Glomerulonephritis With Positive Anti-Glomerular Basement Membrane Antibodies Following Alemtuzumab Treatment.

Presentation A 28 year old female presented to the emergency department with a one week history of headache, vomiting and diaphoresis. Creatinine on admission was 492 and urinalysis revealed blood and protein. This was 5 months after a second infusion of Alemtuzumab, for treatment of highly active relapsing remitting multiple sclerosis. Diagnosis Anti-glomerular basement membrane disease was diagnosed after a vasculitic screen was sent for suspected glomerulonephritis. Treatment Unfortunately despite early diagnosis and immunosuppressive treatment, the patient progressed to end stage kidney failure. Conclusion It is important to maintain a high index of suspicion and test for anti-GBM disease in patients receiving alemtuzumab who develop acute renal failure.

Renal dysfunction in patients taking fumaric acid esters - a retrospective cross-sectional study.

BACKGROUND: Fumaric acid esters (FAE) have been used for over 30 years in the management of psoriasis. There have been a number of case reports linking the use of FAE with nephrotoxicity, including acute renal injury and Fanconi syndrome. However, one large multicentre retrospective trial showed no evidence of renal dysfunction with FAE. OBJECTIVES/AIMS: The aim of this study was to determine the number of patients in our institution being treated with FAE who developed significant proteinuria or renal dysfunction. METHODS: This was a single-centre retrospective study assessing all patients on FAE who attended for follow-up during an 18-week period between February and June 2015. Demographics, comorbidities, duration and dose of treatment with FAE, proteinuria, renal function and other biochemical serum abnormalities were recorded. RESULTS: One hundred and twenty-seven patients were included in the study. Eighty-two patients had proteinuria detected at some stage during treatment with FAE, and 18 of these had persistent proteinuria (positive in at least three consecutive specimens, 12 weeks apart). Six patients (five female) developed proximal tubular dysfunction (PTD). The risk factors for the development of PTD appear to be lower bodyweight (P = 0.03), higher dose per weight (P = 0.03) and longer duration of treatment (P = 0.03). Renal dysfunction improved on discontinuation or dose reduction in FAE. CONCLUSION: Fumaric acid esters are frequently associated with transient or persistent proteinuria. Significant renal dysfunction is rare and usually reversible on dose reduction or discontinuation of FAE. This study highlights the importance of screening for proteinuria. Higher doses per weight of treatment and longer duration of FAE therapy are likely risk factors for PTD.

Posterior reversible encephalopathy syndrome (PRES) associated with liquorice consumption.

IMPORTANCE: Posterior reversible encephalopathy syndrome (PRES) is a medical emergency but prompt recognition, early institution of supportive care and identifying and removing potential triggers are associated with a good clinical outcome. We report an unusual case of PRES associated with liquorice consumption. OBSERVATIONS: A 56-year-old lady presented with thunderclap headache, visual disturbance and a generalised tonic-clonic seizure. Blood pressure on admission was markedly elevated but improved within 24 h. Cranial CT and lumbar puncture were normal (no xanthochromia). She had hypokalaemia. Cranial MRI revealed abnormalities in the occipital lobes consistent with PRES. There was no evidence of restricted diffusion or vasoconstriction. Follow-up MRI 3 weeks later demonstrated complete resolution. On direct questioning she revealed in recent months she had habitually eaten liquorice sweets each day; they were "on special offer" in her local shop. CONCLUSION AND RELEVANCE: Liquorice contains a biologically active compound glycyrrhizic acid which inhibits 11ß hydroxysteroid dehydrogenase. Excessive liquorice consumption can cause mineralocorticoid excess and has been recently reported to cause PRES. We propose that in the absence of other triggers, frequent liquorice consumption precipitated the development of PRES in our patient and should be considered as a possible cause of this condition.

Organ donation and transplantation in general practice.

Raising public awareness of organ donation is high on the national agenda, but the magnitude of the challenge is not well clarified. We investigated the attitudes and experience of general practitioners (GPs) regarding organ donation. A survey of 200 GPs working in Ireland revealed that a minority provided donor cards (38%) or displayed information regarding organ donation (28.2%). Although 81.3% felt comfortable discussing organ donation, just 4.8% broached the subject with their patients or asked them to discuss the issue with their families. 88.7% of GPs could not remember any instance of a patient asking for counselling regarding organ donation in the past 3 months. We found that 31.7%, 24.1% and 34.4% felt informed to advise patients on organ procurement, living donation or immunosuppression medications, respectively. We identified a lack of dialogue and unfamiliarity in primary healthcare regarding organ donation, which may be targeted to increase organ donation rates.

Successful use of combined high cut-off haemodialysis and bortezomib for acute kidney injury associated with myeloma cast nephropathy.

We present the case of a 58-year old female with de novo dialysis-dependent acute kidney injury (AKI) secondary to myeloma cast nephropathy. The patient underwent extended high cut-off haemodialysis (HCO-HD), in conjunction with bortezomib-based chemotherapy, and soon became dialysis independent with normal renal function. To our knowledge, this is the first time this treatment strategy has been employed successfully in an Irish centre.

Warfarin use in hemodialysis patients: what is the risk?

BACKGROUND: There is a paucity of data concerning the risks associated with warfarin in hemodialysis (HD) patients. We compared major bleeding episodes in this group with HD patients not receiving warfarin and with a cohort of non-HD patients receiving warfarin. METHODS: A retrospective review of 141 HD patients on warfarin (HDW), 704 HD patients not on warfarin (HDNW) and 3,266 non-dialysis warfarin patients (NDW) was performed. Hospital admissions for hemorrhagic events and ischemic strokes were examined as was hospital length of stay and blood product use. INR variability was also assessed. RESULTS: The incidence rates for major hemorrhage per 100 patient years was 10.8 in the HDW group as compared to 8.0 in the HDNW (p = 0.593) and 2.1 in the NDW (p < 0.001) groups. Mean units of red blood cell transfusions required was higher in patients on dialysis with no significant difference between HDW and HDNW groups. The risk of ischemic stroke per 100 patient years was 1.7 in the HDW group as compared to 0.7 in the HDNW groups (p = 0.636) and 0.4 in the NDW (p = 0.003). The HDW group had higher inter-measurement INR variability compared to the NDW group (p = 0.034). In patients with atrial fibrillation, HDW group had a higher incidence of ischemic stroke than the NDW group (2.2 versus 0.4 events per 100 patient years; p = 0.024). CONCLUSIONS: This study confirms the higher bleeding risk associated with HD/ESRD but suggests that warfarin use in these patients may not add significantly to this risk. We also demonstrated high rates of ischemic stroke in HD patients despite warfarin use. SUMMARY: Our study compares the frequency of major hemorrhage and secondarily, ischemic stroke in HD patients receiving or not receiving warfarin, with non-HD patients receiving warfarin. The major finding was that frequency of hemorrhage was higher in HD patients receiving warfarin than in non-HD patients receiving warfarin, but not different in HD patients with or without warfarin. A secondary finding was that INR variability was significantly higher in HD patients than non-HD patients on warfarin.

Live birth and infant death record linkage: methodological and policy issues.

Using records from Ohio annual vital statistics tapes, we describe a method for linking live birth and infant death certificates and for dealing with late-registered and unregistered births. In our 1985-87 Cleveland and East Cleveland study population, deceased infants with late-registered births were found to be similar to those with timely registered births. Approximately 4.6% of decedents, however, had unregistered births and these tended to be very premature infants from socially disadvantaged backgrounds who died shortly after delivery (including homicides following birth at home). We discuss the policy implications of failing to link infant deaths with unregistered births in studies of birth outcomes.

Client and birth record linkage: a method, biases, and lessons.

"Due to rising data collection costs and the availability of extant data files, record linkage is becoming increasingly important in evaluation research. We begin by discussing record linkage as a data-generating technique and its applicability to evaluation studies. This paper--part of a larger study assessing the perinatal outcomes of a comprehensive prenatal program for poor, urban women--describes a method for linking client records to live and stillbirth records [in Cleveland, Ohio]. Biases which can enter into the linkage process and general issues which need to be addressed early in an investigation are also discussed."

Evaluation of a new enhanced luminescence immunoassay for confirming the presence of HBsAg in human serum or plasma.

An enhanced luminescence assay was developed to confirm the presence of HBsAg in weakly reactive sera. The test proved reliable in differentiating between truly reactive and falsely reactive samples.

Infant mortality and health care in Mexican communities.

Data from the 1976-77 Mexican Fertility Survey show a high degree of correlation among community background characteristics, access to medical services and utilization of health care in a sample of 125 localities. All of these factors are related to infant mortality at the bivariate level. Use of prenatal and infant health care, but not proximity to medical personnel and facilities, is found to affect infant survival independently of the community's degree of socio-economic development. The findings point to the need to employ separate measures of medical access and health utilization.

Community-level determinants of infant mortality in Mexico.

PIP: Data from pregnancy histories collected by the 1976-77 Mexican Fertility Survey show wide variations in infant mortality among a sample of 125 communities. For example, in regard to community population, localities of 2500 or less averaged 104/1000 live births which was almost 2 times the rate of 56/1000 experienced by cities with 100,000 or more people. While the rates for Mexico's 3 largest cities (Guadalajara, Monterrey, and Mexico City) were slightly higher, this trend was due to the large slum populations. Overall, there were large and statistically significant infant mortality differentials by community population, proportion of the labor force in agriculture, mean wage, access to the nearest urban center, communication means, proportion of households with electricity, piped water and sewers, and distance to the closest 2ndary and preparatory school and university. Considering health care variables, there was an expected relationship between distance to the nearest health care facility and mortality levels. These community-level factors, which have been litte used in previous studies, are highly correlated and do not appear to affect infant survival independently of population size. Community size serves as a summary measure of a locality's overall level of development and comparative risk of early death for its children.^ieng

The effect of female education on marital fertility in different size communities of Mexico.

PIP: Based on a very large sample of married women aged 15 to 49 from the 1970 census of Mexico, the effect of literacy and education on the number of children ever born in different size communities is investigated. While cumulative marital fertility tends to be inversely related to community size, the overall shape of the education-fertility relationship is generally similar in rural, semi-urban, small urban, and large urban localities. These results combined with those for literacy do not support the hypothesis of an urbanization or a literacy threshold at which women's schooling begins to reduce family size. Literate wives have slightly more children than illiterate wives in rural areas, but in more urbanized regions this differential inverses and seems to widen with each increase in size of the community. Fertility is slightly higher at 1 to 3 years of primary school than at no education; it declines slightly at 4 to 5 years primary, and then declines substantially at complete primary, secondary, and preparatory/university levels. A statistically significant but small interaction between education and residence on cumulative marital fertility is noted. The overall greater impact of female education on cumulative marital fertility in urban as compared to semi-urban as compared to rural communities of Mexico is primarily due to the proportion of married women with fertility depressing educational backgrounds rather than to a markedly different effect of education, per se, on fertility. The results emphasize the country-wide importance of completion of the entire 6-year primary cycle.^ieng

Human anti-DNA antibody: reference standards for diagnosis and management of systemic lupus erythematosus.

A technique for the measurement of DNA binding activity of sera is described which uses primary internal reference standards in a Farr assay. This allows the DNA binding activity of test sera to be measured in relation to the reference standards and the results are expressed as units/ml. The use of this standardized assay has led to diminished interassay variation and close interlaboratory correlation, and has provided a clinically useful test. In survey using the standardized assay, normal sera were found to have binding activity which did not exceed 15 units/ml; 71% of patients with systemic lupus erythematosus (SLE) had levels greater than 25 units/ml; while only 8% of patients with diseases other than SLE had levels above 25 units/ml. Values between 15 and 25 units/ml appeared to have little diagnostic significance.