Neonatal Acute Kidney Injury: A Survey of Neonatologists' and Nephrologists' Perceptions and Practice Management.

BACKGROUND: Neonatal acute kidney injury (AKI) occurs in 40 to 70% of critically ill neonatal intensive care admissions. This study explored the differences in perceptions and practice variations among neonatologists and pediatric nephrologists in diagnostic criteria, management, and follow-up of neonatal AKI. METHODS: A survey weblink was emailed to nephrologists and neonatologists in Australia, Canada, New Zealand, India, and the United States. Questions consisted of demographic and unit practices, three clinical scenarios assessing awareness of definitions of neonatal AKI, knowledge, management, and follow-up practices. RESULTS: Many knowledge gaps among neonatologists, and to a lesser extent, pediatric nephrologists were identified. Neonatologists were less likely to use categorical definitions of neonatal AKI (p < 0.00001) or diagnose stage 1 AKI (p < 0.00001) than pediatric nephrologists. Guidelines for creatinine monitoring for nephrotoxic medications were reported by 34% (aminoglycosides) and 62% (indomethacin) of respondents. Nephrologists were more likely to consider follow-up after AKI than neonatologists (p < 0.00001). Also, 92 and 86% of neonatologists and nephrologists, respectively, reported no standardization or infrastructure for long-term renal follow-up. CONCLUSION: Neonatal AKI is underappreciated, particularly among neonatologists. A lack of evidence on neonatal AKI contributes to this variation in response. Therefore, dissemination of current knowledge and areas for research should be the priority.

Neurodevelopmental outcomes among extremely premature infants with linear growth restriction.

OBJECTIVE: To compare neurodevelopmental outcomes in linear growth-restricted (LGR) infants born <29 weeks with and without weight gain out of proportion to linear growth. STUDY DESIGN: We compared 2-year neurodevelopmental outcomes between infants with and without LGR and between LGR infants with and without weight gain out of proportion to linear growth. The outcomes were Bayley-III cognitive, motor, and language scores, cerebral palsy, Gross Motor Function Classification System (GMFCS) level ≥ 2, and neurodevelopmental impairment. RESULT: In total, 1227 infants were analyzed. LGR infants were smaller and less mature at birth, had higher BMI, and had lower Bayley-III language scores (82.3 vs. 85.0, p < 0.05). Among infants with LGR, infants with high BMI had lower language scores compared with those with low-to-normal BMI (80.8 vs. 83.3, p < 0.05), and were more likely to have GMFCS level ≥2 and neurodevelopmental impairment. CONCLUSION: Among infants with LGR, weight gain out of proportion to linear growth was associated with poorer neurodevelopmental outcomes.

Neurodevelopmental outcomes in postnatal growth-restricted preterm infants with postnatal head-sparing.

OBJECTIVE: To compare neurodevelopmental outcomes in postnatal growth-restricted infants born <29 weeks with and without postnatal head-sparing (PHS). STUDY DESIGN: We analyzed developmental outcomes at 2 years of age among postnatally growth-restricted infants with and without head-sparing. The primary outcome was Bayley III cognitive composite score; secondary outcomes included Bayley III motor composite score, moderate/severe cerebral palsy, gross motor functional classification scale level⩾2, and presence or absence of neurodevelopmental impairment (NDI). RESULTS: Of 1098 infants evaluated at 18 to 22 months, 658 were postnatally growth restricted, of whom 301 had head-sparing. In the multivariate model including independent risk factors for poor growth and poor developmental outcome, infants with head-sparing had higher adjusted motor composite scores (mean difference 4.65, P<0.01), but no differences in other neurodevelopmental outcomes. CONCLUSION: PHS is associated with improved neurodevelopmental outcome in extremely preterm infants, specifically Bayley III motor scores, but whether beneficial effects of PHS persist later in life is unknown.

Aging-related changes in brain metabolism are altered by early developmental exposure to diazepam.

To study the long-term effects of prenatal diazepam (DZ) exposure, 31P NMR (nuclear magnetic resonance) spectra and levels of thiobarbituric acid (TBA)-reactive material were measured in the brains of rats from 3 to 26 months of age. In control rats, there were aging-related increases in levels of TBA-reactive material, decreases in intracellular pH (pHi) and alterations in phosphocreatine (PCr) utilization. Prenatal (late gestational) DZ exposure induced lasting, dose-related and age-related alterations in levels of TBA-reactive material and pHi. The results indicate that the prenatal chemical environment can influence cellular metabolism throughout the lifetime of the organism, and that the process of aging can in turn interact with the consequences of prenatal drug exposure.

Electrographic seizures in neonates correlate with poor neurodevelopmental outcome.

OBJECTIVE: To quantify the number, duration, and intensity of electrographic seizures (ESz) in neonates and to compare the outcome of neonates with ESz with those who were at risk but did not have ESz recorded. METHODS: The EEG and outcome data were reviewed from 68 infants who met at-risk criteria for neonatal seizures and underwent prolonged continuous EEG monitoring. Forty infants had ESz. The control group contained 28 infants monitored for at least 18 hours and found not to have ESz. Outcomes for both groups were evaluated using hospital and follow-up clinic records and a standardized telephone interview. RESULTS: The etiology of ESz included asphyxia (n = 23), stroke (n = 7), and other (n = 10, intraparenchymal, subdural, and subarachnoid bleeding; meningitis; sepsis; hyponatremia; and unknown). The cumulative recorded ESz duration was 8 minutes to 30 hours. Forty-three percent of infants with ESz spent 38 minutes to 32 hours in electrographic status. Despite doses of 40 mg/kg of phenobarbital and 20 mg/kg of phenytoin, 30% of infants continued to have ESz. Ten infants with ESz and one without died from causes related to neurologic instability. The occurrence of ESz was correlated with microcephaly (p = 0.04), severe cerebral palsy (CP) (p = 0.03), and failure to thrive (p = 0. 03). In the subgroup of infants with asphyxia, those with ESz were more likely to die of neurologic causes (p = 0.02) and have microcephaly (p = 0.05) or severe CP (p = 0.04). Additionally, those with the greatest number of ESz were more likely to have these severe outcomes. CONCLUSION: The authors' data indicate an association between the amount of electrographic seizure activity and subsequent mortality and morbidity in at-risk infants in general and in infants with perinatal asphyxia. Only with more effective treatment of neonatal electrographic seizures can their potential contribution to poor neurodevelopmental outcome, independent of degree of insult, be ascertained.

Casein peptide release and passage to the blood in humans during digestion of milk or yogurt.

In adult humans, after milk or yogurt ingestion, many peptides derived from alpha s1-, beta- or kappa-caseins were detected in stomach, including the kappa-caseinoglycopeptide, an inhibitor of platelet aggregation. Smaller peptides derived from casein and lactoferrin were recovered from duodenum. Two long peptides, the kappa-caseinoglycopeptide and the N-terminal peptide of alpha s1-casein, were absorbed and detected in plasma. These results support the concept that food-born peptides could have physiological activities in man.

Neonatal exposure to therapeutic caffeine alters the ontogeny of adenosine A1 receptors in brain of rats.

Caffeine is a methylxanthine, commonly used in the premature neonate to treat apnea of prematurity. It is efficacious and appears to have few short-term side effects. An animal model, designed to mimic the developmental period in brain and level and duration of exposure in humans, was used to investigate possible long-term effects of early developmental exposure to caffeine on the ontogeny of the adenosine receptor to which caffeine binds. Specific binding at the adenosine A1 receptor, in five distinct regions of the brain was determined in rats, 14-90 days old, as a function of early postnatal exposure to caffeine, over days 2-6. In cortex, cerebellum and hippocampus but not in the brain stem or hypothalamus, there was an increase in specific binding, following neonatal exposure to caffeine, compared to specific binding in control animals. Kinetic analysis of binding to the A1 site in cortical tissue suggests that this increase was due to an increased maximum binding density (Bmax); binding affinity (Kd) did not change. Thus, limited exposure to caffeine, in the early neonatal period, may result in up-regulation of the adenosine A1 receptor that persists to young adulthood in the rat.

Brainstem maturation in premature infants as a function of enteral feeding type.

OBJECTIVE: To determine whether brainstem maturation as measured by brainstem auditory-evoked responses (BAERs) in preterm infants is a function of dietary intake. STUDY DESIGN: We obtained serial BAERs on infants 28 to 32 weeks' gestation at birth, cared for in the neonatal intensive care unit of a regional referral center in Upstate New York. Waveforms were analyzed for replicability and for the presence of waves III and V. Absolute and interwave latencies were measured. Baseline and follow-up BAER measurements were compared, and the rates of change were calculated. Patient charts were reviewed for type of enteral feeding during the interval between BAERs. Student's t test was used to analyze continuous variables and chi(2) analysis was used to analyze categorical variables. RESULTS: Data from 37 study infants (17 fed breast milk and 20 fed commercial premature formula) revealed that there was no difference in absolute latencies of waves III and V at baseline; however, the rates of decrease of absolute latencies over the study interval were significantly greater in infants receiving human milk. CONCLUSIONS: Infants fed breast milk have faster brainstem maturation, compared with infants fed formula, based on the rate of maturation of BAERs. This effect may be attributable to the constituent composition of breast milk, compared with synthetic formulas.

In vivo 31P nuclear magnetic resonance measurement of chronic changes in cerebral metabolites following neonatal intraventricular hemorrhage.

The purpose of this study was to determine whether cerebral metabolic changes occur after intraventricular hemorrhage in the newborn. Five babies with bilateral grade 3 to 4 intraventricular hemorrhage were compared with 15 preterm infants without intraventricular hemorrhage. Cerebral high-energy phosphorus metabolites and intracellular pH were measured with in vivo 31P nuclear magnetic resonance spectroscopy. Spectra were collected initially within the first 2 weeks of life, and then every other week until discharged from the hospital. The phosphocreatine to inorganic phosphate ratio and the phosphocreatine to adenosine triphosphate ratio were significantly lower in the group with intraventricular hemorrhage, but differences in intracellular pH were not significant. Differences between babies with and without intraventricular hemorrhage varied with postconceptional age: in those with intraventricular hemorrhage, the phosphocreatine to adenosine triphosphate ratio was decreased at all postconceptional ages, and the phosphocreatine to inorganic phosphate ratio was lower in babies with intraventricular hemorrhage and younger than 30 weeks. Results of this study confirm the presence of chronic metabolic changes following intraventricular hemorrhage which may exacerbate neurologic damage after intraventricular hemorrhage in the newborn.

Early dexamethasone-attempting to prevent chronic lung disease.

BACKGROUND: We previously demonstrated improved survival and early outcomes in a pilot trial of 2 doses of intravenous dexamethasone for infants with surfactant-treated respiratory distress syndrome. (1) A multicenter, randomized, double-blind trial was undertaken to confirm these results. METHODS: Infants <30 weeks' gestation were eligible if they had respiratory distress syndrome, required mechanical ventilation at 12 to 18 hours of age, and had received at least 1 dose of exogenous surfactant. Infants were excluded if sepsis or pneumonia was suspected or if congenital heart disease or chromosomal abnormalities were present. A total of 384 infants were enrolled-189 randomized to dexamethasone (.5mg/kg birth weight at 12-18 hours of age and a second dose 12 hours later) and 195 to an equal volume of saline placebo. RESULTS: No differences were found in the dexamethasone versus placebo groups, respectively, regarding the primary outcomes of survival (79% vs 83%), survival without oxygen at 36 weeks' corrected gestational age (CGA; both 59%), and survival without oxygen at 36 weeks' CGA and without late glucocorticoid therapy (46% vs 44%). No significant differences between the groups in estimates from Kaplan-Meier survival analyses were found for median days on oxygen (50 vs 56 days), ventilation (20 vs 27 days), days to regain birth weight (15.5 vs 14 days), or length of stay (LOS; 88 vs 89 days). Infants given early dexamethasone were less likely to receive later glucocorticoid therapy for bronchopulmonary dysplasia during their hospitalization (27% vs 35%). No clinically significant side effects were noted in the dexamethasone group, although there were transient elevations in blood glucose and blood pressure followed by a return to baseline by study day 10. Among infants who died (40 vs 33), there were no differences in the median days on oxygen, ventilation, nor LOS. However, in survivors (149 vs 162), the following were observed: median days on oxygen 37 versus 45 days, ventilation 14 versus 19 days, and LOS 79 versus 81 days, for the dexamethasone versus placebo groups, respectively. CONCLUSIONS: This dose of early intravenous dexamethasone did not reduce the requirement for oxygen at 36 weeks' CGA and survival was not improved. However, early dexamethasone reduced the use of later prolonged dexamethasone therapy, and among survivors, reduced the median days on oxygen and ventilation. We conclude that this course of early dexamethasone probably represents a near minimum dose for instituting a prophylactic regimen against bronchopulmonary dysplasia.

Anesthetic-induced corneal lesions in developmentally sensitive rats.

Developmental critical periods for the induction of abnormalities by exposure to exogenous substances need not be confined to the early embryonic stage of organogenesis. The combination of ketamine hydrochloride and xylazine, two commonly used anesthetic agents, resulted in a corneal epithelial calcium deposition in 84% of rat pups whose exposure was limited to a single injection during the third postnatal week only. Concurrent exposure to ketamine hydrochloride, xylazine, and yohimbine, an alpha 2 adrenergic receptor antagonist, resulted in corneal lesions in only 6% of rat pups so exposed. The etiology is presently not understood but may involve interference with neurally directed corneal development. Corneal desiccation may also play a role. Altered drug metabolism, and toxic interactions resulting from a changing oxygen or light milieu are less likely etiologic mechanisms. Aspects of corneal development and mechanisms by which drugs can interact with and disturb normal maturational sequences can now be approached.

Early developmental exposure to benzodiazepine ligands alters brain 31P-NMR spectra in young adult rats.

Alterations in brain high energy phosphate compounds, using 31P-NMR (nuclear magnetic resonance) spectroscopy, were measured in vivo in young adult (3-4 months) rats following prenatal exposure to ligands acting specifically at benzodiazepine (BDZ) binding sites. The exposure induced a decrease in intracellular pH that indicated a predominant interaction of the drugs in utero with central-type BDZ receptor sites. Late gestational exposure to BDZ ligands also induced changes in brain phosphocreatine (PCr) utilization. Exposure to the lowest dose of DZ (1.0 mg/kg) but not the higher dose (2.5 mg/kg) induced a significant change in PCr utilization. Exposure to the central-type BDZ receptor antagonist RO15-1788 alone clearly altered PCr utilization in adult offspring, and DZ (2.5 mg/kg) when administered concurrently was not able to prevent this effect. Though exposure to a peripheral-type ligand (PK11195) had no effect by itself, it converted the effect of the high dose of DZ to that of the low dose. Together, these results indicate an interaction during development between the central and peripheral-type BDZ binding sites on organization and/or regulation of cellular energy metabolism. Normalized ATP levels were not changed by any prenatal treatment indicating adequate buffering of intracellular ATP by phosphocreatine. The dopaminergic antagonist haloperidol did not alter intracellular pH or any index of phosphate metabolism indicating a selective receptor mediated role for BDZ ligands in influences on the long term organization of intracellular phosphate metabolism.

Neonatal caffeine exposure alters seizure susceptibility in rats in an age-related manner.

Early developmental exposure to caffeine in rats results in decreased susceptibility to certain chemically-induced seizures in the adult. To determine whether this effect first appears in adulthood or is present during preceding developmental stages, we exposed neonatal rats to caffeine and determined seizure thresholds in animals 28, 42 and 70-90 days of age. Rats were unhandled or received either vehicle (water) or caffeine (15-20 mg/kg/day) by gavage (0.05 ml/10 g) over postnatal days 2-6. At 28, 42, or 70-90 days of age, rats were infused intravenously with picrotoxin (PIC), bicuculline (BIC), pentylenetetrazol (PTZ), caffeine (CAFF), strychnine (STR), or kainic acid (KA). Seizure thresholds for each compound were analyzed as a function of neonatal treatment, sex, and age. At 28 days, neonatally caffeine-exposed rats had a higher seizure threshold only for PTZ (P < 0.03). At 42 days, neonatally caffeine-exposed rats had higher seizure thresholds for PIC (P < 0.0007) and PTZ (P < 0.0001) than did controls. These results at 28 and 42 days are compared with previously reported data that demonstrated that in adulthood, rats neonatally exposed to caffeine have higher thresholds for seizure induction with CAFF, PTZ, and KA. Thus, early developmental exposure to caffeine results in decreases in seizure susceptibility that are agent specific and may result in a delay in the decrease in seizure threshold that occurs for many agents between late juvenile ages and adulthood.

Neonatal caffeine alters passive avoidance retention in rats in an age- and gender-related manner.

Chronic administration of an adenosine receptor antagonist disturbs spatial learning and memory in adult mice and neonatal caffeine exposure results in long-term behavioral and biochemical sequelae in mice and rats. We thus postulated that early treatment with caffeine would have latent effects on learning and memory as measured in a passive avoidance paradigm. Rats were not handled or received caffeine (15-20 mg/kg/day) by gavage over postnatal days 2-6. At 28 or 70-90 days of age, rats were trained to avoid an electrified grid and tested for retention 24 h, 72 h, and 7 days later. At 28 days, caffeine-exposed rats required more trials to meet criterion than did control rats, regardless of gender. There was minimal effect on retention of either neonatal treatment or gender at this age. At 70-90 days, there was no effect of either gender or treatment on learning; however, there was a significant effect of gender (P < 0.05) on retention at 24 h that was more pronounced in neonatally caffeine-treated rats (P < 0.01). At 72 h, the effect of caffeine on retention differed between male and female rats. Neonatal caffeine exposure significantly improved retention in females (P < 0.01) and significantly decreased retention in males (P < 0.05). Thus, caffeine exposure limited to the first week of life resulted in alterations in passive avoidance retention that became apparent over pubertal development. These changes were a function of the gender of the animal.

Effects of neonatal exposure to caffeine on adenosine A1 receptor ontogeny using autoradiography.

The ontogeny of adenosine A1 receptor density was assessed via autoradiographical analysis of [3H]cyclohexyladenosine ([3H]CHA) binding in brains of 14-31-day-old rats as a function of exposure to caffeine over postnatal days 2-6. This exposure period was analogous to the period during which human infants are administered caffeine as treatment for apnea of prematurity. [3H]CHA binding was greatest in CA1 and CA3 hippocampus in both caffeine-exposed and control rats across all ages. Within the anterior, ventral, lateral and medial regions of the thalamus of unmanipulated rats, [3H]CHA binding did not change with age. In caffeine-exposed rats, however, [3H]CHA binding increased significantly within these thalamic subregions as the rats aged. In addition, with age in both treatment groups, the molecular and granular layers of the cerebellum and the CA1 and dentate gyrus of the hippocampus displayed increasing [3H]CHA density. Furthermore, regardless of age, [3H]CHA binding was decreased in the molecular layer of neonatally caffeine-exposed animals as compared to controls. Thus, limited exposure to caffeine within the first postnatal week altered the subsequent expression of adenosine A1 receptors in most subregions of the thalamus and in the molecular layer of the cerebellum.

Dextromethorphan ameliorates effects of neonatal hypoxia on brain morphology and seizure threshold in rats.

Hypoxic injury to the brain is mediated in part by NMDA receptors. Therefore, NMDA receptor blockade with dextromethorphan (DM), a non-competitive channel blocker, was hypothesized to ameliorate injury even when given after the hypoxic insult. Rats were exposed to 8% oxygen for 3 h on postnatal day 7. Within 20 min of exposure, animals received 30 mg/kg i.p. DM or normal saline. Littermates maintained in room air for 3 h also received DM or saline. At 14 days of age, 7 days after exposure, cortical thickness and hippocampal area were measured. At 70-90 days of age, approximately two months after exposure, in a separate group of rats, seizure threshold using pentylenetetrazol (PTZ) and passive avoidance learning and retention were determined. There were no gross changes in cellular morphology and no evidence for cellular necrosis in any of the exposure groups. However, cortical thickness was decreased in animals exposed to hypoxia. DM administration prevented this decrease. Hippocampal area was unaffected. Seizure susceptibility in adulthood was increased in animals exposed to hypoxia in the neonatal period. DM prevented the decrease in seizure threshold. There was no difference in passive avoidance learning or retention as a function of neonatal exposure condition. Mild to moderate hypoxia, previously thought not to produce any histologic changes, causes significant short-term loss of cortical thickness and long-term decrease in seizure threshold. DM appears to ameliorate these effects even when given after the hypoxic insult. These results implicate the glutamate receptor system in the pathophysiology of hypoxia damage and suggest that treatment with a glutamate receptor blocker when neonatal asphyxia is suspected would help ameliorate the consequences of such an insult.

Neonatal caffeine exposure alters developmental sensitivity to adenosine receptor ligands.

Studies were done to determine whether the apparent changes in behavioral sensitivity to adenosine receptor ligands that occur with age and with neonatal caffeine exposure were due to a change in sensitivity of the receptor for the ligand or to a more fundamental change in the receptor. Using an animal model that mimics the brain developmental period and level of caffeine exposure in human premature neonates treated with caffeine for apnea of prematurity, behavioral and neurochemical investigations were undertaken. The locomotor responses to acute challenge with caffeine (15, 30 and 60 mg/kg) and with D-phenylisopropyladenosine (D-PIA) (0.038 and 0.38 mg/kg), an adenosine receptor agonist, were measured in control and neonatally caffeine-exposed rats at 12, 15, 18, and 28 days of age. The dissociation constants (Kd) and maximal binding densities (Bmax) for agonist binding at the adenosine A1 receptor site were determined over a similar time period. Caffeine displacement of an adenosine A1 agonist was also measured to examine in vitro sensitivity to caffeine as a function of age and neonatal caffeine exposure. Our studies demonstrated that the differential responses to adenosine receptor ligands seen as a function of both age and neonatal caffeine exposure could not be overcome by merely increasing the doses of ligand administered. In addition, the results of the binding studies indicated that changes in the adenosine receptor are occurring as a function of age in different regions of the brain of control animals and that this development is influenced by neonatal caffeine exposure.

Ultrasonic interferometry: study of particle sedimentation in liquid.

An ultrasonic interferometry method was designed to study sedimentation of particles in liquid. The method, based on A mode echography, measures the amplitude of ultrasonic waves reflected (echo E1) by a fixed interface I1 called "solid plate-sediment" interface formed when particles are sedimenting on a solid plate. The amplitude of the echo depends both on mechanical properties of the three media (solid plate, sediment and suspension) on the thickness of the sediment and on the presence of a second mobile interface I2 called "sediment-suspension" interface. In the first phase of sedimentation when the second interface is very close to the first, two reflected waves interfere. Then, in the second phase of sedimentation when the sediment is thick enough, the amplitude of the echo E1 depends only on the sediment and solid plate properties. The first phase will give information on the sedimentation rate of particles (SR). We have compared SR of particles determined by this method with SR measured in a cylindrical tube of the same geometry as the ultrasonic measurement cell and with theoretical values of the sedimentation rate given by theoretical models.

Aggregation of red blood cells studied by ultrasound backscattering.

The erythrocyte aggregation phenomenon is an important factor in capillary circulation. This phenomenon can be evaluated by a number of methods (microscopic observations, viscometry, light measurements) which cannot be applied simply to in vivo measurements. In contrast, ultrasound which propagates through soft tissues allows measurement of the mechanical properties of red blood cell (RBC) suspensions which depend on the aggregation phenomenon. We devised an apparatus in order to measure in vitro the ultrasonic backscattering intensity of RBC suspensions. First, with latex particles of different sizes, the ultrasonic backscattering coefficient has been measured in order to evaluate the apparatus response. Then, the ultrasonic backscattering coefficient of different aggregated erythrocyte suspensions has been measured and correlated with the erythrocyte sedimentation rate. Finally, the size of RBC aggregates of different suspensions has been evaluated.

Determination of erythrocyte transit times through micropores. II-- Influence of experimental and physicochemical factors.

A new red blood cell filtration system, termed the Cell Transit Time Analyzer (CTTA), has been developed in order to measure the individual transit times of a large number of cells through cylindrical micropores in special "oligopore" filters: the system operates on the electrical conductometric principle and employs special computer software to provide several measures of the resulting transit time histogram. Using this system with filters having pore diameters of 4.5 or 5.0 cm and length to diameter ratios of 3.0 to 4.7, we have evaluated the effects of several experimental factors on the flow behavior of normal and modified human RBC. Our results indicate : 1) linear PBC pressure - flow behavior over a driving pressure range of 2 to 10.5 cm H2O with zero velocity intercepts at delta P = 0, thus suggesting the Poiseuille - like nature of the flow; 2) resistance to flow or "apparent viscosities" for normal RBC which are between 3.1 to 3.9 cPoise and are independent of driving pressure and pore geometry; 3) increased flow resistance (i.e., increased transit times) for old versus young RBC and for RBC made less deformable by DNP-induced crenation or by heat treatment at 48 degrees C; 4) increased mean transit time and poorer reproducibility when using EDTA rather than heparin as the anticoagulant agent. Further, using mixtures of heat-treated and normal RBC and various percentile values of the transit time histogram. We have been able to demonstrate the presence of sub-populations of rigid cells and thus the value of measurements which allow statistical analyses of RBC populations.