Standardizing nomenclature in regional anesthesia: an ASRA-ESRA Delphi consensus study of upper and lower limb nerve blocks

BACKGROUND

Inconsistent nomenclature and anatomical descriptions of regional anesthetic techniques hinder scientific communication and engender confusion; this in turn has implications for research, education and clinical implementation of regional anesthesia. Having produced standardized nomenclature for abdominal wall, paraspinal and chest wall regional anesthetic techniques, we aimed to similarly do so for upper and lower limb peripheral nerve blocks.

METHODS

We performed a three-round Delphi international consensus study to generate standardized names and anatomical descriptions of upper and lower limb regional anesthetic techniques. A long list of names and anatomical description of blocks of upper and lower extremities was produced by the members of the steering committee. Subsequently, two rounds of anonymized voting and commenting were followed by a third virtual round table to secure consensus for items that remained outstanding after the first and second rounds. As with previous methodology, strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement.

RESULTS

A total of 94, 91 and 65 collaborators participated in the first, second and third rounds, respectively. We achieved strong consensus for 38 names and 33 anatomical descriptions, and weak consensus for five anatomical descriptions. We agreed on a template for naming peripheral nerve blocks based on the name of the nerve and the anatomical location of the blockade and identified several areas for future research.

CONCLUSIONS

We achieved consensus on nomenclature and anatomical descriptions of regional anesthetic techniques for upper and lower limb nerve blocks, and recommend using this framework in clinical and academic practice. This should improve research, teaching and learning of regional anesthesia to eventually improve patient care.

Standardizing nomenclature in regional anesthesia: an ASRA-ESRA Delphi consensus study of abdominal wall, paraspinal, and chest wall blocks

BACKGROUND

There is heterogeneity in the names and anatomical descriptions of regional anesthetic techniques. This may have adverse consequences on education, research, and implementation into clinical practice. We aimed to produce standardized nomenclature for abdominal wall, paraspinal, and chest wall regional anesthetic techniques.

METHODS

We conducted an international consensus study involving experts using a three-round Delphi method to produce a list of names and corresponding descriptions of anatomical targets. After long-list formulation by a Steering Committee, the first and second rounds involved anonymous electronic voting and commenting, with the third round involving a virtual round table discussion aiming to achieve consensus on items that had yet to achieve it. Novel names were presented where required for anatomical clarity and harmonization. Strong consensus was defined as ≥75% agreement and weak consensus as 50% to 74% agreement.

RESULTS

Sixty expert Collaborators participated in this study. After three rounds and clarification, harmonization, and introduction of novel nomenclature, strong consensus was achieved for the names of 16 block names and weak consensus for four names. For anatomical descriptions, strong consensus was achieved for 19 blocks and weak consensus was achieved for one approach. Several areas requiring further research were identified.

CONCLUSIONS

Harmonization and standardization of nomenclature may improve education, research, and ultimately patient care. We present the first international consensus on nomenclature and anatomical descriptions of blocks of the abdominal wall, chest wall, and paraspinal blocks. We recommend using the consensus results in academic and clinical practice.

Post Renal Transplant Castleman’s Disease Resolved After Graft Nephrectomy: A Case Report

Angiofollicular lymphoid hyperplasia (Castleman's disease) is a lymphoproliferative process thought to be mediated by overexpression of II interleukin-6. Castleman's disease has two variants: Castleman's disease has two variants: Hyaline vascular type and plasma cell variant (multicentric Castleman's disease). The hyaline vascular type tends to be localized, and the plasma cell variant shows more systematic signs and carriers a worse clinical prognosis. Castleman's disease is associated with B-cell lymphoma, Kaposi sarcoma, Human herpes virus 8 (HHV-8), and Epstein-Barr virus. Castleman's disease have been described thrice post kidney transplant. In this report, we document the course of a renal recipient who developed the plasma cell variant of Castleman's disease at 16 months after failure of his allograft and return to dialysis. He displayed clinical resolution of this complication after graft nephrectomy. To our knowledge, this is the first case where the disease manifestations disappeared after graft removal. Our patient experienced chronic renal allograft rejection which may have driven all the systematic manifestations of multicentric castleman's disease and possibly reactivated a latent HHV-8 infection. In this case immunohistochemical testing for HHV-8 was not available to prove a role for this agent.

Interaction between cyclosporin A and nonsteroidal antiinflammatory drugs

OBJECTIVE

Although cyclosporin A (CyA) has been shown in a series of controlled trials to be of benefit to patients with rheumatoid arthritis (RA), the majority of patients continue to require nonsteroidal antiinflammatory drugs (NSAID) for relief of joint pain and stiffness. Our aim was to determine whether there is a clinically important difference in calculated creatinine clearance when CyA is given concurrently with NSAID with high cyclooxygenase activity (indomethacin and ketoprofen) compared with sulindac, which has been claimed to have fewer renal effects than other NSAID, and compared with a simple analgesic, paracetamol.

METHODS

Patients with RA started 2.5 mg/kg CyA/day and dosage was increased cautiously to 5 mg/kg/day or less if the serum creatinine rose by > or = 30% above baseline. The mean stabilized dose was 171.43 +/- 48.94 mg/day. Once CyA dose was stabilized, patients were allocated in random order to possible sequences of 4 week periods of acetaminophen, indomethacin, ketoprofen, and sulindac. Monitoring of cyclosporine levels, nephrotoxicity, and hepatoxicity, and adjustment of doses were by an "unblinded" clinician not in direct contact with study patients. All other assessments were made by a "blinded" clinician. Patients were instructed to take the identical appearing gelatin capsules qid. The multiple crossover design was analyzed using analysis of variance procedures for repeated measures.

RESULTS

35 patients were enrolled, of whom 32 patients completed the acetaminophen and at least one course of NSAID. The calculated creatinine clearance was increased by 2.79 ml/min (3.5%) on average for acetaminophen versus all 3 NSAID (6% for indomethacin, 2.3% for ketoprofen, 2.6% for sulindac). The study had adequate power to detect a true difference of more than 10% in mean creatinine clearance for each major comparison.

CONCLUSION

NSAID studied did not produce a clinically important difference in the calculated creatinine clearance in these patients-the difference with acetaminophen was modest and not of clinical significance. There is no evidence that any of the 3 NSAID studied have an advantage or disadvantage. It seems reasonable to allow patients to continue an NSAID of their or their clinician's choice.

Economic analysis of Neoral in de novo renal transplant patients in Canada

This pilot economic evaluation was performed as part of the Canadian arm of an international randomized, controlled, double-blind safety and tolerability trial (OLM-105/NOF-2). The clinical study compared the safety and tolerability of a new microemulsion oral formulation of cyclosporine A (Neoral) with the oral cyclosporine. A preparation currently in use (Sandimmune SGC)/(SGC). To assess the economic impact of Neoral in newly grafted renal transplant patients, primary cost data were collected at the five participating Canadian centers and evaluated from the Ministry of Health (MOH) and hospital perspectives. The results of this cost analysis are presented in this paper. Since the new formulation has shown more consistent absorption and a more predictable pharmacokinetic profile, medical resource utilization and, consequently, cost of treatment could be expected to be lower for those renal transplant recipients treated with Neoral than for those receiving standard SGC. The findings of this study support this hypothesis. Robustness of the conclusion was confirmed with sensitivity analyses. Reduced health care costs for patients treated with Neoral were primarily a result of fewer hospitalization days and lower physician costs for inpatient and outpatient procedures.

Combination therapy of cyclosporine with methotrexate and gold in rheumatoid arthritis (2 pilot studies)

OBJECTIVE

To evaluate the efficacy and toxicity of cyclosporine A (CyA) in combination with gold and methotrexate (MTX) in patients with rheumatoid arthritis (RA).

METHODS

Twenty patients with RA with partial response to oral MTX and 20 patients with partial response to im gold had CyA added to their regimen for 6 months, withdrawn over 2 months and the patients monitored for 4 months.

RESULTS

There was a significant improvement in joint count, joint score, joint swelling, grip strength and joint pain in patients taking the combination with no significant increase in adverse reactions.

CONCLUSION

CyA in combination with gold or MTX may, over a 6 month period, increase efficacy in patients with refractory RA without significant increase in toxicity.

Development of a central matching system for the allocation of cadaveric kidneys: a simulation of clinical effectiveness versus equity

OBJECTIVES

1) To develop a computer-based simulation to prospectively study the impacts of explicitly incorporating different equity criteria into the process of allocating kidneys to recipients, given the scarcity of this resource. 2) To assess the tradeoffs between systems that allocate kidneys based only on medical criteria, systems that allocate kidneys based only on equity criteria, and systems that consider both medical and equity criteria.

METHODS

A computer-based simulation was developed that describes the flows of patients and kidneys. This model provides information at various time points about the number of patients in the system who are awaiting transplants, the number of kidneys available for transplantation, the number of transplantations performed for each matching algorithm, and the number of kidneys discarded (when applicable), as well as the means and standard deviations of the HLA-match scores, number of days from registration to transplantation, and number of days (from registration) of those who are still waiting for transplants. Five different matching algorithms were compared, ranging from determination of the allocation by a single medical criterion (i.e, HLA match) to determination by a single equity criterion (i.e., relative position in the waiting queue). The remaining algorithms represent different strategies of weighting these two considerations. Estimates regarding the main parameters of the model were derived utilizing data collected through the Multiple Organ Retrieval and Exchange Programme of Ontario, Canada.

RESULTS

The simulation was set to run for a period of ten years. A tradeoff between graft survival (or improved HLA matching) and equal treatment of patients regardless of their likelihood to benefit was found. It is clear that an algorithm that allocates kidneys based only on temporal location of patient on the waiting list is likely to be unacceptable because of the very poor average HLA-match scores that it yields. Pool size was found to be a major determinant in the attainment of optimal matching from a medical perspective.

CONCLUSIONS

1) The final choice about any allocation algorithm to be used requires that a value judgment be made, i.e., how great a reduction in HLA-match score should be traded in order to improve equity score (or vice versa). 2) A computer-based simulation model is a feasible way to prospectively test the impact of any given allocation algorithm on any given system.

Renal biopsy specimens from patients with rheumatoid arthritis and apparently normal renal function after therapy with cyclosporine. Canadian Multicentre Rheumatology Group

Renal biopsies were performed in 14 patients with severe rheumatoid arthritis who had no evidence of compromised renal function after completion of treatment with low-dose cyclosporine (< or = 5 mg/kg/d). Mean serum creatinine at the time of biopsy was 0.84 mg/dL (range, 0.59 to 1.23 mg/dL). In the 13 patients who had received 6 months of cyclosporine therapy, mild glomerular expansion was noted in two biopsy specimens, obsolescent glomeruli (range, 5% to 20%) in five, and glomerular amyloid deposits in one. Five biopsy specimens had mild and three had mild to moderate interstitial fibrosis. Moderate interstitial fibrosis with a striped pattern was attributed to cyclosporine in the 14th patient. The results of a second biopsy performed in one patient after a further 18 months of therapy were unchanged. Although the renal biopsy changes were minimal in 13 patients and pathologic features characteristic of cyclosporine nephropathy were absent from all but one biopsy, a greater frequency of adverse effects due to cyclosporine could not be excluded. In the absence of clinical data, long-term cyclosporine therapy must be administered with caution to patients with rheumatoid arthritis, who commonly have underlying renal damage, and the value of renal biopsies in predicting and preventing end-stage renal failure remains to be determined.

Cyclosporin A nephropathy in patients with rheumatoid arthritis

Patients with RA are at risk of cyclosporin A (CyA) toxicity as they have an increased incidence of underlying renal pathology and because of the probable co-administration of NSAIDs. CyA dose, blood levels, and changes in serum creatinine are linked to the severity of renal biopsy changes in patients with RA and other autoimmune disorders, but only limited data regarding the safety of long-term CyA therapy have been reported. Low-dose CyA (preferably without NSAID co-administration) should be reserved for those patients with a poor prognosis who can be carefully monitored using a combination of renal function studies, CyA blood levels and renal biopsy assessment. Consideration should be given to the development of a management strategy that includes renal biopsy at defined intervals in order to detect the onset of progressive renal damage, and which could potentially allow eligible patients to benefit from long-term CyA therapy.

The quality of life in renal transplantation--a prospective study

Methodologically sound measures of quality of life are required to judge accurately the impact of successful renal transplantation on patient well-being. The time trade-off (TTO) method is a reproducible and valid measure which we used to prospectively assess changes in the quality of life of 27 patients on maintenance dialysis who subsequently underwent renal transplantation. TTO scores approaching 0 signify a very poor quality of life, while scores approaching 1 represent perfect health. Of 98 dialysis patients who completed baseline TTO interviews, 31 consecutive patients subsequently received 28 cadaveric and 3 living related kidney transplants. Four of 31 patients did not complete a second TTO assessment, because of death in 2 patients and graft loss in 2 others. The remaining 27 patients completed a second TTO interview an average of 30.9 months following transplantation (range 1.5-52, 95% confidence interval [CI] 24.4-37.5) and formed the study cohort. At the time of study the mean serum creatinine for the cohort was 173 mumol/L (range 90-290, 95% CI 152-195 mumol/L). The employment rate rose 27% following transplantation (P = 0.10); but when males alone were analyzed, a significant increase of 38% (P = 0.048) was noted. During the dialysis period, the mean baseline TTO score was 0.41 (95% CI 0.33-0.49), confirming the observations of others. Following transplantation, the mean TTO score rose to 0.74 (95% CI 0.67-0.81), a difference that is statistically significant (P < 0.001). The mean increase in TTO score observed as a result of successful transplantation was 0.33 (95% CI 0.26-0.40). This magnitude of improvement was found in 20 of 27 patients (74%), whose TTO scores lay within or above the 95% CI (0.26-0.40) for the mean change in score of 0.33. One patient's score fell, while the remaining 6 patients had improvements in their TTO score which fell below the lower 95% CI value (0.26) for the mean change in score. We conclude that the 95% CI of 0.26-0.40 identifies a range in which clinically important improvements in quality of life will be found for the majority of patients receiving successful kidney transplants.

Terminal loop cutaneous ureterostomy in renal transplantation

Patients presenting for renal transplantation with urinary diversion abnormalities pose serious problems. The use of a terminal loop cutaneous ureterostomy (TLCU) in patients whose outcome was satisfactory was first described in 1977. Primary urinary drainage was achieved in 3 recipients of cadaver renal allografts by creating a TLCU. This method of drainage has been satisfactory in these patients with follow-up between four and thirty months. We suggest that this simple technique should be considered more frequently for selected patients who require supravesical urinary diversion.

Cyclosporine nephrotoxicity in rheumatoid arthritis: no effect of short term misoprostol treatment

We assessed the effect of the prostaglandin E1 analog misoprostol on cyclosporine nephrotoxicity in patients with rheumatoid arthritis (RA). Thirteen patients with RA were given cyclosporine with misoprostol tablets, 800 micrograms/day for one week in a randomized, double blind, placebo controlled crossover trial. All had cyclosporine nephrotoxicity, documented by an increase in serum creatinine of at least 15% over the values before the start of cyclosporine treatment. Mean glomerular filtration rate (GFR) (single shot 51Cr-EDTA plasma clearance) at baseline was 77.3 ml/min (SD, 22.0). After misoprostol, it was 80.0 ml/min (SD, 18.9); after placebo, 79.1 ml/min (SD, 20.0). None of these changes were statistically significant. Serum creatinine levels and whole blood cyclosporine levels were also unchanged. Power to detect at least a 5 ml/min rise in GFR was 0.92. Short term misoprostol treatment does not improve the GFR of patients with RA on cyclosporine.

A comparison of evaluative indices of quality of life and cognitive function in hemodialysis patients

In the setting of end-stage renal disease, the reproducibility and responsiveness of three health-related quality-of-life instruments were evaluated. The Time Trade Off instrument (TTO) is a generic instrument used to evaluate the utility of a health state. The Hemodialysis Quality-of-Life questionnaire (HQL) is a disease-specific instrument. A series of function-specific tests evaluated neurocognitive function. The TTO and HQL instruments are patient centric in that patient values define the health status while the neurocognitive function tests reflect the values of healthcare professionals. Forty-seven chronic hemodialysis patients participated. Those with adequate dialysis, defined as a Kt/V (a measure of small solute removal during hemodialysis) above 1.0 were maintained at the level for two administrations of the three instruments separated by six to eight weeks. The test-retest intraclass correlation coefficient exceeded 0.90 for all five domains of the HQL questionnaire and exceeded 0.70 for nine neurocognitive function tests. Patients with inadequate dialysis (Kt/V less than 0.8) had Kt/V increased to above 1.0. The TTO was not responsive. For the HQL questionnaire, an item was considered responsive if a 1-point improvement, on a 7-point Likert type scale, occurred significantly more often among those with an improvement in hemodialysis treatment compared to those without improvement. Only one item had such a change and therefore the HQL cannot be considered responsive.(ABSTRACT TRUNCATED AT 250 WORDS)

Cyclosporine monitoring in autoimmune and other diseases

Cyclosporine (CsA) is being increasingly used for the treatment of disorders other than transplantation. In contrast to transplant recipients, most of these patients can have CsA therapy discontinued without life-threatening consequences, and the dose of CsA can therefore be restricted in order to limit the incidence and severity of toxicity, including nephrotoxicity. The utility of either CsA blood levels or pharmacokinetic profiling to ensure adequacy of therapy or to prevent incipient as well as overt toxicity has not been confirmed in this group of patients, and prevention of nephrotoxicity usually depends on limiting the dose of CsA and careful assessment of renal function. Frequent measurement of CsA levels beyond the initiation period in patients with autoimmune and other nontransplant diseases cannot be currently justified, and should be reserved for those situations where drug interactions, unexpected toxicity or the possibility of inadequate therapy is likely.

Early function as the principal correlate of graft survival. A multivariate analysis of 200 cadaveric renal transplants treated with a protocol incorporating antilymphocyte globulin and cyclosporine

We examined the factors determining graft survival in 200 consecutive cadaveric renal transplants managed on a quadruple-therapy protocol: Minnesota antilymphoblast globulin, cyclosporine, azathioprine, and low-dose prednisone. Perioperative central venous pressure monitoring and volume expansion were emphasized. To avoid CsA nephrotoxicity in the early posttransplant period, patients were treated with ALG until renal function was established (a mean of 7 days). Therapeutic CsA levels were achieved before ALG was discontinued. Azathioprine was used to supplement CsA in patients with nephrotoxicity or rejection. Twelve-month graft survival was 85% (first transplants 86%, retransplants 79%), with patient survival of 95%. ALG was not associated with excessive clinical cytomegalovirus infections, which occurred in 5% of patients, or with malignancy. When 3 technical failures were excluded, an analysis of numerous factors in the pretransplant and peritransplant period revealed that the strongest correlate of one-year graft survival was early renal function. Grafts with delayed function (DF) had 75% survival, compared with 91% for grafts with good early function (EF). A multivariate analysis confirmed this association: the relative risk of graft loss was increased 2.86 times for DF compared with EF. The mechanism of the deleterious effect of DF was apparently multifactorial: the DF group, by definition, contained all the kidneys that never functioned, but some risk also persisted in kidneys that achieved function. One reason for this may be that DF kidneys that achieved function had higher mean serum creatinine values at 1 month: elevated serum creatinine values at 1 month were strongly associated with increased risk of graft loss regardless of initial function. There was also a higher number of rejection episodes diagnosed in the DF group. These observations suggest that early renal function is a major determinant of graft outcome and should be a target for efforts to further improve renal graft survival.

Production in vitro of antibodies directed against alloantigen-specific recognition sites on T cells and on lymphocytotoxic HLA antibodies

We have examined the mechanism of immunological unresponsiveness in a recipient (P.S.) with a long-term functioning renal allograft. P.S., whose HLA type is A1, A30; B14, B18; DR1, w8; DRw52; DQw1 and in whose serum we had earlier demonstrated the presence of antiidiotypic antibodies, received a kidney from a cadaver donor of HLA type A1, A10, B8 in March, 1970. Peripheral blood B lymphocytes from the patient were transformed with Epstein-Barr virus (EBV), and by the cluster-picking technique a B cell line was propagated with continuous production of antibodies. Antiidiotypic antibodies with two distinct biological functions were demonstrable; one specifically inhibiting the lymphocytotoxic activity of anti-HLA-B8, B5, and DR3 reference typing sera, and the other specifically inhibiting proliferative responses in MLC of the recipient's lymphocytes and of third party cells sharing B14, DR1, DQw1 with the patient against stimulator cells carrying B8, DR3 antigens. Immunodepletion experiments demonstrated that the inhibitory activity was associated with the IgM fraction. Absorption experiments suggested that different antibodies may be responsible for the inhibition of lymphocytotoxic activity of anti-HLA sera and of the proliferative responses in MLC. Antiidiotypic antibodies have been postulated to be important in maintaining allograft tolerance in vivo, thereby enhancing renal allograft survival. The availability of such antibodies in large quantities, produced in vitro, could provide antisera for the immunochemical characterization of specific idiotypic receptors on immunoglobulins and T lymphocytes.

Dialyzer re-use--a multiple crossover study with random allocation to order of treatment

A multiple crossover research study was used to evaluate the effect of dialyzer re-use on fever, blood leaks, serum urea and creatinine values and symptoms. Each of 6 crossover periods consisted of 4 weeks on either single-use or re-use, 1 week washout, 4 weeks on the alternative treatment and 1 week washout. The re-use consisted of 6 uses of each dialyzer and the washout weeks consisted of 3 single-use sessions. Analysis of paired observations within rather than between patients showed no effects of time (i.e. among crossover periods 1 through 6) or number of re-uses (i.e. among uses 1 through 6). There was no significant difference for temperature change during dialysis, blood leak rate, or the serum urea and creatinine values before the first dialysis of each washout period. There were no differences for symptoms of pruritus, cramps, nausea, headache, chest pain, backache or fatigue. There were no clinical advantages or disadvantages associated with dialyzer re-use.

Low dose cyclosporine in rheumatoid arthritis: a pilot study

A 6 month open trial of cyclosporine (CyA) was conducted in 20 patients with active rheumatoid arthritis unresponsive to second line therapy. The dosage was monitored to achieve a serum blood level of 75-150 ng/ml. A 25% reduction in ARA joint count (baseline mean 38.2; 6 month or time of CyA withdrawal mean 28.7; p less than 0.001) was observed for all patients. Fifteen completed the 6 month CyA regimen and 5 developed toxicity requiring CyA to be permanently withdrawn. For the 15 patients completing 6 months of CyA, improvement was 36% (baseline 34.7; 6 month mean 22.2; p less than 0.001). Corresponding improvements were also observed on the other main study outcomes of pain and functional ability. Improvement occurred between 12-20 weeks, somewhat later than in other studies. Toxicity included mild hypertension (4 patients) and gastrointestinal intolerance (2). Three patients were withdrawn from CyA due to nephrotoxicity. There was a clinically significant reduction in calculated creatinine clearance but this returned to baseline within 6 months after CyA was withdrawn for all except 2 patients who took 12 months to return to baseline.

MLC-inhibiting serum in mice after transfusion with 3 M KCl-extracted soluble antigen

Balb/c (H-2d) mice were transfused weekly with 3 M KCl-extracted soluble antigen prepared from splenocytes of C3H/HeJ (C3H)(H-3k) mice. One week after each transfusion, spleen and serum samples were collected from transfused mice and pooled. The serum was absorbed with erythrocytes and spleen cells from C3H mice and heat inactivated. Spleen cells from transfused mice were tested for proliferative responses in mixed lymphocyte culture (MLC) against stimulator cells from the antigen donor C3H or from third party SJL (H-2s) mice. The proliferative responses of lymphocytes from soluble-antigen-transfused Balb/c mice to stimulator cells from C3H and SJL mice were not suppressed. Furthermore, suppressor cells could not be demonstrated in spleens of transfused mice in in vitro coculture experiments. The MLC inhibition test was utilized to investigate the presence of MLC-inhibiting serum from transfused mice. The results demonstrate that serum capable of inhibiting responses of Balb/c mice were induced after three weekly injections of soluble antigen and that this inhibition in MLC was specific for the stimulator cells from the antigen donor C3H mice. These findings differ from our studies using whole blood transfusions where (1) MLC inhibiting antibodies developed in Balb/c mice after only one transfusion of C3H whole blood, and (2) serum from blood transfused mice achieve greater inhibition than soluble-antigen-induced serum. These results suggest that although soluble antigen is capable of inducing MLC inhibiting serum, the kinetics of this induction may be different from transfusion with whole blood.

Measurement of quality of life in end-stage renal disease: the time trade-off approach

The quality of life of patients with end-stage renal disease was estimated using the time trade-off technique. The sample included 103 transplant, 60 hospital hemodialysis, 57 home/self-care, and 52 continuous ambulatory peritoneal dialysis patients. Test-retest reliability was high: intra-class correlation coefficient 0.81 (p less than 0.001). The correlations of the time trade-off with the Spitzer Quality of Life index and a visual analogue scale completed by the nephrologists, nurses, friends/relatives, and the patient were positive and statistically significant, but still relatively low (r = 0.22-0.43; p less than 0.01). The time trade-off demonstrated evidence for discriminative construct validity by ordering treatment groups according to a priori prediction. The mean time trade-off values and standard deviations (where death is 0 and full health is 1) were 0.43 (0.26) for hospital hemodialysis 0.49 (0.23) for home/self-care hemodialysis, 0.56 (0.29) for continuous ambulatory peritoneal dialysis, and 0.84 (0.24) for transplant. Analysis of variance showed transplant to be different from all other groups (p less than 0.001) with age, sex, time with end-stage renal disease, and work status making no significant independent contribution. The partial correlation coefficients between time trade-off score and items in the physical, social, and emotional functioning sub-scales of the Rand questionnaire showed that physical functioning was far more important than social or emotional functioning. The time trade-off is reliable, demonstrates evidence for validity, and suggests that the quality of life for patients with end-stage renal disease is much poorer than that reported previously.

Induction of antiidiotypic antibodies by blood transfusions. Characterization of T cell alloantigen-specific receptors by sera from transfused mice

Balb/c (H-2d) mice were transfused weekly with 0.1 ml of whole blood from C3H (H-2k) mice. One week after 3 blood transfusions (BT), the mice were bled and the sera collected and pooled. The 3BT serum was absorbed twice with C3H lymphocytes and IgG isolated by ion-exchange chromatography. Balb/c anti-C3H, Balb/c anti-Balb/c, and Balb/c anti-SJL (H-2s) lymphocytes were generated in the mixed lymphocyte cultures and metabolically labeled with 35S-methionine. Cell lysates were prepared from labeled lymphocytes and precleared by absorption with normal mouse serum. Immunoprecipitation was carried out by 3BT-IgG and NMS-IgG. 3BT-IgG specifically precipitated 7 molecules (30K, 60K, 72K, 86K, 92K, 97K, 145K) from Balb/c anti-C3H lymphocytes. In contrast, 3BT-IgG did not precipitate these molecules from Balb/c anti-Balb/c or from Balb/c anti-SJL lymphocytes. The data suggest that BT induces antibodies directed against the blood donor alloantigen-specific receptors on recipient's T lymphocytes.

MLC-inhibiting antibodies in mice after blood transfusions

Balb/c (H-2d) mice were transfused weekly with 0.1 ml of whole blood from C3H/HeJ (C3H) (H-2k) mice. One and two weeks after each transfusion, mice were bled and the sera were collected and pooled. Serum samples from transfused mice were absorbed with erythrocytes and spleen cells from C3H mice, and then heat-inactivated. The presence of antiidiotypic antibodies in these sera was investigated using the mixed lymphocyte culture (MLC) inhibition test, in which spleen cells from normal Balb/c mice were tested for proliferative responses to x-irradiated C3H stimulator cells in the presence of sera from transfused mice. Sera obtained from transfused mice caused significant inhibition of responses in MLC. This inhibition in MLC was specific for stimulator cells from the blood donor (C3H), and little or no inhibition was observed with stimulator cells from third-party SJL mice. In addition, the inhibitory effect in MLC was specific for responder cells from the recipient Balb/c mice and no inhibition was observed with responder cells from blood donor C3H mice. These results suggest that blood transfusions induce antiidiotypic antibodies that can block the T cell antigen-specific receptors and cause inhibition of responses of the recipient mice to blood donor alloantigens in MLC. Thus in this strain combination, disparate for the entire H-2 region, antiidiotypic antibodies developed after 1 blood transfusion. These findings are in contrast to our earlier published results in which antiidiotypic antibodies developed after 3 transfusions in recipient-blood donor combination incompatible for the K and I regions. These data suggest that the development of antiidiotypic antibodies may be related to the level of histoincompatibility at the H-2 complex between recipient and the blood donor.

Polyclonal B cell hyperplasia associated with Epstein-Barr virus causing acute renal allograft failure

Six weeks post cadaver renal transplantation, a patient developed a flu-like illness. Acute renal failure unresponsive to anti-rejection therapy occurred and he died four days later from Pneumocystis carinii pneumonia and Streptococcus viridans septicemia. Autopsy revealed a diffuse polymorphic polyclonal B cell infiltrate occupying most organs, including the allograft. Primary Epstein-Barr Virus (EBV) infection was established by 1) rising anti-EBV antibody titres; 2) the demonstration of EBV nuclear antigen in the infiltrate and 3) the presence of EBV specific DNA sequences in affected tissues. EBV associated polymorphic B cell hyperplasia can mimic rejection and result in acute allograft failure.

Hypocalcaemic response to streptomycin in malignant hypercalcaemia

We report a case of malignant hypercalcaemia associated with primary hepato-cellular carcinoma in whom streptomycin produced a notable and reproducible fall in serum calcium. A hypocalcaemic response to streptomycin has been reported from experimental animals but not previously from man.