define all patients with benign hypertensive nephrosclerosis. In patients with no co-existing disease, 185 biopsies were classified solely as benign hypertensive nephrosclerosis (2.5%). Sixty-nine percent of patients were male and 72% aged over 50 years. Sixty-four percent had diastolic blood pressure above 90 mmHg and severe hypertension (diastolic > 120 mmHg) was present in 9%. Protein excretion of > 1.5 g/day was noted in 40%, with 22% excreting > 3 g/day. Eighteen percent had serum albumin values under 30 g/l. Eighty-one percent had serum creatinine > 120 mumol/l; in 51% this was > 250 mumol/l. There was significant correlation between serum creatinine and systolic blood pressure at time of biopsy (p = 0.01) and between serum creatinine and serum albumin (p = 0.001). Benign hypertensive nephrosclerosis accounts for 2.5% of all registered biopsies. Significant proteinuria is a common finding and proteinuria within the nephrotic range does occur. Systolic blood pressure appears to influence serum creatinine levels. Hypertensive nephropathy should be considered in all patients with heavy proteinuria and renal impairment.

The short term effects of oral labetalol in patients with chronic renal disease and hypertension

This double-blind, controlled, crossover study compared the effects on blood pressure control, glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) of labetalol, methyldopa and placebo in patients with chronic renal disease and hypertension. When compared with placebo, BP was significantly lower during treatment with both labetalol and methyldopa (P greater than 0.05) but did not differ significantly between the two active treatment periods; post-exercise heart rates were also significantly lower on labetalol than placebo (P less than 0.05). After treatment with labetalol, ERPF was significantly greater than with the placebo (P less than 0.05) but did not differ significantly between the active treatments. GFR did not differ significantly between the three groups. No significant differences were observed in haematology or liver function test results on labetalol compared with placebo. Labetalol is a safe and effective antihypertensive in patients with hypertension associated with chronic renal disease. In the short term it leads to an increase in ERPF which may be beneficial for such patients.

Diabetic glomerulosclerosis without diabetes mellitus--two case reports and a review of the literature

The duration of diabetes mellitus and presence of hyperglycaemia appear to be important in the development of diabetic nephropathy. The presence of nodular glomerulosclerosis is thought to be pathognomonic of the condition. We report two patients with histological features of diabetic glomerulosclerosis who did not have diabetes mellitus. The discussion reviews the literature and concludes that diabetic glomerulosclerosis with normal glucose tolerance is very rare and that most cases are due to overt diabetes mellitus or a degree of glucose intolerance. However, cases with only minimal glucose intolerance suggest that factor(s) other than hyperglycaemia are responsible for diabetic renal damage.

Very late recurrence of renal vasculitis

We report a case of renal vasculitis with a relapse occurring 9 and a half years after the original presentation. The plasma creatinine six months before relapse was only 118 mumol/l. During the initial illness there was histological evidence of glomerular damage but at the time of relapse renal biopsy showed the remaining glomeruli to be normal with the destructive process causing fibrinoid necrosis of arteries.

Post-transplant erythrocytosis and immunosuppression with cyclosporin: a case-control study

Review of 142 renal transplant recipients treated with cyclosporin and prednisolone revealed 23 patients with post-transplant erythrocytosis. The clinical characteristics of these patients were compared with 23 cyclosporin/prednisolone-treated control subjects matched for age, sex, and duration of transplant. Erythrocytosis developed between 6 weeks and 30 months (median 12 months) after transplant. It persisted in 16 patients and resolved spontaneously in five. In two patients the decrease in haematocrit was associated with acute leukaemia in one and sudden deterioration of renal function in the other. In the study group there were fewer HLA (A, B and DR) mismatches (P less than 0.05) and greater pretransplant haematocrit (P less than 0.01) than in the control group. Other clinical factors--previous allografts, panel reactive cytotoxic antibodies, duration and type of dialysis, transplant function, pre- and post-transplant blood pressure, number of rejection episodes, cyclosporin concentration and dose, smoking habits and use of diuretics--did not differ significantly between the two groups. In our experience, erythrocytosis in cyclosporin-treated patients is a relatively common phenomenon and does not, in general, resolve spontaneously. It is unrelated to transplant function or rejection episodes but affects patients with well-matched kidneys and elevated pretransplant haematocrit values.

The detection of antibodies in pregnancy: a comparison of two assay systems

In this study we have compared the ability of two assay systems, erythrocyte antibody rosette inhibition (EAI) and cellular enzyme-linked immunospecific assay (CELISA) to detect maternal alloantibody activity during pregnancy. Antibody activity to antigens on paternal lymphocytes was present in nine of 23 primigravid sera tested by EAI and in seven of 23 by CELISA. In multiparous sera, antibodies directed to paternal lymphocytes were detected in 11 of 15 individuals by EAI and in six of 15 by CELISA. The techniques correlated significantly when assaying the humoral response in sera from multiparous women. The lack of correlation when assaying primigravid sera suggests that both assays encounter difficulty in detecting the low titres of antibodies present.

Fetus as an allograft: noncytotoxic maternal antibodies to HLA-linked paternal antigens

A cellular enzyme-linked immunospecific assay (CELISA) was used to monitor maternal humoral responses in human pregnancy. Non-cytotoxic IgG antibodies to paternal lymphocytes were detected in sera from 6 of 20 normal first trimester primigravidae and 6 of 13 multiparae. No antibody activity against lymphocytes from their partners was detected in sera from any of the 15 nulliparous women. The differences in antibody response between primigravidae and nulliparae (P = 0.024) and between multiparae and nulliparae (P = 0.005) were statistically significant. Lymphocytotoic antibodies to T- and B-lymphocytes were present in sera from three multiparae, but from none of the women in the other two groups. Family studies indicated that the non-cytotoxic pregnancy-associated maternal antibodies were directed to HLA-linked antigens (P less than 0.001). Evidence obtained using cell panels and platelet absorption suggested, however, that these antibodies were not directed to the currently recognized HLA specificities (HLA-A, -B, -C, or -DR).