Immunological properties of subcellular rat lymphocyte preparations. Primary allogeneic stimulation in vitro by fractions containing Ia (RT1-B), but not RT1-A antigens.

Rat thymocyte membrane fractions have been prepared which exhibit strain-specific primary mixed-lymphocyte reaction (MLR)-stimulating and Ia (RT1-B) antigenic properties. These preparations lack the antigenicity of classical, serologically-defined RT1-A (Ag-B) antigens, as defined by in vitro serologic assays. Furthermore, after immunization of allogeneic hosts, specific anti-Ia and MLR-blocking antibodies, but not anti-AgB, alloantibodies are elaborated. Thymidine suicide experiments show that the same clones respond to whole cells and the fragments made from those cells, and the response segregates appropriately in F2 progeny as a major histocompatibility complex (RT1)-linked phenomenon. Hence, it is possible to generate Ia-related allogeneic helper signals in primary, as well as secondary, in vitro responses, using subcellular membrane fragments that have restricted expression of RT1-B-, but not RT1-A-, encoded antigens.

Response to inhaled beta-agonist in a patient receiving beta-adrenergic blockers.

A 52-year-old man receiving long-term hemodialysis and a beta-adrenergic blocker for hypertension had symptoms of acute bronchospasm when exposed to a new hemodialyzer. Resistant to two doses of subcutaneous epinephrine (1 mL of 1:1000 dilution) and one intravenous dose of aminophylline (250 mg), the bronchospasm was rapidly relieved by metaproterenol sulfate given by inhalation one hour later.

Psychosocial crisis in diabetic renal failure.

Twenty-nine diabetic renal failure patients suffered a psychosocial crisis at the time when chronic dialysis or renal transplantation was required. These patients could be classified into groups as to the impact of the crisis in terms of participation in life-support therapy. Group 1 consisted of potentially lethal mechanism (9 patients): discontinued dialysis (5); refused to start dialysis (3); overt act to cause personal harm (1). Group 2 contained probably nonlethal mechanism (11 patients): threatened to discontinue dialysis or to never start dialysis if not given a chance for a transplant (5); threatened to discontinue dialysis or to never start dialysis (5); threatened to cause personal harm (1). Group 3 consisted of a combination of mechanisms (9 patients): with drug abuse (4); without drug abuse (5). Important similarities between the groups were easier to document than were subtle differences in the kinds of options in family and employment relationships; in the degree of objective and subjective handicap due to impaired vision; in the level of expectation and/or disappointment following renal transplantation; and in the capacity to cope with changing personal relationships produced by the complications of diabetes.

Beta-thromboglobulin levels in the nephrotic syndrome.

Beta-thromboglobulin (BTG), a platelet-specific protein released on platelet aggregation, was measured in 13 patients with clinical and biochemical evidence of the nephrotic syndrome. All 13 patients had increased concentrations of BTG compared to both 10 normal controls and to 12 non-nephrotic azotemic patients (p < 0.001). In five patients with the nephrotic syndrome in remission, the BTG levels returned to normal. These results support the contention that the nephrotic syndrome is associated with a state of hypercoagulability and suggest that increased platelet aggregation may be the primary underlying mechanism.

Tuberculosis in patients undergoing maintenance hemodialysis.

Tuberculosis was diagnosed in eight patients undergoing maintenance hemodialysis and occurred with an incidence 10 times that of the general population. Dialysis-associated tuberculosis is characterized by intermittent fever, anorexia, weight loss and hepatomegaly. Ascites was present in 50 per cent of the patients. A recently converted positive tuberculin skin test was observed in five of eight patients. Tuberculosis was extrapulmonary in seven of eight cases and consequently the diagnosis was frequently delayed. Over-all mortality was 37.5 per cent and correlated with the duration of symptoms prior to initiation of therapy. A trial of antituberculous therapy is warranted in patients undergoing dialysis in whom fever of unknown origin, anorexia, weight loss and/or hepatomegaly develop particularly in areas endemic for tuberculosis.

Quality of life: subjective and objective improvements with recombinant human erythropoietin therapy.

The debilitating symptoms of the anemia associated with end-stage renal disease (ESRD) may have a profound effect on patients' quality of life. Until now it has been difficult to differentiate symptoms caused by the anemia from those caused by uncleared uremic toxins and other concomitant diseases. Treatment with recombinant human erythropoietin (EPOGEN, AMGEN Inc, Thousand Oaks, CA) largely eliminates the anemia associated with ESRD; it therefore offers a means of improving patients' quality of life while also clarifying the possible causes of the various symptoms. However, because quality of life involves many factors, such as self-concept, interpersonal relations, and work identity, an improvement in the anemia will have a varying impact on different individuals.

Prehepatic hyperalimentation.

A technique for prehepatic infusion of parenteral nutrients is described. Portal vein hyperalimentation allows hepatic modification and control of the infused nutrients before delivery of these substances into the general circulation and theoretically should reduce the incidence of metabolic complications of hyperalimentation. The clinical experience with prehepatic infusions is reported and the metabolic investigations are described. Transumbilical catheters provided prehepatic delivery of parenteral nutrients for 1 month after esophagogastrectomy for esophageal malignancy without serious infection or portal vein thrombosis. Close surveillance of blood glucose and serum osmolarity demonstrated metabolic stability during the infusion period. Nitrogen balance studies showed better nitrogen economy than is achieved by infusion of similar solutions into the central systemic circulation. Indirect calorimetry indicated that the nitrogen used for production of energy was less than the amount supplied by prehepatic infusions. The same basic liver function abnormalities encountered with systemic infusion of hyperalimentation solutions were noted. The patients gained weight after esophagogastrectomy and did not experience the attrition from malnutrition which usually occurs in the first several months after esophageal resection.

Dialysate delivery: historical, theoretical, and practical aspect.

Maintenance hemodialysis has progressed from a tentative therapy for a few patients in Seattle to a generally available treatment sustaining 100,000 patients around the world. The technical principles of dialysis are sufficiently understood to permit fabrication of disposable dialyzers in sheet, coil, or hollow-fiber configuration. Dialysate delivery systems can serve either single patients or groups of patients with high efficiency. Reduction in size of single-parent systems by incorporation of dialysate regeneration or miniaturization of components in a suitcase will promote patient mobility.

Perspectives on the improvement of quality of life with epoetin alfa therapy.

Epoetin alfa (recombinant human erythropoietin) effectively diminishes the anemia associated with end-stage renal disease (ESRD). Although many clinical manifestations of ESRD have been attributed to uremic toxins, the ability of epoetin alfa therapy to improve several of these conditions, such as diminished energy levels, appetite, cold tolerance, sexual function, and cognitive abilities, suggests that anemia may be an important factor in uremia-associated symptoms. Correction of this anemia results in improvements in the patient's quality of life. These improvements can be measured by objective criteria such as exercise tolerance tests, or by subjective standards such as patient response to questionnaires. In studies to date, both subjective and objective data show that epoetin alfa therapy significantly improves the quality of life of patients with ESRD.

Absence of anemia in maintenance hemodialysis.

Anemia is usual in untreated uremia. Persistent anemia is thought to be universal in uremic patients treated by maintenance hemodialysis (MH). A retrospective chart analysis of 549 patients on (MH) at five facilities in Brooklyn, found that eleven (2%) of these patients had a hematocrit (Hct) in the normal range (40%). To distinguish this subset of patients from the majority of MH, we compared both groups for: (1) etiology of the renal disease, (2) presence of residual renal function, (3) dialysis prescription, (4) decreased arterial O2 saturation, (5) greater use of vitamins or anabolic steroids, (6) absence of parathyroid disease. The relatively high hematocrit was not explained by any factor evaluated in this small subset of MH patients.