Avoiding steroids in pediatric renal transplantation: long-term experience from a single centre

We report our experience in pediatric renal transplantation avoiding steroids whenever possible. Immunosuppression consisted of an initial induction with antithymocyte globulin followed by maintenance therapy with a calcineurin inhibitor and MMF. Steroids were only given to selected patients because of the primary disease, recurrence, rejection, or PTLD. Thirty-four transplants grafted into 32 recipients between 1995 and 2005 were followed for a median of 3.5 yr (range 1-9.8). All patients survived. Graft rejection occurred in 10 cases during the first year post-transplantation and graft survival at one, five, and seven yr was 97, 88 and 88%, respectively. Steroids were given to half of the patients (n = 16); in nine cases due to rejection. Only four patients (13%) were continuously on steroids. Calculated GFR at one to five yr post-transplant were 73, 74, 68, 64, and 70 mL/min/1.73 m(2). Unfortunately PTLD occurred in three patients, but all survived with functioning grafts. Accordingly, our findings indicate that steroid avoidance in pediatric renal transplantation is possible with good results with respect to acute graft rejection as well as long-term graft survival.

The influence of folic acid supplement on the outcome of pregnancies in the county of Funen in Denmark. Part II. Congenital anomalies. A randomised study

OBJECTIVE

The effect of folic acid supplement on the prevalence of congenital anomalies was studied in a Danish population.

MATERIAL AND METHODS

From 1983 to 1986 all Danish women resident in the county of Funen were offered free folic acid when pregnant or planning a pregnancy. Folic acid dose was randomised to 2.5 or 1.0 mg. A randomised control group was not feasible for ethical reasons. Hospitals, midwives and most general practitioners cooperated to procure information on close to all pregnancies and congenital anomalies were recorded.

RESULTS AND CONCLUSIONS

In a total of 14,021 pregnancies resulting in child birth 8184 women (58.4%) had folic acid with randomisation. Supplement was started in the randomised group before the last menstrual period in 1359/8184 (16.6%) and in the first 19 weeks of pregnancy in 6825/8184 (83.4%). The prevalence of congenital anomalies was 224 in 8293 children (27.0/1000). No dose-dependent differences were found in either total anomalies or in those specific malformations which have been reported to occur with reduced prevalence with periconceptional folic acid. The result was probably influenced by a start of supplement too late to affect malformation development in many cases and by the high level of both folic acid doses given compared to usual recommendations. Pregnancies without folic acid supplement showed prevalences similar to the supplemented groups.

The influence of folic acid supplement on the outcome of pregnancies in the county of Funen in Denmark. Part I

OBJECTIVE

To determine whether a supplement of folic acid given preconceptionally or early in pregnancy had any influence on, birth weight, incidence of preterm labour, low birth weight and small for gestational age. Furthermore, the aim was to elucidate, whether the outcome differed following the administration of two different dosages of folic acid, namely 2.5 and 1.0 mg.

MATERIAL

All women in the childbearing age living on the island of Funen, Denmark (population 500,000) were offered a supplement of folic acid over a period of 3 years and 3 months. 14,021 women, who gave birth to 13,860 single-born and 325 multiborn children, were registered. A total of 8184 women took part in the double-blind randomized trial: 2310 had a supplement of folic acid without being randomized and 2721 women received no folic acid supplement. No information regarding the use of folic acid was available in 806 pregnancies. Abortions (512) were excluded.

RESULTS AND CONCLUSIONS

A supplement 1.0 mg folic acid had the same effect as 2.5 mg. The effects of supplementing the diet with folic acid given preconceptionally or in the first half of pregnancy in an affluent Northern country were a slight increase of birth weight and a decrease in the incidence of preterm labour, infants with low birth weight and small for gestational age. The greatest effect was seen in the groups receiving folic acid preconceptionally.

The influence of folic acid supplement on the outcome of pregnancies in the county of Funen in Denmark. Part III. Congenital anomalies. An observational study

OBJECTIVE

The effect of folic acid supplement on the prevalence of congenital anomalies was studied in a Danish population.

MATERIAL AND METHODS

From 1983 to 1986 all Danish women resident in the county of Funen were offered free folic acid when pregnant or planning a pregnancy. Data concerning the starting time of folic acid supplement and congenital anomalies were recorded on close to all pregnancies. Children of folic acid supplemented mothers were subdivided as to start of supplement with dividing lines at week 7 and week 11 calculated from the last menstrual period. Structural malformations were subdivided into an early group with malformation development in the first 7 weeks from the last menstrual period and a late group where malformations develop in weeks 8 to 11.

RESULTS

In a total of 14,021 pregnancies 10,494 pregnant women (74.8%) had folic acid supplement. No folic acid was taken by 2721 women (19.4%) and in 806 cases (5.8%) information was lacking. The prevalence of congenital anomalies was 380 in 14,185 children (26.7/1000). Children whose mothers started folic acid supplement before the 7th week of pregnancy showed a significantly lower prevalence of the malformations which develop in the first 7 weeks, when compared to pregnancies with a later start of supplement. The result was interpreted as a clearcut trend.

The effect of in vitro procedures on cyclic AMP accumulation in human leucocytes

The aim of this study was to investigate the effect of various methodological procedures or protocols on cyclic AMP formation in human leucocytes. The data showed that: (1) ATP content and lactate production was unaffected by hypotonic lysis during leucocyte isolation; (2) there was a linear relation between cell number/sample and the production of cyclic adenosine 3':5'-monophosphate (cAMP); (3) the interindividual variation markedly affected cAMP production during long observation periods (years), whereas day-to-day variation within a week was less important; (4) whole blood could be stored for up to 4 h (at 4 degrees C or 23 degrees C) without affecting cAMP accumulation; (5) isolated MNL could be stored for up to 2 h (at 4 degrees C) without affecting cAMP accumulation; and finally that (6) choice and concentration of phosphodiesterase inhibitors markedly influenced the basal and isoprenaline-induced cAMP accumulation. Evidence is provided that the rate of cAMP accumulation in response to isoprenaline of cells incubated in the presence of 2.5 mM 3-isobutyl-1-methyl-xanthine (IBMX) is reflecting the rate of cellular cAMP production.

Beta-adrenoceptor responsiveness in intact leukocytes from adults and newborn infants; effect of phosphodiesterase inhibitors

Intact mononuclear and polymorphonuclear leukocytes from adults and newborn infants were used to estimate the beta 2-adrenoceptor responsiveness in vitro. The accumulation of cAMP in response to receptor stimulation by isoprenaline was used as a measure of the receptor responsiveness. The relevance of the method is dependent on the activity of the cAMP phosphodiesterase inside the cells. The xanthine derivatives, theophylline (4 mmol l-1) and 3-isobutyl-l-methyl-xanthine (0.1-2.5 mmol l-1), were used to inhibit the cAMP phosphodiesterase activity. It appears that 3-isobutyl-l-methyl-xanthine at 2.5 mmol l-1 inhibits the phosphodiesterase activity almost completely. By use of this concentration no age-dependent changes in the isoprenaline-stimulated cAMP accumulation in mononuclear and polymorphonuclear leukocytes from adults and newborn infants could be demonstrated.

[Nephropathia epidemica. Hantavirus and acute renal insufficiency]

Puumala virus belongs to the hantavirus group and as other members of the group it can cause acute renal insufficiency. Other hantaviruses are responsible for Korean hemorrhagic fever and other hemorrhagic fevers with renal involvement. In Scandinavia, hantavirus nephropathy is better known as nephropathia epidemica. Hantavirus cause asymptomatic infections in mice and rats and the virus is thought to be transmitted to man via inhalation of desicated saliva, urine or feces from infected animals. In the other Nordic countries, the bank vole (Clethrionomys glareolus) is the commonest natural host. Laboratory infections from rats have been reported from all over the world. The disease presents with fever, back and/or abdominal pain, acute renal insufficiency and a bleeding tendency. The latter is usual less pronounced in the European than in the Asian forms of hantavirus infection. The disease is commoner in men and is endemic in forested areas. The greatest incidence is seen in those years when the numbers of mice are greatest. The mortality in nephropathia epidemica appears to be less than 0.5% in contrast to a mortality of about 10% in Korean hemorrhagic fever. Diagnosis is made by demonstration of a significant increase in antibody titer to hantavirus. Treatment is symptomatic and consists primarily of restitution of fluid and electrolyte balance, at times with dialysis. After recovery from hantavirus infection renal function returns to normal. The incidence and prevalence of nephropathia epidemica in Denmark are unknown. The first two cases of Puumala virus infection in Denmark are reported.

Effect of folic acid supplementation on small-for-gestational-age infants born at term

The effect of 250 micrograms folic acid (FA)/day or placebo given to 21 small-for-gestational-age infants born at term was studied during the first 3 months of life. The design of the study was double blind with random allocation. No randomization was performed in respect of breast-feeding or formula-feeding with a folate content of 60-70 micrograms/l. No significant differences were observed in haemoglobin concentration, haematocrit, weight and length between FA-supplemented and non-supplemented infants. A negative correlation was demonstrated between gestational age and erythrocyte folate (E-folate) concentration at 1 week. E-folate content was higher when no supplement was given in breast-fed than in formula-fed infants.

Adrenal function in children with bronchial asthma treated with beclomethasone dipropionate or budesonide

The effect of inhaled beclomethasone dipropionate and budesonide on the adrenal function was studied in 30 children (aged 7 to 15 years) with mild bronchial asthma. The trial was designed as a prospective double-blind parallel study of the effect of stepwise increase of either beclomethasone dipropionate or budesonide from 200 micrograms through 400 micrograms, to 800 micrograms daily in three consecutive periods of 4 weeks. At the end of each period, the adrenal stress response was evaluated by measurements of serum cortisol and androstenedione during a short adrenocorticotropic hormone test. The unstimulated diurnal production of glucocorticosteroids was assessed by measurements of free cortisol in 24-hour urine samples. Free cortisol in urine was found a valid measure of the total diurnal excretion of cortisol metabolites, since it exhibited a good correlation to the fractional cortisol metabolites measured by gas chromatography. The adrenal response to adrenocorticotropic hormone stimulation was unaffected by treatment or dose. The unstimulated diurnal production of glucocorticosteroids demonstrated a highly significant dose-related suppression in response to the inhaled steroids. No significant difference was found between the two topical steroids (probability value 5.3%), and yet the suppression was apparent in the group of children treated with beclomethasone dipropionate but not in the group of children treated with budesonide. Further studies are desirable in order to ascertain whether budesonide offers an improved ratio between beneficial anti-inflammatory effect and unwanted systemic activity.

Passage of dietary antigens into the blood of children with coeliac disease. Quantification and size distribution of absorbed antigens

The uptake of ovalbumin (OA) from egg and beta-lactoglobulin (BLG) from cow's milk into the blood was investigated for seven hours after a test meal in five children with coeliac disease on a gluten free diet and after gluten challenge, and in five children with normal jejunal mucosa. Ovalbumin was detectable by ELISA in three of five coeliac children (maximal concentrations 8-178 ng/ml serum) and in five of five controls (maximal 4-91 ng/ml serum). Beta-lactoglobulin was detected in three of five coeliac children (maximal 0.6-6 ng/ml serum) and in two of five controls (maximal 0.5 and 50 ng/ml serum). No clear relationship was seen between maximal antigen concentrations and titres of serum IgG or IgA antibodies determined by ELISA, or as percentage antigen binding in a Farr type radioimmunoassay. Ovalbumin and beta-lactoglobulin was seen in serum of all coeliac patients and controls by HPLC fractionation in combination with ELISA, either in high MW fractions, or at the Mr of native OA and BLG, respectively. In one control degradation products (about 17 kD) of BLG were detectable in serum. The serum concentrations of OA and BLG were increased on gluten challenge in four or five coeliac children, indicating increased macromolecular passage through the gut mucosa in untreated coeliac disease.

Reduced albumin binding of MADDS--a measure for bilirubin binding--in sick children

The reserve albumin concentration for binding of MADDS (monoacetyldiaminodiphenyl sulphone) in plasma is used as a measure of the reserve albumin concentration for binding of unconjugated bilirubin. The aim of the present study was to investigate whether a reduction in the reserve albumin concentration for binding of MADDS could exist in sick children after 5 months of age, where the bilirubin binding properties of the albumin has reached the adult level. The material included 75 children, 1-15 years of age with mild infections, severe bacterial infections, acute viral hepatitis, chronic hepatic diseases or uraemia, and a control group of 22 healthy children. The reserve albumin concentration was significantly lower in children with severe bacterial infections, acute viral hepatitis, and uraemia, than in healthy children (p less than 0.01), while the reserve albumin concentration in children with mild infections and chronic hepatic diseases did not differ significantly from that of the control group (p greater than 0.05). The total albumin concentration in plasma in either of the groups of sick children did not differ significantly from that of the healthy children. The plasma concentration of unconjugated bilirubin was elevated in the group of children with acute viral hepatitis, but not enough to influence the concentration of reserve albumin for binding of MADDS to a significant degree. The reserve albumin concentration was significantly lower in children with acute viral hepatitis than in children with severe bacterial infections (p less than 0.05).

Serum IgG subclass antibodies to gliadin and other dietary antigens in children with coeliac disease

IgG subclasses of antibodies to the dietary antigens gliadin, glycgli (a gluten component), ovalbumin (OA) and beta-lactoglobulin (BLG) were quantified in children with coeliac disease (CD), nine on a gluten-containing diet, 15 on a gluten-free diet, and in appropriate controls. In addition, total serum IgG subclasses were measured. IgG1 and IgG3 antibodies to gluten and glycgli were detected in 9/9 and 8/9 CD-patient on a gluten-containing diet, respectively, and in 4/15 and 6/15 patients on a gluten-free diet. None of the controls had appreciable levels of IgG1 antibodies and only 1/22 of the controls had IgG3 antibodies to gliadin and glycgli. IgG2 and IgG4 antibodies to the same antigens were found in a few coeliacs and controls. Consecutive samples from coeliac children (8 patients) showed a clear relation between the exposure to gluten and a rise in IgG1 (8/8) and IgG3 antibody levels (7/8). In contrast, IgG antibodies to OA and BLG were almost exclusively of the IgG1 and IgG4 subclasses. The highest levels were found in children with CD, but the differences between the groups were not significant. Total serum IgG subclasses did not differ between the groups, but the IgG2 and IgG4 levels in most coeliac children were low. The production of IgG1 and IgG3 antibodies to gluten components may be an important precondition for the development of coeliac disease in susceptible individuals.

Terbutaline depot tablets in childhood asthma. A double-blind controlled study

Thirty children 8-13 years old, with perennial asthma and with a reversibility of greater than or equal to 20% in lung function (FEV1) were given a sustained-release preparation of terbutaline sulphate 5 mg twice a day and ordinary tablets 2.5 mg three times a day; each treatment lasted 1 week. The design of the study was double-blind, cross-over, with a randomized allocation of the drugs. Both drugs improved the lung function significantly. The children had significantly less coughing during the night when they took depot tablets than when they took ordinary tablets. The side effects were few with both treatments. Most of the patients preferred the depot tablets.

Diatoms and drowning--once more

The content of diatoms in 5 samples: lung-, kidney- and liver-tissue plus columna- and femur-marrow from each of four drowned and four non-drowned persons has been investigated. Diatom valves were found in all the samples. It seems, however, impossible to point out any characteristic differences between the composition of the diatom 'flora' in drowned and non-drowned persons. Consequently it will not be possible by means of diatoms to prove that a person died by drowning.

Arthrography of the ankle. Value in diagnosis of rupture of the lateral ligaments

Arthrography was performed in 105 cases with freshly sprained ankles and signs of rupture of the anterior talofibular ligament. They were subsequently operated upon. The arthrographic films were examined retrospectively to assess the value of different criteria for the differential diagnosis between rupture of the anterior talofibular ligament and combined rupture of this and the calcaneofibular ligament. The diagnostic value of arthrography was found to be high in isolated rupture of the anterior talofibular ligament, and is acceptable in the combined ruptures.