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Background Estimating glomerular filtration rate (GFR) in acute kidney injury (AKI) is challenging, with limited data comparing estimated and gold standard methods to assess GFR. The objective of our study was to assess the performance of the kinetic estimated GFR (KeGFR) and Jelliffe equations to estimate GFR in AKI, using a radioisotopic method (technetium-diethylenetriaminepentaacetic acid) as a reference measure. Methods We conducted a prospective multicenter observational study in hospitalized patients with AKI. We computed the Jelliffe and KeGFR equations to estimate GFR and compared these estimations to measured GFR (mGFR) by a radioisotopic method. The performances were assessed by correlation, Bland–Altman plots and smoothed and linear regressions. We conducted stratified analyses by age and chronic kidney disease (CKD). Results The study included 119 patients with AKI, mostly from the intensive care unit (63%) and with Stage 1 AKI (71%). The eGFR obtained from the Jelliffe and KeGFR equations showed a good correlation with mGFR (r = 0.73 and 0.68, respectively). The median eGFR by the Jelliffe and KeGFR equations was less than the median mGFR, indicating that these equations underestimated the mGFR. On Bland–Altman plots, the Jelliffe and KeGFR equations displayed a considerable lack of agreement with mGFR, with limits of agreement >40 mL/min/1.73 m2. Both equations performed better in CKD and the KeGFR performed better in older patients. Results were similar across AKI stages. Conclusions In our study, the Jelliffe and KeGFR equations had good correlations with mGFR; however, they had wide limits of agreement. Further studies are needed to optimize the prediction of mGFR with estimatation equations.

Chronic kidney disease (CKD) is a major health issue and cardiovascular risk factor. Validity assessment of administrative data for the detection of CKD in research for drug benefit and risk using real-world data is important. Existing algorithms have limitations and we need to develop new algorithms using administrative data, giving the importance of drug benefit/risk ratio in real world.The aim of this study was to validate a predictive algorithm for CKD GFR category 4-5 (eGFR30 mL/min/1.73 mThis is a retrospective cohort study using chart collection and administrative databases.The study was conducted in a community outpatient medical clinic and pre-dialysis outpatient clinic in downtown Montreal and rural area.Patient medical files with at least 2 serum creatinine measures (up to 1 year apart) between September 1, 2013, and June 30, 2015, were reviewed consecutively (going back in time from the day we started the study). We excluded patients with end-stage renal disease on dialysis. The study was started in September 2013.Glomerular filtration rate was estimated using the CKD Epidemiological Collaboration (CKD-EPI) from each patient's file. Several algorithms were developed using 3 administrative databases with different combinations of physician claims (diagnostics and number of visits) and hospital discharge data in the 5 years prior to the cohort entry, as well as specific drug use and medical intervention in preparation for dialysis in the 2 years prior to the cohort entry.Chart data were used to assess eGFR. The validity of various algorithms for detection of CKD groups was assessed with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).A total of 434 medical files were reviewed; mean age of patients was 74.2 ± 10.6 years, and 83% were older than 65 years. Sensitivity of algorithm #3 (diagnosis within 2-5 years and/or specific drug use within 2 years and nephrologist visit ≥4 within 2-5 years) in identification of CKD G4-5ND ranged from 82.5% to 89.0%, specificity from 97.1% to 98.9% with PPV and NPV ranging from 94.5% to 97.7% and 91.1% to 94.2%, respectively. The subsequent subgroup analysis (diabetes, hypertension, and65 and ≥65 years) and also the comparisons of predicted prevalence in a cohort of older adults relative to published data emphasized the accuracy of our algorithm for patients with severe CKD (CKD G4-5ND).Our cohort comprised mostly older adults, and results may not be generalizable to all adults. Participants with CKD without 2 serum creatinine measurements up to 1 year apart were excluded.The case definition of severe CKD G4-5ND derived from an algorithm using diagnosis code, drug use, and nephrologist visits from administrative databases is a valid algorithm compared with medical chart reviews in older adults.L’insuffisance rénale chronique (IRC) est un problème de santé majeur et un facteur de risque cardiovasculaire. La validité de la détection de l’IRC à partir des bases de données administratives est importante pour les études évaluant en situation réelle les bénéfices et les risques des médicaments. Les algorithmes existants comportent des limites et, compte tenu de l’importance revêtue par ce rapport bénéfices/risques, le développement de nouveaux algorithmes utilisant les bases de données administratives s’avère essentiel.Valider le pouvoir prédictif d’un algorithme pour détecter l’insuffisance rénale chronique sévère (DFGe30 mL/min/1.73 mÉtude de cohorte rétrospective réalisée à partir des dossiers médicaux et de données administratives.Des cliniques médicales communautaires et de protection rénale de Montréal et des régions rurales périphériques.Les dossiers médicaux de patients avec au moins deux mesures de la créatinine sérique (en moins d’un an) entre le 1er septembre 2013 et le 30 juin 2015 ont été revus consécutivement, en reculant dans le temps. Les patients avec insuffisance rénale terminale et dialysés ont été exclus. L’étude a débuté en septembre 2013.Le DFG a été estimé à l’aide de la formule CKD Epidemiological Collaboration (CKD-EPI) à partir du dossier médical de chaque patient. Nous avons développé différents algorithmes en utilisant trois banques de données administratives avec différentes combinaisons de facturations médicales (diagnostics et nombre de visites en néphrologie) et de données colligées au congé de l’hôpital dans les cinq ans précédant l’entrée dans la cohorte, de même qu’avec la consommation de certains médicaments et les interventions médicales subies en préparation à la dialyse dans les deux ans précédant l’entrée dans la cohorte.Les données des dossiers médicaux ont été utilisées pour définir le DFGe. La validité des algorithmes développés a été évaluée en utilisant la sensibilité, la spécificité, la valeur prédictive positive (VPP) et la valeur prédictive négative (VPN).En tout, 434 dossiers médicaux ont été revus; l’âge moyen des patients était de 74.2 ± 10.6 ans et 83% avaient plus de 65 ans. La sensibilité de l’algorithme no.3 (diagnostic dans un délai de 2 à 5 ans et/ou l’usage de médicaments spécifiques dans un délai de 2 ans, et au moins quatre visites médicales en néphrologie dans les 2 à 5 ans précédant la date d’entrée dans la cohorte) dans l’identification d’une insuffisance rénale sévère (CKD G4-5ND) variait de 82.5% à 89.0%. La spécificité de ce même algorithme variait de 97.1% à 98.9% avec une PPV et une NPV allant respectivement de 94.5.% à 97.7% et de 91.1% à 94.2%. L’analyse de sous-groupes (patients diabétiques, hypertendus, âgés de moins de 65 ans ou âgés de 65 ans et plus) ainsi que la comparaison de la prévalence prédite dans une cohorte de patients âgés par rapport aux données de la littérature font valoir la précision de notre algorithme pour les patients avec insuffisance rénale sévère (CKD G4-5ND).Notre cohorte était composée essentiellement de sujets âgées, les résultats pourraient ne pas s’appliquer à tous les adultes. Les patients n’ayant pas eu deux mesures de la créatinine sérique à l’intérieur d’un an ont été exclus.Chez les personnes âgées, la définition de cas pour une insuffisance chronique rénale sévère (CKD G4-5ND) estimée par un algorithme utilisant les codes diagnostic, la consommation de médicaments spécifiques et les services médicaux de néphrologie tirés des données administratives s’avère un algorithme valide comparativement à l’examen du dossier médical.

OBJECTIVES: (1) To evaluate the association between acute kidney injury (AKI) in the PICU and long-term mortality and (2) to determine the extent to which adding the urine output (UO)–defined AKI alters the association. METHODS: A 2-center retrospective cohort study of children (≤18 years old) admitted to the PICU between 2003 and 2005 for noncardiac surgery, with follow-up until 2010. Patients with end stage renal disease, no provincial health insurance number, who died during hospitalization, or could not be linked to administrative data were excluded. One hospitalization per patient was included. AKI was defined by using serum creatinine criteria and/or UO criteria. Mortality was ascertained by using administrative data. Cox regression analysis was performed to evaluate the association between AKI and long-term mortality. RESULTS: The study population included 2041 patients (55.7% male, mean admission age 6.5 ± 5.8 years). Of 2041 hospital survivors, 9 (0.4%) died within 30 days, 51 (2.5%) died within 1 year, and 118 (5.8%) died within 5 to 7 years postdischarge. AKI was independently associated with 5- to 7-year mortality (adjusted hazard ratio [95% confidence interval]: 3.10 [1.46–6.57] and 3.38 [1.63–7.02], respectively). Including UO did not strengthen the association. CONCLUSIONS: AKI is associated with 5- to 7-year mortality. Because this is an observational study we cannot determine if AKI is causative of mortality or of the pathophysiology. However, patients with AKI represent a high-risk group. It is reasonable that these patients be considered for targeted follow-up until future researchers better elucidate these relationships

Background and objectives Little is known about the long-term burden of AKI in the pediatric intensive care unit. We aim to evaluate if pediatric AKI is associated with higher health service use post–hospital discharge. Design, setting, participants, & measurements This is a retrospective cohort study of children (≤18 years old) admitted to two tertiary centers in Montreal, Canada. Only the first admission per patient was included. AKI was defined in two ways: serum creatinine alone or serum creatinine and/or urine output. The outcomes were 30-day, 1-year, and 5-year hospitalizations, emergency room visits, and physician visits per person-time using provincial administrative data. Univariable and multivariable Poisson regression were used to evaluate AKI associations with outcomes. Results A total of 2041 children were included (56% male, mean admission age 6.5±5.8 years); 299 of 1575 (19%) developed AKI defined using serum creatinine alone, and when urine output was included in the AKI definition 355 of 1622 (22%) children developed AKI. AKI defined using serum creatinine alone and AKI defined using serum creatinine and urine output were both associated with higher 1- and 5-year hospitalization risk (AKI by serum creatinine alone adjusted relative risk, 1.42; 95% confidence interval, 1.12 to 1.82; and 1.80; 1.54 to 2.11, respectively [similar when urine output was included]) and higher 5-year physician visits (adjusted relative risk, 1.26; 95% confidence interval, 1.14 to 1.39). AKI was not associated with emergency room use after adjustments. Conclusions AKI is independently associated with higher hospitalizations and physician visits postdischarge.

To develop a pediatric-specific hypertension algorithm using administrative data and use it to evaluate the association between acute kidney injury (AKI) in the intensive care unit (ICU) and hypertension diagnosis 5 years post-discharge. Two-center retrospective cohort study of children (≤ 18 years old) admitted to the pediatric ICU in Montreal, Canada, between 2003 and 2005 and followed until 2010. Patients with a valid healthcare number and without end-stage renal disease were included. Patients who could not be merged with the provincial database, did not survive admission, underwent cardiac surgery, had pre-existing renal disease associated with hypertension or a prior diagnosis of hypertension were excluded. AKI defined using the Kidney Disease: Improving Global Outcomes (KDIGO) definition. Using diagnostic codes and medications from administrative data, novel pediatric-specific hypertension definitions were designed. Both the evaluation of the prevalence of hypertension diagnosis and the association between AKI and hypertension occurred. Nineteen hundred and seventy eight patients were included (median age at admission [interquartile range] 4.3 years [1.1–11.8], 44% female, 325 (16.4%) developed AKI). Of these patients, 130 (7%) had a hypertension diagnosis 5 years after discharge. Patients with AKI had a higher prevalence of hypertension diagnosis [non-AKI: 84/1653 (5.1%) vs. AKI: 46/325 (14.2%), p

The progression from acute kidney injury (AKI) to chronic kidney disease (CKD) is not well understood in children.We aimed to develop a pediatric CKD definition using administrative data and use it to evaluate the association between AKI in critically ill children and CKD 5 years after hospital discharge.Retrospective cohort study using chart collection and administrative data.Two-center study in Montreal, Canada.Children (≤18 years old) admitted to two pediatric intensive care units (ICUs) between 2003 and 2005. We a priori excluded patients with end-stage renal disease or no health care number. Only the first admission during the study period was included. We excluded patients who could not be linked to administrative data, did not survive hospitalization, or had preexisting renal disease.Acute kidney injury was defined using Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Patients were defined as having CKD 5 years post-discharge if they had ≥1 CKD diagnostic code or ≥1 CKD-specific medication prescription.Chart data used to define the exposure (AKI) were merged with provincial administrative data used to define the outcome (CKD). Cox regression was used to evaluate the AKI-CKD association.A total of 2235 (56% male) patients were included, and the median admission age was 3.7 years. A total of 464 (21%) patients developed AKI during pediatric ICU admission. At 5 years post-discharge, 43 (2%) patients had a CKD diagnosis. Patients with both stage 1 and stage 2-3 AKI had increased risk of a CKD diagnosis, with the adjusted hazard ratios (95% confidence intervals) of 2.2 (1.1-4.5) and 2.5 (1.1-5.7), respectively (Results may not be generalizable to non-ICU patients. We were not able to control for post-discharge variables; future research should try to explore these additional potential risk factors further.Acute kidney injury is associated with 5-year post-discharge CKD diagnosis defined by administrative health care data.Chez l’enfant, la progression de l’insuffisance rénale aigüe (IRA) vers l’insuffisance rénale chronique (IRC) est encore mal connue.Nous souhaitions élaborer une définition de l’IRC pédiatrique à partir des données administratives, et l’employer pour évaluer l’association entre l’IRA chez les enfants gravement malades et un diagnostic d’IRC cinq ans après leur sortie de l’hôpital.Étude de cohorte rétrospective réalisée à partir des dossiers médicaux et des données administratives.Deux centres hospitaliers de Montréal (Canada).L’étude porte sur des enfants (≤18 ans) admis à deux unités de soins intensifs (USI) pédiatriques entre 2003 et 2005. Les patients atteints d’insuffisance rénale terminale ou sans numéro d’assurance-maladie ont été exclus d’emblée. Seule la première admission survenue au cours de l’étude a été retenue. Les patients n’ayant pu être reliés aux données administratives, n’ayant pas survécu à l’hospitalisation ou souffrant d’une néphropathie préexistante ont été exclus.L’IRA a été définie selon les critères KDIGO (Les données des dossiers médicaux, utilisées pour définir l’exposition (IRA), ont été couplées aux données administratives provinciales, utilisées pour définir le résultat (IRC). Un modèle de régression de Cox a servi à établir l’association entre IRA et IRC.Ont été inclus 2 235 patients (56 % de garçons), dont l’âge médian à l’admission était de 3,7 ans. De ce nombre, 464 (21 %) ont développé une IRA en cours d’hospitalisation à l’USI pédiatrique. Cinq ans après leur sortie de l’hôpital, 43 patients (2 %) avaient reçu un diagnostic d’IRC. Les patients atteints d’une IRA de stade 1 et de stade 2-3 ont présenté un plus grand risque de progresser vers l’IRC (rapport de risque ajusté [IC à 95 %] 2,2 [1,1 – 4,5] et 2,5 [1,1 – 5,7] respectivement,Les résultats pourraient ne pas s’appliquer aux patients non admis aux USI pédiatriques. Nous n’avons pu ajuster les résultats avec les variables après la sortie de l’hôpital. Des études futures devraient examiner plus attentivement ces potentiels facteurs de risque supplémentaires.L’IRA chez l’enfant a été associée à une progression vers l’IRC cinq ans après la sortie de l’hôpital, telle que définie par les données administratives de santé.

Large studies evaluating pediatric acute kidney injury (AKI) epidemiology and outcomes are lacking, partially due to underuse of large administrative health care data.To assess the diagnostic accuracy of administrative health care data-defined AKI in children admitted to the pediatric intensive care unit (PICU).Retrospective cohort study utilizing chart and administrative data.Children admitted to the PICU at 2 centers in Montreal, QC.Patients between 0 and 18 years old with a provincial health insurance number, without end-stage renal disease and admitted to the PICU between January 1, 2003, and March 31, 2005, were included.The AKI was defined from chart data using the Kidney Disease: Improving Global Outcomes (KDIGO) definition (Chart-AKI). The AKI defined using administrative health data (Admin-AKI) was based onData available from retrospective chart review, including baseline and PICU patient characteristics, and serum creatinine (SCr) and urine output (UO) values during PICU admission, were merged with provincial administrative health care data containing diagnostic and procedure codes used for ascertaining Admin-AKI. Sensitivity, specificity, positive, and negative predictive value of Admin-AKI compared with Chart-AKI (reference standard) were calculated. Univariable associations between Admin-AKI and hospital mortality were evaluated.A total of 2051 patients (55% male, mean age at admission 6.1 ± 5.8 years, 355 cardiac surgery, 1696 noncardiac surgery) were included. The AKI defined by SCr or UO criteria occurred in 52% of cardiac surgery patients and 24% of noncardiac surgery patients. Overall, Admin-AKI detected Chart-AKI with low sensitivity, but high specificity in cardiac and noncardiac surgery patients. Sensitivity increased by 1.5 to 2 fold with each increase in AKI severity stage. Admin-AKI was associated with hospital mortality (13% in Admin-AKIThese data were generated in a PICU population; future research should study non-PICU populations.Use of administrative health care data to define AKI in children leads to AKI incidence underestimation. However, for detecting more severe AKI, sensitivity is higher, while maintaining high specificity.On dispose de peu d’études à grande échelle évaluant l’épidémiologie et l’évolution de l’insuffisance rénale aigüe (IRA) chez les enfants, notamment en raison d’une sous-utilisation des données administratives du système de santé.Évaluer la précision diagnostique de l’IRA définie à partir des données administratives en santé chez des enfants admis aux unités de soins intensifs pédiatriques (USIP).Une étude de cohorte rétrospective utilisant des données administratives et les données provenant des dossiers médicaux.Les USIP de deux centres hospitaliers de Montréal, au Canada.Ont été inclus les patients âgés de 0 à 18 ans possédant un numéro d’assurance-maladie provincial qui ont été admis aux USIP entre le 1er janvier 2003 et le 31 mars 2005 avec une insuffisance rénale non terminale.L’IRA-Dos a été définie à partir des dossiers médicaux en utilisant les critères du KDIGO (Kidney Disease: Improving Global Outcomes). L’IRA-Admin a été définie à partir des données administratives en santé avec les codes d’IRA de la neuvième révision de la Classification internationale des maladies (CIM-9).Les données tirées de l’examen rétrospectif des dossiers médicaux, soit les valeurs de créatinine sérique (SCr) et de diurèse pendant le séjour aux USIP et les caractéristiques des patients, initiales et à l’admission, ont été fusionnées aux données administratives provinciales en santé contenant les codes de diagnostic et de procédure utilisés pour établir l’IRA-Admin. La sensibilité, la spécificité et les valeurs prédictives négative et positive de l’IRA-Admin, en comparaison à l’IRA-Dos (standard de référence), ont été calculées. L’association univariée entre l’IRA-Admin et la mortalité à l’hôpital a également été évaluée.Un total de 2 051 patients ont été inclus (355 ayant subi une cardiochirurgie et 1 696 non opérés). L’âge moyen des sujets à l’admission était de 6,1 ± 5,8 ans et 55 % étaient des garçons. L’IRA définie par les critères de SCr et de diurèse a été diagnostiquée chez 52 % des patients opérés et chez 24 % des patients non opérés. Pour l’ensemble de la cohorte (patients opérés ou non), l’IRA-Admin a détecté l’IRA-Dos avec une faible sensibilité, mais avec une spécificité élevée. La sensibilité s’est accrue de 1,5 à 2 fois pour chaque passage à un stade supérieur de gravité de l’IRA. Enfin, l’IRA-Admin a été associée à un taux plus élevé de mortalité à l’hôpital (13 % des patients IRA-AdminCes résultats concernent une population de patients hospitalisés aux USIP. Des études futures devraient inclure des populations non admises aux USIP.L’utilisation des données administratives en santé pour définir l’IRA chez les enfants a mené à une sous-estimation de son incidence. Cependant, la méthode montre une plus grande sensibilité dans la détection des cas plus graves d’IRA, tout en conservant une spécificité élevée.

Background Short-term treatment for people with type 2 diabetes using a low dose of the selective endothelin A receptor antagonist atrasentan reduces albuminuria without causing significant sodium retention. We report the long-term effects of treatment with atrasentan on major renal outcomes.Methods We did this double-blind, randomised, placebo-controlled trial at 689 sites in 41 countries. We enrolled adults aged 18-85 years with type 2 diabetes, estimated glomerular filtration rate (eGFR) 25-75 mL/min per 1.73 m(2) of body surface area, and a urine albumin-to-creatinine ratio (UACR) of 300-5000 mg/g who had received maximum labelled or tolerated renin-angiotensin system inhibition for at least 4 weeks. Participants were given atrasentan 0.75 mg orally daily during an enrichment period before random group assignment. Those with a UACR decrease of at least 30% with no substantial fluid retention during the enrichment period (responders) were included in the double-blind treatment period. Responders were randomly assigned to receive either atrasentan 0.75 mg orally daily or placebo. All patients and investigators were masked to treatment assignment. The primary endpoint was a composite of doubling of serum creatinine (sustained for >= 30 days) or end-stage kidney disease (eGFR = 90 days, chronic dialysis for >= 90 days, kidney transplantation, or death from kidney failure) in the intention-to-treat population of all responders. Safety was assessed in all patients who received at least one dose of their assigned study treatment. The study is registered with ClinicalTrials. gov, number NCT01858532.Findings Between May 17, 2013, and July 13, 2017, 11 087 patients were screened; 5117 entered the enrichment period, and 4711 completed the enrichment period. Of these, 2648 patients were responders and were randomly assigned to the atrasentan group (n=1325) or placebo group (n=1323). Median follow-up was 2.2 years (IQR 1.4-2.9). 79 (6.0%) of 1325 patients in the atrasentan group and 105 (7.9%) of 1323 in the placebo group had a primary composite renal endpoint event (hazard ratio [HR] 0.65 [95% CI 0.49-0.88]; p=0.0047). Fluid retention and anaemia adverse events, which have been previously attributed to endothelin receptor antagonists, were more frequent in the atrasentan group than in the placebo group. Hospital admission for heart failure occurred in 47 (3.5%) of 1325 patients in the atrasentan group and 34 (2.6%) of 1323 patients in the placebo group (HR 1.33 [95% CI 0.85-2.07]; p=0.208). 58 (4.4%) patients in the atrasentan group and 52 (3.9%) in the placebo group died (HR 1.09 [95% CI 0.75-1.59]; p=0.65).Interpretation Atrasentan reduced the risk of renal events in patients with diabetes and chronic kidney disease who were selected to optimise efficacy and safety. These data support a potential role for selective endothelin receptor antagonists in protecting renal function in patients with type 2 diabetes at high risk of developing end-stage kidney disease. Copyright (C) 2019 Elsevier Ltd. All rights reserved.

Metformin presents better survival rates than other oral antidiabetics in the treatment of type 2 diabetes. However, these benefits may be dampened by inadequate treatment adherence.We aimed to investigate the relationship between adherence level to metformin therapy and all-cause mortality over 10 years in incident metformin users.A nested case-control study was conducted using a large cohort of beneficiaries of the Quebec public drug insurance plan, aged 45 to 85 years, who initiated metformin between 2000 and 2009. Each case of all-cause death during follow-up was matched with up to 10 controls. Adherence to metformin was measured using the medication possession ratio (MPR). Conditional logistic regression models were used to estimate rate ratios (RRs) for mortality between adherent (MPR ≥ 80%) and nonadherent patients (MPR80%). Subgroup analyses were conducted according to age (45-64 and 65-85 years) and comedication use (antihypertensive/cardiovascular drugs and statins).The cohort included 82 720 incident metformin users, followed up for 2.4 [0.8-4.4] years (median [interquartile range]) and 4747 cases of all-cause deaths. Analyses revealed decreased mortality risks after long-term adherence to metformin. Specifically, RRs were 0.84 (95% CI = [0.71-0.98]) and 0.69 [0.57-0.85] after 4 to 6 and ≥6 years of adherence to metformin, respectively. Survival benefits of long-term adherence (≥4 years) were also observed across most subgroups and particularly in patients using neither antihypertensive/cardiovascular drugs nor statins (0.57 [0.41-0.77]).Long-term adherence to metformin is associated with decreased risks of all-cause mortality in incident metformin users. Further research should investigate whether survival benefits vary according to the comorbidity burden of patients.

The rapid increase in glomerular filtration rate in a normal contralateral kidney after uninephrectomy is well known in living kidney donors but much less well described in chronic kidney disease (CKD). The purpose of this study is to determine the magnitude of this initial compensatory capacity in (CKD) groups 3 to 5 (G3 to G5) patients undergoing uninephrectomy and the clinical factors predicting it. This is a retrospective study of all cases (142) of uninephrectomy in patients with estimated glomerular filtration rate (eGFR; with MDRD equation)60 ml/min/1.73 m(2), between 2003 and 2010, in two University of Montreal-affiliated teaching hospitals.Baseline eGFR, patients' comorbidities, and surgical characteristics and complications were noted. The change of eGFR after nephrectomy was evaluated; moreover, the expected post-op eGFR, i.e. without compensation by the contralateral kidney following surgery, was estimated in a sub-group of patients who had a preoperative renal scintigraphy and compared to the actual eGFR at hospital discharge.The mean change of eGFR from baseline to hospital discharge was -5 ± 12 ml/min/1.73 m(2) (-11 %; 95 % CI -16 to -6 %; P 0.001). In univariate and multivariate analyses, baseline eGFR did not influence significantly these results. However, in the multivariate model, radical nephrectomy vs. partial nephrectomy and preoperative hypertension predicted a worse renal outcome. In the sub-group of patients with preoperative renal scintigraphy, the actual eGFR at hospital discharge was also higher than expected from the renal split function (13 ml/min/1.73 m(2); 95 % CI 10 to 16; P 0.001).After uninephrectomy, the contralateral kidney in patients with CKD G3 to G5 still has a clinically significant initial compensatory capacity. The compensation is statistically smaller if the patient had hypertension or a radical uninephrectomy. This initial compensation is rapid and most probably haemodynamic (hyperfiltration). However, most of the included patients had a CKD G3, limiting the strength of the conclusion for the G4 toG5 patients; the length of observation covers the early postoperative period, i.e. less than 2 weeks, in more than half of the cohort.L’accroissement rapide du débit de filtration glomérulaire du rein controlatéral à la suite d’une uninéphrectomie (uniNPX) est bien connu pour les donneurs de rein vivants, mais est beaucoup moins bien documenté dans le cas des patients souffrant d’une insuffisance rénale chronique (IRC).L’étude avait pour objectif principal de déterminer à quel point la capacité de compensation initiale du rein controlatéral est maintenue chez les patients souffrant d’IRC de stade 3 à 5 après une NPX et quels facteurs cliniques sont susceptibles d’aider à prévoir la perte d’activité fonctionnelle du rein.Il s’agit d’une étude rétrospective de 142 cas de NPX pratiquées entre 2003 et 2010 au sein de deux centres hospitaliers universitaires affiliés à l’Université de Montréal, sur des patients présentant un débit de filtration glomérulaire estimé (DFGe) par l’équation MDRD, inférieur à 60 ml/min/1.73 mLa mesure du débit de filtration glomérulaire préopératoire, les maladies concomitantes inscrites au dossier, les particularités de la chirurgie ainsi que les complications survenues par la suite, ont été notées pour chaque patient. La variation du DFG a été évaluée après la chirurgie. De plus, le DFG post-op attendu, calculé en ne tenant pas en compte la compensation offerte par le rein controlatéral après la chirurgie, a été estimé pour un sous-groupe de patients qui avaient subi une scintigraphie rénale préopératoire et comparé à la mesure du DFG faite au moment de la sortie de l’hôpital.La variation moyenne du DFG entre les mesures prises avant la chirurgie et celles prises lors de la sortie de l’hôpital était de −5 ± 12 ml/min/1.73 mÀ la suite d’une néphrectomie, le rein controlatéral des patients atteints d’insuffisance rénale chronique de stade 3 à 5 possède toujours une capacité compensatoire significative du point de vue clinique. Par contre, la compensation est moindre si le patient souffre d’hypertension avant la chirurgie ou lorsqu’il subit une uniNPX radicale, elle est également rapide et probablement hémodynamique (hyperfiltration). Il importe également de noter que la majorité des patients ayant participé à l’étude avait une IRC de stade 3 et que ceci ne permet pas de tirer des conclusions sans équivoque pour les patients de stades 4 et 5. De plus, les observations se sont déroulées sur une très courte période, moins de deux semaines pour plus de la moitié de la cohorte, immédiatement après la chirurgie.

Background: To separate non-(1–84)parathyroid hormone [non-(1–84)PTH] from PTH(1–84), we developed new HPLC gradients and observed that the peak coeluting with hPTH(1–84) could be separated into two entities recognized by a cyclase-activating PTH (CA-PTH) assay that reacts with the first four amino acids of the PTH structure.Methods: Sera from six healthy individuals and five patients with primary hyperparathyroidism, and eight pools of sera from patients in renal failure were fractionated by HPLC. A total (T)-PTH assay reacting with the (15–20) region, the CA-PTH assay, and a COOH-terminal (C)-PTH assay with a (65–84) structure requirement were used to measure basal and fractionated PTH values.Results: T-PTH was higher than CA-PTH in all healthy controls [mean (SD), 3.13 (0.37) vs 2.29 (0.33) pmol/L; P Conclusions: This new molecular form of PTH has structural integrity of the (1–4) region but presumably is modified in the region (15–20), which is usually recognized by the T-PTH assay. Its clinical implications remain to be defined.

Background: The appropriate observation period, rate and risk factors of complications after a percutaneous renal biopsy remain debated. Methods: We retrospectively studied native kidney biopsies performed in our institution between January 2007 and July 2011. Outpatients had either an 8- (67%) or a 24-hour (33%) observation period. Results: 312 biopsies were reviewed (287 patients), 51% of patients were female and the mean age was 54 ± 15 years. Half of these biopsies were performed in outpatients. A total of 15% of patients developed a symptomatic hematoma, 9% received a red blood cell transfusion and 1% required an angio-intervention. Eighty-four percent of the complications manifested within the first 8 h, 86% at 12 h and 94% at 24 h. Outpatients experienced significantly less complications, all manifesting within the first 8 h, 14% required an observation period longer than planned. The risk of symptomatic hematoma increased to 11, 20, 35 and 40% in patients with >200, 140-200, 100-140 and 9/l platelets, respectively (p = 0.002). It also increased in hemodialysis patients (29% compared to 14%, p = 0.02). We found no association of risk with the number of biopsy passes and only a trend with needle size. Conclusion: Symptomatic hematomas occurred in 15% of kidney biopsies and were strongly associated with platelet count and hemodialysis. Outpatients experienced fewer complications; therefore, we can conclude that same-day discharge in selected patients is safe.

Background: Commercial intact parathyroid hormone (I-PTH) assays detect molecular form(s) of human PTH, non-(1-84) PTH, different from the 84-amino acid native molecule. These molecular form(s) accumulate in hemodialyzed patients. We investigated the importance of non-(1-84) PTH in the interpretation of the increased I-PTH in progressive renal failure.Methods: Five groups were studied: 26 healthy individuals, 12 hemodialyzed patients, and 31 patients with progressive renal failure subdivided according to their glomerular filtration rate (GFR) into 11 with a GFR between 60 and 100 mL · min−1 · 1.73 m−2, 12 with a GFR between 30 and 60 mL · min−1 · 1.73 m−2, and 8 with a GFR between 5 and 30 mL · min−1 · 1.73 m−2. We evaluated indicators of calcium and phosphorus metabolism and creatinine clearance (CrCl) in the progressive renal failure groups, and the HPLC profile of I-PTH and C-terminal PTH in all groups.Results: Only patients with a GFR Conclusions: As I-PTH increases progressively with GFR decrease, part of the increase is associated with the accumulation of non-(1-84) PTH, particularly when the GFR is

Cisapride (Propulsid) is a gastrointestinal prokinetic agent commonly used to treat nocturnal heartburn as well as a variety of other gastrointestinal disorders. The use of cisapride has been associated with acquired long QT syndrome and ventricular arrhythmias such as torsades de pointes which produces sudden cardiac death. These cardiotoxic effects can be due to blockade of one or more types of K+ channel currents in the human heart. For this reason we compared the effects of cisapride on two cloned human cardiac K+ channels, Kv1.5 and the human ether-a-go-go-related gene (HERG) stably transfected into mammalian cells. Using patch clamp electrophysiology, we found that cisapride was a potent inhibitor of HERG displaying an IC50 value of 44.5 nmol/l when tail currents at −40 mV were measured following a 2 s test depolarization to +20 mV. When HERG currents were measured at the end of prolonged (20 s) depolarizing steps to +20 mV, the apparent affinity of cisapride was increased and measured 6.70 nmol/l. The main effect of cisapride was to enhance the rate of HERG current decay thereby reducing current at the end of the voltage clamp pulse. Furthermore, the potency of cisapride for the HERG channel was similar to that observed for the class III antiarrhythmic agent dofetilide (IC50=15.3 nmol/l) and the nonsedating antihistamine terfenadine (IC50=56.0 nmol/l). In contrast to its effects on HERG, cisapride inhibited Kv1.5 channel currents weakly displaying an IC50 value of 21.2 μmol/l. It is concluded that cisapride displays specific, high affinity block of the human cardiac K+ channel HERG. It is likely that this interaction underlies the proarrhythmic effects of the drug observed under certain clinical settings.

Ascites becomes refractory to medical treatment in nearly 10% of cirrhotic patients, who then require repeated large-volume paracentesis. In this prospective study we evaluated the use of transjugular intrahepatic portosystemic shunt (TIPS) in 30 patients with refractory ascites. TIPS was successful in all and resulted in a 54% reduction in portacaval gradient (from 22.8 +/- 0.8 to 10.4 +/- 0.6 mm Hg). Ascites became easily controlled with diuretics in 26 patients following TIPS. Ascites recurrence associated with shunt stenosis was observed during follow-up in eight patients; revision could be undertaken in five of them and resulted in good control of ascites. In responders, a marked decrease in plasma aldosterone and renin activity, a reduction in serum creatinine, and a rise in urinary sodium excretion were observed. Creatinine and inulin clearances improved significantly; PAH clearance remained unchanged. However, new-onset or worsening hepatic encephalopathy was seen in 14 patients. Severe disabling chronic encephalopathy occurred in five patients; it could be reversed successfully by balloon occlusion of the shunt in three. The cumulative survival rate was 41 and 34% at 1 and 2 years, respectively. In summary, TIPS can control refractory ascites in a majority of patients but is associated with a high rate of chronic disabling HE. In addition, the survival rate is poor. Randomized trials are needed to evaluate the exact role of TIPS in the management of refractory ascites. It is unlikely to improve survival but can ameliorate quality of life in nontransplant candidates and be useful as a bridge to transplantation, in particular, to improve denutrition associated with longstanding tense ascites.

Background/Aims: Endothelin-1 (ET-1) is a potent vasoconstrictor that may be involved in the pathogenesis of splanchnic and renal hemodynamic changes associated with portal hypertension. The aim of this study was to measure the concentration of ET-1 and of its precursor Big endothelin-1 (Big ET-1) in the systemic circulation as well as in the splanchnic and renal venous beds and to evaluate changes after the relief of portal hypertension following transjugular intraheptic portosystemic shunt placement. Methods: Plasma concentrations of ET-1 and of Big ET-1 were measured in the vena cava, renal vein, hepatic vein and portal vein in ten patients with cirrhosis and refractory ascites before and 1–2 months after transjugular intrahepatic portosystemic shunt. The porto-caval gradient, creatinine clearance, plasma aldosterone and renin activity, as well as daily urinary sodium excretion were measured at the same time. Results: The plasma concentration of ET-1 and Big ET-1, respectively, in peripheral blood of normal volunteers were 0.28±03 and 3.95±0.34 pg/ml; the concentrations of both peptides were higher in patients with cirrhosis, both in vena cava (0.61±0.14 and 10.01±1.47 pg/ml), hepatic vein (0.62±0.13 and 13.93±1.77 pg/ml), portal vein (1.21±0.12 and 17.84±1.98 pg/ml) and renal vein (0.76±0.12 and 14.21±1.55 pg/ml). Moreover ET-1 and Big ET-1 concentrations were more elevated in the portal vein that in the vena cava (+98% and +70%) and slightly higher in the renal vein as compared to the vena cava (+25% and +42%). After transjugular intrahepatic portosystemic shunt, a rise in creatinine clearance and urinary sodium excretion (+49%; and +53%) was observed together with a marked reduction in plasma aldosterone and renin activity (−59% and −49%). ET-1 and Big ET-1 concentrations remained unchanged in the vena cava whereas a significant reduction of ET-1 and Big ET-1 occured both in the portal vein (−43% and − 44%) and in the renal vein (−53% and −29%). Portal vein and renal vein concentrations of both peptides became similar to vena cava levels. Conclusions: Splanchnic and renal hemodynamic changes occurring in patients with cirrhosis and refractory ascites could be related to the production of ET-1 by splanchnic and renal vascular beds. This was abolished by transjugular intrahepatic portosystemic shunt, which could explain the exacerbation of systemic vasodilation and the improvement in renal perfusion observed after the procedure.

A molecular form of PTH different from PTH-(1-84) and present in normal serum is recognized by two-site intact (I-) PTH assays; it responds to Ca2+ changes in the same way that PTH carboxyl-terminal fragments do. To evaluate the impact of this finding, we have compared basal, stimulated, and nonsuppressible I-PTH values in 14 normal subjects and 15 renal failure patients, subdivided into 8 patients with low (12 pmol/L; LBI) and 7 with high (12 pmol/L; HBI) basal I-PTH. Samples obtained under various calcemic conditions in these 3 groups were further fractionated by high performance liquid chromatography (HPLC) and assayed for I-PTH, and the various peaks observed were quantitated by planimetry. Differences among the 3 groups were reinterpreted knowing the exact composition of I-PTH. Basal I-PTH was greatly increased in HBI (mean +/- SD, 44.1 +/- 38.6 pmol/L) compared to that in normal subjects (2.5 +/- 0.8 pmol/L; P0.001) or LBI (6.1 +/- 2.4 pmol/L; P0.001); the difference was less in these last 2 groups (P0.01). Similar differences were observed for stimulated and nonsuppressible I-PTH, except for stimulated I-PTH, which was similar in normal and LBI subjects. Two I-PTH HPLC molecular forms accounted for I-PTH immunoreactivity in the 3 groups. In normal subjects, PTH-(1-84) accounted for 74.9 +/- 4.3%, 79.0 +/- 3.0%, and 87.2 +/- 1.0% of I-PTH in hyper-, normo-, and hypocalcemia, respectively, but only for 44.6 +/- 2.5%, 50.5 +/- 0.7%, and 63.6 +/- 0.1% in renal failure patients, with similar results in HBI and LBI. The accumulation of a non-(1-84) PTH peak accounted for the difference between normal subjects and renal failure patients. When basal, stimulated, and nonsuppressible I-PTH values were separated into their 2 components, prior differences between HBI and LBI or normal subjects remained unchanged because of very high I-PTH values in HBI, but differences between normal and LBI subjects were entirely explained by the accumulation of the non-(1-84) PTH peak [basal, 3.0 +/- 1.2 vs. 0.5 +/- 0.2 pmol/L (P0.001); stimulated, 6.8 +/- 2.3 vs. 2.3 +/- 1.0 pmol/L (P0.001); nonsuppressible, 1.3 +/- 0.7 vs. 0.2 +/- 0.08 pmol/L (P0.001)]; PTH-(1-84) values were similar (basal, 3.1 +/- 1.2 vs. 2.0 +/- 0.6 pmol/L; stimulated, 12.0 +/- 3.9 vs. 15.5 +/- 6.6 pmol/L; nonsuppressible, 1.1 +/- 0.6 vs. 0.52 +/- 0.22 pmol/L). Thus, a non-(1-84) PTH molecular form detected by two-site I-PTH assays accumulates in renal failure and accounts for a larger proportion of I-PTH than that in normal subjects. Levels of I-PTH 1.57 times higher than those in normocalcemic subjects are thus required in renal failure to achieve similar PTH-(1-84) concentrations. The composition of I-PTH is also identical in all hemodialyzed patients.

Uncontrolled hypertension is associated with an increased risk of end-stage renal disease (ESRD). Intensified blood pressure control may slow progression of chronic kidney disease; however, the impact of antihypertensive agent adherence on the prevention of ESRD has never been evaluated. Here we assessed the impact of antihypertensive agent adherence on the risk of ESRD in 185,476 patients in the RAMQ databases age 45 to 85 and newly diagnosed/treated for hypertension between 1999 and 2007. A case cohort study design was used to assess the risk of and multivariate Cox proportional models were used to estimate the adjusted hazard ratio of ESRD. Adherence level was reported as a medication possession ratio. Mean patient age was 63 years, 42.2% male, 14.0% diabetic, 30.3% dyslipidemic, and mean follow-up was 5.1 years. A high adherence level of 80% or more to antihypertensive agent(s) compared to a lower one was related to a risk reduction of ESRD (hazard ratio 0.67; 95% confidence intervals 0.54–0.83). Sensitivity analysis revealed that the effect is mainly in those without chronic kidney disease. Risk factors for ESRD were male, diabetes, peripheral artery disease, chronic heart failure, gout, previous chronic kidney disease, and use of more than one agent. Thus, our study suggests that a better adherence to antihypertensive agents is related to a risk reduction of ESRD and this adherence needs to be improved to optimize benefits.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT • Non-adherence is probably an important source of preventable cardiovascular morbidity and mortality. • However, until now there have been very few large effectiveness studies assessing the relationship between adherence levels to antihypertensive medication and major cardiovascular outcomes for primary prevention of cardiovascular disease. WHAT THIS STUDY ADDS • The study results suggest that there is an association between better adherence to antihypertensive agents and a relative risk reduction of coronary artery disease. • Adherence to antihypertensive agents needs to be improved so that patients can benefit from the full protective effects of antihypertensive therapies. AIMS Antihypertensive (AH) agents have been shown to reduce the risk of cardiovascular events, including coronary artery disease (CAD). Previous surveys have shown that a substantial number of patients with diagnosed hypertension remain uncontrolled. Non-adherence to AH agents may reduce the effectiveness. The aim was to evaluate the impact of better adherence to AH agents on the occurrence of CAD in a real clinical setting. METHODS A cohort of 83 267 patients was reconstructed using the Regie de l'assurance maladie du Quebec databases. Patients were eligible if they were between 45 and 85 years of age without indication of cardiovascular disease, and had been newly treated with AH agents between 1999 and 2004. A nested case–control design was used to study the incidence of CAD. Every case of CAD was matched for age and duration of follow-up to up to 15 randomly selected controls. The adherence level was measured by calculating the medication possession ratio. Cases' adherence was calculated from the start of follow-up to the time of the CAD (index date). For controls, adherence was calculated from the start of follow-up to the time of selection (index date). Rate ratios of CAD were estimated by conditional logistic regression adjusting for covariables. RESULTS The mean patient age was 65 years, 37% were male, 8% had diabetes and 18% had dyslipidaemia. High adherence level (96%) to AH therapy compared with lower adherence level (59%) was associated with a relative risk reduction of CAD events (rate ratios 0.90; 0.84, 0.95). Risk factors for CAD were male gender, diabetes, dyslipidaemia and developing a cardiovascular condition disease during follow-up. CONCLUSION Our study suggests that better adherence to AH agents is associated with a risk reduction of CAD. Adherence to AH agents needs to be improved so that patients can benefit from the full protective effects of AH therapies.

The ganglioside composition of seven experimental brain tumors was examined in C57BL/6J mice. The tumors were produced from 20-methylcholanthrene (20-MC) implantation into either the cerebrum or cerebellum and were maintained in serial transplants through many generations. The tumors studied were grown subcutaneously as solid tumors, and cells from two of the tumors were also studied in culture. Histologically, all of the tumors were similar and could be broadly classified as highly malignant, poorly differentiated anaplastic astrocytomas. The total ganglioside sialic acid content of the solid tumors was markedly lower than that in adult mouse brain. In addition to N-acetylneuraminic acid (NeuAc), the gangliosides in the solid tumors contained significant amounts of N-glycolylneuraminic acid (NeuGc). The seven solid tumors fell into two general groups with respect to ganglioside composition. Furthermore, the differences in ganglioside composition between the two tumor groups were strongly associated with differences in tumor cell cohesion. The tumors in one group had high levels of GM3 hematosides, low levels of oligosialogangliosides, and grew as firm cohesive tissues. The tumors in the other group, however, had lower levels of GM3 hematosides, noticeable amounts of oligosialogangliosides and grew as soft noncohesive tissues. In culture, clonal cells from one of the tumors in the first group grew as clumps or islands and contained GM3 as the only major ganglioside, whereas clonal cells from a tumor in the second group grew as sheets or monolayers and contained little GM3, but expressed several gangliosides with complex structures. In marked contrast to the gangliosides in the solid tumors, the gangliosides in the cultured tumor cells contained trace amounts of NeuGc. Since NeuGc containing gangliosides are abundant in mouse nonneural tissues, the high content of NeuGc gangliosides in the solid tumors may arise from infiltration of nonneural tissue elements, e.g., macrophages, lymphocytes, and endothelial cells.

Transjugular intrahepatic portosystemic shunt (TIPS) is used increasingly as a treatment for refractory ascites. The aim of the present study was to determine the prognostic value of different parameters in predicting a favorable evolution following TIPS in a cohort of 53 cirrhotic patients without organic renal disease and with refractory ascites.Patients were classified as good responders if they survived more than 6 months, without severe chronic hepatic encephalopathy and with good control of ascites. The prognostic value for a good outcome was evaluated using age, creatinine clearance, plasma renin activity, plasma aldosterone, and Pugh score.Good control of ascites was obtained in 90%. The cumulative survival rate was 54% at 6 months, 48% at 1 yr, and 39% at 2 yr. The vast majority of patients died of complications of hepatic insufficiency. Severe chronic hepatic encephalopathy developed in 26%. Overall, a good clinical response was observed in 47%. Creatinine clearance was identified as the only pre-TIPS factor to be significantly and independently associated with a good clinical response to TIPS for refractory ascites. A good clinical response was observed in 57% of patients with a creatinine clearance36 ml/min compared to 9% of those with a clearance36 ml/min (p0.01). This cutoff point in creatinine clearance had a sensitivity of 96% and a specificity of 36%; positive predictive and negative predictive values were 57% and 90%, respectively.TIPS might be useful for the treatment of refractory ascites in cirrhotic patients without severe renal function impairment. However, the TIPS usefulness still has to be demonstrated compared to large volume paracentesis or Leveen shunt. In patients with poor renal function or with liver failure after TIPS, liver transplantation should be considered.

An increased set point of PTH stimulation by ionized calcium (Ca++) has been observed in renal failure patients with severe secondary hyperparathyroidism. The extension of this concept to all renal failure patients has remained problematic, even if it could explain elevated PTH levels in the absence of other biochemical abnormalities. We were particularly interested in seeing whether the concept could fit patients with progressive renal failure (PRF). To achieve this, we studied 26 normals (N), 9 patients with PRF, and 12 hemodialyzed patients (HD) in the basal state and during parathyroid function tests. The latter two groups were studied at the end of winter and end of summer, respectively. Patients with PRF had normal levels of Ca++, PO4, and 1,25(OH)2D, and they had low-normal concentrations of 25(OH)D; their basal I- and C-PTH levels were 3- and 4-fold higher than N, as were their creatinine levels. HD had significantly lower levels of Ca++ and 1,25(OH)2D, and they had higher levels of phosphate, creatinine, I-PTH, and C-PTH than N or PRF. Stimulated levels of I-PTH were similar in N (13.6 +/- 4.3 pmol/L) and PFR (18 +/- 3.3 pmol/L) and elevated in HD (37.1 +/- 28.7 pmol/L; P0.001 vs. N, and P0.05 vs. PRF). Nonsuppressible I-PTH was increased 2-fold in PRF (N = 0.64 +/- 0.19 vs. PRF = 1.28 +/- 0.46 pmol/L; P0.01) and 6-fold in HD (3.95 +/- 2.85 pmol/L; P0.001 vs. others). But the set point of I-PTH stimulation by Ca++ was normal in PRF (N = 1.18 +/- 0.03 vs. PRF = 1.20 +/- 0.04 mmol/L; not significant) and decreased in HD (1.09 +/- 0.04 mmol/L; P0.001 vs. others). Similar results were obtained with the set point of C-PTH and of the C-PTH/I-PTH ratio. A positive correlation was observed between serum Ca++ concentration and the set point value when all three populations were analyzed together (r = 0.759, n = 47, P0.0001). These results indicate that the set point of PTH stimulation is normal in PRF and decreased in hypocalcemic HD. The set point seems to adjust to the ambient Ca++ concentration of the patients, by mechanisms yet to be elucidated. This does not suggest participation of this factor to the genesis of the secondary hyperparathyroidism of PRF.

We have previously shown that the Nichols assay for intact parathyroid hormone (I-PTH) reacts with a non-(1–84) molecular form of PTH. This form behaves as a carboxy-terminal fragment and accumulates in renal failure, accounting for 40–60% of the measured immunoreactivity. We wanted to see whether this was a common event with other commercial two-site I-PTH assays. We thus compared the ability of three commercial kits [Nichols (NL), Incstar (IT), and Diagnostic System Laboratories (DSL)] to measure I-PTH in 112 renal failure patients and to detect hPTH(1–84) and non-(1–84)PTH on HPLC profiles of serum pools from uremic patients with I-PTH concentrations of 10–100 pmol/L. The behavior of synthetic hPTH(7–84), a fragment possibly related to non-(1–84)PTH was also compared with hPTH(1–84) in the three assays. The I-PTH concentrations measured with the three assays in the 112 uremic samples were highly related (r2 ≥ 0.89, P

Substance P like immunoreactivity (SPLI) and total protein (TP) concentrations in plasma and saliva were measured in 80 healthy female patients divided into the following four groups: women in group 1 were not pregnant and they were awaiting tubal ligation; women in group 2 were not pregnant but they experienced acute postoperative pain following hysterectomy; women in group 3 were pregnant and were awaiting elective cesarean section; and women in group 4 were in active labor and experienced acute labor pain. Pain intensity was assessed using verbal Likert pain scores. The absolute measured concentration of SPLI (SPLIabs) was divided by the TP concentration to obtain corrected SPLI (SPLIcorr) concentration. Results were expressed mean +/- 1 SE and analyzed using analysis of variance with 95% confidence (P < 0.05). SPLIcorr concentrations were 1.8 +/- 0.1, 1.8 +/- 0.2, 1.1 +/- 0.1 1.1 +/- 0.1 pg/mg protein in groups 1, 2, 3 and 4, respectively. Patients in both pregnant groups had significantly lower plasma SPLIcorr concentrations compared to the non-pregnant groups. However, the presence of acute postoperative pain or labor pain did not significantly alter plasma SPLIcorr concentrations. Saliva SPLI concentrations were not significantly different among the four groups.

We present an unusual case of postoperative headache in a child after an epidural block. A seven-year-old girl (ASA 1) was scheduled to undergo a urological procedure under general anaesthesia combined with an epidural technique for intra- and postoperative analgesia. Although there was no evidence of dural puncture when the block was performed, the patient developed a headache postoperatively. The headache, which was accompanied by neck pain, appeared in the sitting or standing position and was relieved by decubitus. According to the mother, her child had never complained of those symptoms in the past. After independent evaluation by an anaesthetist and a neurologist, a postdural puncture headache (PDPH) was considered the most likely diagnosis. As oral analgesics failed to provide relief, and epidural blood patch (EBP) using 10 ml autologous blood was performed under light sedation. This was followed by resolution of the symptoms. Epidural injections of opioids and local anaesthetics are becoming increasingly popular for pain management in children. This implies that there may be an increasing number of unintentional dural punctures that may result in more PDPHs in children. Epidural blood patches are effective in treating PDPHs in adults but their use has been reported very rarely in children. Resolution of the patient's symptoms following EBP supported the diagnosis while illustrating that EBP can be useful in the treatment of PDPH in children.

Although infectious mononucleosis is usually a benign illness, life-threatening complications may occur. We describe a 17-year-old pregnant girl who developed necrotizing epiglottitis and dysphagia progressing to aspiration pneumonia and respiratory failure. The factors predisposing to this life-threatening complication are discussed.