Four decades of chronic haemodialysis: lessons from the past and implications for the future.

BACKGROUND: There have been substantial changes in the provision of chronic haemodialysis (HD) therapy over time, yet data regarding the impact of these differences on clinical outcomes are limited. AIM: To identify factors which have significantly changed over the last 40 years in relation to patients receiving maintenance HD therapy. METHODS: All 2,647 patients who were established on the chronic HD programme in Northern Ireland between 1970 and 2010 were included. Clinical data and survival outcomes were obtained from a prospectively recorded database. The study period was divided into four decades in order to assess the temporal changes. RESULTS: The total number of patients receiving HD therapy has risen, and the mean age of the HD population has increased significantly (39.0 years in the 1970s vs. 66.8 years in the 2000s, p < 0.001). Diabetic nephropathy has emerged as the commonest aetiology for ESRD (0% in the 1970s to 20.3% in the 2000s, p < 0.001). The median survival of patients on HD has improved significantly over time from 5.2 months (95% CI 2.6-15.5) in the 1970s to 41.7 months (95% CI 38-45.2) in the 2000s (p < 0.0001). Factors that remained significant in determining survival were age, primary renal diagnosis, and decade of commencement of dialysis. CONCLUSIONS: Survival on HD has significantly improved despite older patients with multiple co-morbidities being accepted for treatment reflecting both increased dialysis frequency and better management of cardiovascular risk factors. The increasing age of HD patients and their improved survival have implications for future planning and delivery of dialysis.

The evolution of renal transplantation in clinical practice: for better, for worse?

BACKGROUND: Kidney transplantation is the optimal form of renal replacement therapy for most patients with end-stage renal disease. Attempting to improve graft and recipient survival remains challenging in clinical practice. AIM: To identify the factors that have significantly changed over the past four decades and assess their impact on renal transplant outcomes. DESIGN: Retrospective review of all renal transplant procedures in a single UK region. METHODS: All 1346 renal transplant procedures performed between 1 January 1967 and 31 December 2006 were reviewed. Clinical data, histological reports and outcomes were available from a prospectively recorded database. The study period was divided into four decades to assess the changes in renal transplantation over time. RESULTS: Significant changes that have occurred include an increase in donor and recipient ages, a greater proportion of recipients with diabetic nephropathy, a longer wait before the first transplant procedure, a fall in the incidence and impact of acute rejection, a smaller proportion of deaths due to cardiovascular disease, (P < 0.001 for all) and a trend to increased deaths from malignancy (P = 0.06) over time. In multivariate analysis, death censored graft survival was significantly influenced by the era of transplantation, donor and recipient ages, living vs. deceased donor status, and histological evidence of acute rejection, chronic allograft nephropathy, or disease recurrence. Significant factors in recipient survival were the era of transplantation, recipient age, a primary renal diagnosis of diabetic nephropathy or unspecified chronic renal failure, and biopsy proven acute rejection. CONCLUSION: There have been major changes in the clinical practice related to renal transplantation over the past four decades; some have been beneficial and others detrimental to survival. Regular review of outcomes is essential to guide renal services development and maximize graft and recipient survival.

Influence of prolonged hospitalization on overall bed occupancy: a five-year single-centre study.

BACKGROUND: Effective bed use is crucial to an efficient NHS. Current targets suggest a decrease in mean occupancy as the most appropriate method of improving overall efficiency. The elderly and those suffering from complex medical problems are thought to account for a high proportion of overall bed occupancy. AIM: To assess the effect of prolonged hospital stay (>100 days) on overall bed occupancy in a modern teaching hospital. DESIGN: Retrospective analysis. METHODS: Analysis of all admission episodes (n = 117,178) over a five-year period in a large teaching hospital in a single UK region, serving a population of approximately 200,000. A logistic regression multi-factorial model was used to assess the effect of demographic and diagnostic variables on duration of stay. RESULTS: A prolonged stay (>100 days) was seen in 648 admission episodes (0.6%). These accounted for 11% of the overall bed occupancy over the 5-year period. Excluding all prolonged admission episodes from our analysis made no difference to the overall median length of stay. DISCUSSION: Prolonged hospitalizations have a significant impact on bed occupancy. Targeting these very long (>100 days) hospital stays may better improve overall efficiency, compared to targeting mean or median length of stay.

Association of functional heme oxygenase-1 gene promoter polymorphism with renal transplantation outcomes.

Heme oxygenase-1 (HO-1) is a cytoprotective molecule and increased expression in experimental transplant models correlates with reduced graft injury. A functional dinucleotide repeat (GT)(n) polymorphism, within the HO-1 promoter, regulates gene expression; a short number of repeats (S-allele <25) increases transcription. The role of this HO-1 gene promoter polymorphism on renal transplant outcomes was assessed. DNA from 707 donor/recipient pairs (n = 1414) of first deceased donor renal transplants (99% Caucasian) was genotyped. Graft survival was not significantly impacted by carriage of an S-allele by the donor (hazard ratio 0.89, 95% CI 0.71-1.11; p = 0.28) or recipient (hazard ratio 1.19, 95% CI 0.95-1.48; p = 0.13). Similarly neither donor nor recipient genotype influenced recipient survival (hazard ratio 0.89, 95% CI 0.67-1.18; p = 0.41, and hazard ratio 1.22, 95% CI 0.93-1.62; p = 0.16). The hazard ratios changed only minimally in multivariate analysis including significant survival factors. Genotype did not alter the incidence of acute rejection or chronic allograft nephropathy. There is no evidence of a protective effect for the S-allele of the HO-1 gene promoter polymorphism on graft or recipient survival in clinical renal transplantation.

An investigation into the efficacy of hatchery disinfectants against strains of Staphylococcus aureus associated with the poultry industry.

The efficacy of 18 commercial disinfectants was investigated using the type strain, isolate 24 (I. 24), of pulsed-field gel electrophoresis pattern related Staphylococcus aureus that have shown to be associated with clinical disease in Northern Ireland broilers. Eight quartenary ammonium compound (QAC), four peroxygen, three amphoteric (AMP), one phenolic along with two chlorine-based disinfectants were tested at their manufacturer's recommended concentration (MRC) and at three 10-fold dilutions of the MRC. The efficacy of disinfectants against I. 24 was assessed in conditions with no hatchery organic matter (HOM) and in conditions with no HOM present. In addition, 17 S. aureus strains, related and non-related to I. 24 and obtained from the poultry industry were screened for any increase in resistance relative to I. 24. All disinfectants were effective against all test strains when tested in the absence of HOM. Products from the QAC and peroxygen groups were the most potent. The performance of all disinfectants was reduced in the presence of HOM. Under these conditions all chlorine-based, two out of three AMP, and one out of eight QAC disinfectants were not effective against I. 24 when tested at the MRC. The results emphasise the importance of proper application on appropriate areas, using the correct concentration and exposure time for the disinfectant.

Bacterial chondronecrosis with osteomyelitis ('femoral head necrosis') of broiler chickens: a review.

Bacterial chondronecrosis with osteomyelitis (BCO) in chickens was first reported in 1972 and is now recognized as an important cause of lameness in broiler chickens. Recent systematic studies of causes of lameness in birds reared in Northern Ireland have shown that it was the most common cause of lameness, being present in 17.3% of lame birds. Furthermore, it was also detected in birds presented as ''found dead''. Overall losses in male birds due to BCO were estimated to be 0.75% of all birds placed, which, in addition to welfare concerns, represents considerable economic loss. The disease has been seen in birds ranging from 14 to 70 days of age, but most cases occurred around 35 days old. It is most commonly caused by Staphylococcus aureus, but Escherichia coli, coagulase-negative staphylococci and Enterococcus spp. are sometimes involved, as are, rarely, other bacteria. The lesions are most commonly found associated with the growth plates of long bones, particularly the proximal growth plate of the femur and tibiotarsus, but other bones may also be affected. Since lesions were visible to the naked eye in only 40 to 67% of cases, histological examination is recommended where no lesions are visible macroscopically. As the lesion may be present in only one growth plate, and because histological examination is often not carried out, BCO is almost certainly underdiagnosed. The exact pathogenesis of the condition is unknown, but it is thought that adherence of blood-borne bacteria to exposed cartilage at the tips of metaphyseal blood vessels is fundamental. Under controlled experimental conditions, infection of birds with the immunosuppressive viruses chicken anaemia virus and infectious bursal disease virus increased the incidence of the disease, while restricting feed intake reduced the incidence of disease. S. aureus strains identical to, or closely related to, isolates recovered from naturally occurring cases of the disease (as determined by pulsed-field gel electrophoresis) have been recovered from fluff-debris in hatcheries, and also from the environment of breeding flocks, indicating that infection in the breeding farm and in the hatchery could be an important source of infection. It has also been shown that humans can carry poultry strains of S. aureus on their hands. There is a higher incidence of BCO in birds hatched from floor eggs. Thus, hygiene and management practice on breeder farms and in the hatchery may influence the occurrence of the disease. Bacteraemia is a prerequisite for BCO. Indeed, in some flocks suffering losses due to BCO, there are also losses due to staphylococcal septicaemia. Thus, appropriate treatment of affected flocks should reduce losses due to septicaemia. It should also reduce the occurrence of bacteraemia and the development of further cases of BCO. However, birds in which BCO has already developed, are unlikely to respond to treatment. Control of BCO by vaccination seems unlikely in the short term. Simple bacterins have not been effective and much basic research is needed to identify the important virulence factors. Furthermore, more than one type of bacterium is capable of causing the disease. Bacterial interference has been used successfully in humans and turkeys to prevent staphylococcal diseases, and warrants investigation for the prevention of BCO in chickens. This may have an advantage in that the interfering bacterium may also exclude some of the other bacteria that can cause BCO. The recent development of a disease model in which S. aureus is given by a natural route allows the potential for further investigation of the role of predisposing factors, and intervention strategies, including vaccination and bacterial interference, for the prevention of BCO.

Bacterial chondronecrosis with osteomyelitis ('femoral head necrosis') of broiler chickens: a review.

Bacterial chondronecrosis with osteomyelitis (BCO) in chickens was first reported in 1972 and is now recognized as an important cause of lameness in broiler chickens. Recent systematic studies of causes of lameness in birds reared in Northern Ireland have shown that it was the most common cause of lameness, being present in 17.3% of lame birds. Furthermore, it was also detected in birds presented as ''found dead''. Overall losses in male birds due to BCO were estimated to be 0.75% of all birds placed, which, in addition to welfare concerns, represents considerable economic loss. The disease has been seen in birds ranging from 14 to 70 days of age, but most cases occurred around 35 days old. It is most commonly caused by Staphylococcus aureus, but Escherichia coli, coagulase-negative staphylococci and Enterococcus spp. are sometimes involved, as are, rarely, other bacteria. The lesions are most commonly found associated with the growth plates of long bones, particularly the proximal growth plate of the femur and tibiotarsus, but other bones may also be affected. Since lesions were visible to the naked eye in only 40 to 67% of cases, histological examination is recommended where no lesions are visible macroscopically.As the lesion may be present in only one growth plate, and because histological examination is often not carried out, BCO is almost certainly underdiagnosed. The exact pathogenesis of the condition is unknown, but it is thought that adherence of blood-borne bacteria to exposed cartilage at the tips of metaphyseal blood vessels is fundamental. Under controlled experimental conditions, infection of birds with the immunosuppressive viruses chicken anaemia virus and infectious bursal disease virus increased the incidence of the disease, while restricting feed intake reduced the incidence of disease. S. aureus strains identical to, or closely related to, isolates recovered from naturally occurring cases of the disease (as determined by pulsed-field gel electrophoresis) have been recovered from fluff-debris in hatcheries, and also from the environment of breeding flocks, indicating that infection in the breeding farm and in the hatchery could be an important source of infection. It has also been shown that humans can carry poultry strains of S. aureus on their hands. There is a higher incidence of BCO in birds hatched from floor eggs. Thus, hygiene and management practice on breeder farms and in the hatchery may influence the occurrence of the disease. Bacteraemia is a prerequisite for BCO. Indeed, in some flocks suffering losses due to BCO, there are also losses due to staphylococcal septicaemia. Thus, appropriate treatment of affected flocks should reduce losses due to septicaemia. It should also reduce the occurrence of bacteraemia and the development of further cases of BCO. However, birds in which BCO has already developed, are unlikely to respond to treatment. Control of BCO by vaccination seems unlikely in the short term. Simple bacterins have not been effective and much basic research is needed to identify the important virulence factors. Furthermore, more than one type of bacterium is capable of causing the disease. Bacterial interference has been used successfully in humans and turkeys to prevent staphylococcal diseases, and warrants investigation for the prevention of BCO in chickens. This may have an advantage in that the interfering bacterium may also exclude some of the other bacteria that can cause BCO. The recent development of a disease model in which S. aureus is given by a natural route allows the potential for further investigation of the role of predisposing factors, and intervention strategies, including vaccination and bacterial interference, for the prevention of BCO.

Comparison of Staphylococcus aureus recovered from personnel in a poultry hatchery and in broiler parent farms with those isolated from skeletal disease in broilers.

Personnel from one broiler hatchery, and workers on 18 separate broiler parent farms which supply the hatchery, were tested for hand and nasal carriage of Staphylococcus aureus. In both locations, nasal carriage of S. aureus was more common than hand carriage. A total of 63 S. aureus strains were characterised by biotyping, protein A analysis and pulsed field gel electrophoresis (PFGE) typing. Of these, 36 were recovered from broiler hatchery personnel, 14 from broiler parent farm personnel and 13 from cases of skeletal disease in commercial broilers. Biotyping and protein A analysis indicated that none of the strains recovered from hatchery personnel were of the poultry biotype, but that two strains recovered from the hands of two broiler parent farm personnel could be grouped together with 12/13 of strains recovered from skeletal disease in broilers, as poultry biotypes. PFGE-typing could not distinguish 9/13 strains recovered from skeletal disease in broilers and one of the strains from the broiler parent farm personnel from isolate 24 (I. 24), which is the predominant S. aureus strain type associated with clinical disease in N. Ireland broiler flocks. The present study found no evidence of nasal carriage of S. aureus strains of poultry biotype by humans. The finding of hand carriage by broiler parent farm personnel, suggests that handling by personnel may contribute to the dissemination of I. 24 or other S. aureus strains associated with skeletal disease in broilers.

Paraoxonase polymorphisms are not associated with cardiovascular risk in renal transplant recipients.

BACKGROUND: Paraoxonase (PON1) gene variants have been identified as risk factors for cardiovascular disease (CVD). There are two common PON1 polymorphisms at position 55 (Leu-Met change) and 192 (Gln-Arg change) of the amino acid chain. Leucine at position 55 and arginine at position 192 have been associated with increased cardiovascular risk. The increased prevalence of CVD in renal transplant recipients can be only partly explained by the increased prevalence of conventional risk factors. METHODS: We therefore investigated PON1 polymorphisms in renal transplant recipients (N = 491) with (N = 103) and without CVD (N = 388) using polymerase chain reaction-restriction fragment length analysis. PON1 polymorphisms and their associated PON1/arylesterase activities were also assessed in a subgroup of patients (N = 165). RESULTS: The genotype distribution and allele frequencies for both polymorphisms were similar in both groups. The frequencies for LL, LM, and MM genotypes for the 55 position in patients with CVD were 0.39, 0.51, and 0.10, respectively, compared with 0.43, 0.43, and 0.14 in patients without CVD (P = 0.31). The distribution for the QQ, QR, and RR genotypes at the 192 position were 0.48, 0.43, and 0.09, respectively, in patients with CVD compared with 0.46, 0.46, and 0.08 in patients without CVD (P = 0.8). There were highly significant differences in serum activities of PON1/arylesterase between genotypes defined by 55 and 192 polymorphisms. Leucine at position 55 and arginine at position 192 were associated with higher activities. CONCLUSION: These data indicate that there is no association between the PON1 gene variants, conferring higher enzyme activity, and the increased cardiovascular risk in renal transplant recipients.

Development of an experimental model of bacterial chondronecrosis with osteomyelitis in broilers following exposure to Staphylococcus aureus by aerosol, and inoculation with chicken anaemia and infectious bursal disease viruses.

A series of experiments was designed in an attempt to reproduce bacterial chondronecrosis with osteomyelitis in broiler chickens using a natural route of infection. Birds in isolators were exposed to a suspension of Staphylococcus aureus by aerosol or exposed to S. aureus and subsequently inoculated with chicken anaemia virus (CAV) alone, or with CAV and infectious bursal disease virus (IBDV). Subsequently, S. aureus was recovered and bacterial chondronecrosis with osteomyelitis was diagnosed, by histology, in the proximal end of the femur and/or tibiotarsus of lame birds exposed to S. aureus with and without CAV and IBDV infections. Birds fed 60% of the recommended feed intake for the breed developed a lower incidence of S. aureus infection and/or bacterial chondronecrosis (P < 0.05) than birds fed 100% of the recommended intake. A significantly lower incidence of S. aureus was recovered (P < 0.05) in birds simultaneously exposed to S. aureus and inoculated with CAV and IBDV at day 21, than in birds exposed to S. aureus at day 10, and inoculated with CAV and IBDV at day 21. With the exception of birds exposed to S. aureus at 1 day old, a higher incidence of bacterial chondronecrosis was diagnosed in birds exposed to S. aureus and inoculated with CAV and IBDV than in birds exposed to S. aureus alone. It is hypothesised that inoculation with CAV and IBDV at day 21 enhanced the development of bacterial chondronecrosis in birds exposed to S. aureus at day 10 and fed 100% of the recommended feed intake or ad libitum.

The use of pulsed field gel electrophoresis to investigate the epidemiology of Staphylococcus aureus infection in commercial broiler flocks.

Pulsed field gel electrophoresis (PFGE) analysis of SmaI restriction patterns was used to type 109 isolates of Staphylococcus aureus collected from broiler farms and hatcheries in Northern Ireland. Forty-seven isolates from clinical conditions in broilers and 62 strains from hatcheries, were examined. The PFGE patterns demonstrated a similarity between 85% of strains from clinical sources and 71% of the hatchery isolates. The association of disease with the predominant strain type and presence of these same strains in the hatchery, indicates that the hatchery is a potential source of the infection for clinical broiler disease.

Study of leg weakness in two commercial broiler flocks.

The major causes of leg weakness/lameness were investigated in two male commercial broiler flocks. The numbers of dead and lame birds culled from the flocks each day were recorded by the flock managers. Forty-four lame birds and 22 sound birds were examined postmortem during a period of six weeks and the proximal and distal end of each femur, tibiotarsus and tarsometatarsus were examined histologically. Attempts were made to isolate bacteria and viruses from the proximal end of each femur. Blood samples were examined for antibodies to chicken anaemia virus (CAV), infectious bursal disease virus (IBDV) and Mycoplasma species. Bacterial chondronecrosis with osteomyelitis was identified in the proximal end of the femur of eight of the 44 lame birds, and in the proximal end of the tibiotarsus of a further bird (20.4 per cent). Gram-positive bacteria were present in all the lesions. Staphylococcus aureus was recovered from 62.5 per cent of the lesions confirmed by histology. Bacterial chondronecrosis associated with S aureus has thus been identified as an important cause of leg weakness in these commercial broilers. Lesions suggestive of the condition were visible macroscopically in only 11.1 per cent of the cases subsequently diagnosed by histology and bone histology is therefore required before a diagnosis can be excluded. Angular limb deformities (13.6 per cent) and spondylolisthesis (11.4 per cent) were the most common macroscopic lesions identified as causes of lameness. The overall incidence of tibial dyschondroplasia was similar in both the lame and sound broilers, but severe lesions were found only in lame birds (4.5 per cent).

Treatment of renal failure in idiopathic membranous nephropathy with azathioprine and prednisolone.

BACKGROUND: Progressive deterioration in renal function occurs in 20-50% of patients with idiopathic membranous nephropathy (IMN). Several treatment regimens have been used to reverse this with varying effect and toxicity. METHODS: Thirteen patients (10 males, 3 females, median age 56 years) with IMN and progressive renal failure were treated with oral prednisolone 20-60 mg/day and azathioprine 1.3-2.7 mg/kgBW/day. All patients were followed up for a minimum of 2 years with a median follow-up of 73 months (range 24-103 months). RESULTS: Ten patients responded to treatment with a fall in serum creatinine and renal function stabilized in the remainder. Two patients relapsed, one of whom responded to an increase in immunosuppression, the other is now on dialysis. Proteinuria has significantly reduced in 10 patients, and only four patients still have nephrotic-range proteinuria. Mean (+/- SE) peak pretreatment serum creatinine of 229 (+/- 161) mumol/l and urinary protein of 11.8 (+/- 1.8) g/24 have fallen to 163 (+/- 65) mumol/l and 3.25 (+/- 1.0) g/24 h after 12 months treatment (P < 0.005, Wilcoxon matched pairs test). Immunosuppressive treatment has been successfully withdrawn in four patients after intervals ranging from 12 to 60 months. Adverse effects, which occurred in 10 patients, have been mild and have not led to treatment withdrawal though dose reductions have been necessary in some patients. CONCLUSIONS: Oral prednisolone and low-dose azathioprine is an effective therapy for progressing renal failure due to IMN, and induces remission of nephrotic syndrome. Side-effects are less than other immunosuppressive regimens.

Susceptibility of VLDL to oxidation in patients on regular haemodialysis.

Oxidation of VLDL in vitro increases macrophage uptake and promotes foam cell formation, and the dyslipidaemia of chronic renal failure is characterised by an increase in VLDL. However, little information is available with regard to the susceptibility of VLDL to oxidation in patients at increased risk of atherosclerosis. We have therefore assessed the composition and susceptibility to oxidation of VLDL from haemodialysis patients and control subjects. VLDL from haemodialysis patients contained increased lipid hydroperoxides (81.6 +/- 12.6 versus 16.1 +/- 3.4 nmol/mg protein, P < 0.001) and malondialdehyde (35.9 +/- 7.3 versus 16.0 +/- 4.1 nmol/mg protein, P < 0.05). Susceptibility to oxidation was increased as shown by an increased rate of propagation of the copper induced lipid peroxidation chain-reaction (11.6 +/- 1.5 x 10(-5) versus 7.6 +/- 1.1 x 10(-5)abs. U/min, P < 0.05) and a greater increase in conjugated diene formation during peroxidation (0.47 +/- 0.04 versus 0.25 +/- 0.03 abs. U, P < 0.001). Increased VLDL peroxidation in dialysis patients may contribute to the increased risk of cardiovascular disease observed in this group of patients.

Effect of hemodialysis on total antioxidant capacity and serum antioxidants in patients with chronic renal failure.

Cardiovascular disease is the major cause of mortality in patients receiving hemodialysis for chronic renal failure. Increased lipid peroxidation and depletion of chain-breaking antioxidants may contribute to increased risk of atherosclerosis. We have therefore assessed the effect of a single episode of hemodialysis on antioxidant status in 22 patients and control subjects. Overall, total antioxidant capacity of serum was increased in dialysis patients, but there was a marked reduction after hemodialysis [571 +/- 31 vs 342 +/- 22 mumol/L Trolox (water-soluble vitamin E analog) equivalents, P < 0.001]. The increase in total antioxidant capacity before hemodialysis was almost entirely due to relatively high serum urate. Among individual chain-breaking antioxidants, dialysis led to a decrease in urate (398 +/- 15 vs 136 +/- 12 mumol/L, P < 0.001), ascorbate (10.5 +/- 1.7 vs 5.9 +/- 1.0 mumol/L, P < 0.01), and lipid-corrected tocopherol (4.70 +/- 0.56 vs 4.26 +/- 0.39 mumol/mmol cholesterol, P < 0.05). Protein thiol groups increased after dialysis (328 +/- 16 vs 422 +/- 22 mumol/L, P < 0.001), whereas albumin remained unchanged (40.1 +/- 1.1 vs 41.0 +/- 1.6 g/L, not significant). Although total antioxidant capacity of serum is increased in hemodialysis patients, depletion of key chain-breaking antioxidants may lead to accelerated atherogenesis.

Effect of immunosuppressive drug regime on cardiovascular risk profile following kidney transplantation.

We have previously studied cardiovascular risk markers apolipoprotein (a) (apo(a)) and plasma fibrinogen in 146 control, 60 haemodialysis (HD), 53 continuous ambulatory peritoneal dialysis (CAPD) and 66 renal transplant subjects. Fibrinogen concentration was higher in all 3 renal replacement groups compared to controls. Apo(a) was higher in the CAPD group only. We have now restudied those dialysis patients (24 HD, 16 CAPD) who have since undergone transplantation. Fibrinogen concentration remained elevated in CAPD patients (mean (SE) 3.9 (0.17) vs. 3.77 (0.20) grams/l) and increased in HD patients (2.88 (0.16) vs. 3.72 (0.13) grams/l, P < 0.0001). Apo(a) fell in both groups (CAPD, geometric mean 287 vs. 151 U/l, P = 0.008; HD, 230 vs. 179 U/l, P = 0.013). Fibrinogen concentration was higher in the recent group compared to the original group (3.74 (0.11) vs. 3.19 (0.12) grams/l, P = 0.001). None of the 66 original patients received cyclosporin (cyA) compared to 35 of the 40 in the present study. In this recent group, patients maintained on prednisolone and azathioprine alone had significantly lower fibrinogen levels than those receiving cyA. Furthermore, the fall in apo(a) was smaller (31% vs. 74%) and the increase in apolipoprotein B (apo B) greater (0.55 (0.15) vs. 0.18 (0.05) grams/l, P = 0.014) in cyA-treated patients. CyA may have an adverse effect on cardiovascular risk profile in renal transplant recipients.

Oxidative stress in haemodialysis.

Patients with chronic renal failure, including those receiving regular long-term haemodialysis, have a high incidence of premature cardiovascular disease. Oxidative stress, which occurs when there is excessive free-radical production or low antioxidant levels, has recently been implicated as a causative factor in atherogenesis. The aim of this study was to determine if chronic renal failure and haemodialysis were associated with increased oxidative stress. Serum malondialdehyde was measured as a marker of lipid peroxidation in 15 patients with conservatively managed chronic renal failure (CRF), 15 patients with CRF undergoing regular haemodialysis and 15 healthy controls. Selenium, glutathione peroxidase and antioxidant vitamins were also measured. Malondialdehyde was elevated in dialysis patients in comparison to CRF and control groups (dialysis 1.16 +/- 0.08 mumol/l, CRF 0.94 +/- 0.07, controls 0.66 +/- 0.10). Antioxidants, including vitamin C, selenium and glutathione peroxidase, were decreased in dialysis patients and to a lesser extent in the CRF group (vitamin C-dialysis 16.43 +/- 3.76 mumol/l, CRF 34.5 +/- 8.6, controls 56.11 +/- 7.41; selenium-dialysis 0.77 +/- 0.07 mumol/l, CRF 0.69 +/- 0.06, controls 1.09 +/- 0.06: glutathione peroxidase-dialysis 101 +/- 5 U/l, CRF 160 +/- 11, controls 290 +/- 10). These findings indicate oxidative stress in patients with CRF which is further exacerbated by haemodialysis, as evidenced by increased lipid peroxidation and low antioxidant levels. This stress may play a role in the development of atherosclerosis in these groups.