[Asthma caused by methylene-diphenyl-diisocyanate cast in a nurse]. / Asthma forårsaget af methylen-diphenyl-diisocyanat-gips hos en sygeplejerske.

A case of a 35 year-old female nurse without atopic disposition is presented. For one year (1990-1991), she worked in an emergency room, applying synthetic casts containing MDI 0-3 times daily. She developed rhinitis, itchy eyes and nightly wheezing, during employment in the emergency room, with subsequent serious asthma attacks in 1992 and 1996. Just before the last attack, the patient's husband had used insulation foam containing MDI. A specific bronchial provocation test was performed with MDI-based synthetic cast material. The patient developed an asthma attack after seven hours, with a 48% drop in FEV1, suggesting that MDI is the causative agent.

Diabetes mellitus after renal transplantation: as deleterious as non-transplant-associated diabetes?

BACKGROUND: Despite use of lower doses of corticosteroid hormones after renal allotransplantation in the era of cyclosporine and tacrolimus, posttransplant diabetes mellitus remains a common clinical problem. METHODS: We prospectively investigated the effect of posttransplant diabetes on long-term (mean follow-up, 9.3+/-1.5 years) graft and patient survival in the 11.8% of our renal transplant population (n = 40) who developed diabetes after kidney transplantation, and we compared outcome in 38 randomly chosen nondiabetic control patients who had received transplants concurrently. RESULTS: Twelve-year graft survival in diabetic patients was 48%, compared with 70% in control patients (P = 0.04), and Cox's regression analysis revealed diabetes to be a significant predictor of graft loss (P = 0.04, relative risk = 3.72) independent of age, sex, and race. Renal function at 5 years as assessed by serum creatinine level was inferior in diabetic patients compared to control patients (2.9+/-2.6 vs. 2.0+/-0.07 mg/dl, P = 0.05). Two diabetic patient who experienced graft loss had a clinical course and histological features consistent with diabetic nephropathy; other diabetes-related morbidity in patients with posttransplant diabetes included ketoacidosis, hyperosmolar coma or precoma, and sensorimotor peripheral neuropathy. Patient survival at 12 years was similar in diabetic and control patients (71% vs. 74%). CONCLUSIONS: Posttransplant diabetes mellitus is associated with impaired long-term renal allograft survival and function, complications similar to those in non-transplant-associated diabetes may occur in posttransplant diabetes, and, hence, as in non-transplant-associated diabetes, tight glycemic control may also be warranted in patients with posttransplant diabetes.

Parathyroidectomy does not correct hypertension in patients on maintenance hemodialysis.

Both hypertension and secondary hyperparathyroidism (2 degrees HPT) are common features of the uremic syndrome. It has been suggested that 2 degrees HPT causes hypertension in end-stage renal disease (ESRD). We compared predialysis blood pressure (BP), weight and dose of antihypertensive medications (AHM) prescribed in 19 hemodialysis patients 1 month before total parathyroidectomy (PTx), during the first month after PTx, and long-term (mean 16 months) in 12 of 19 patients. At the time of PTx, study patients had a mean age of 47 +/- 9 years, mean duration of ESRD was 112 +/- 57 months, and mean intact parathyroid hormone (PTH) level of 1,181 +/- 552 pg/ml. Mean BP and predialysis weight were equivalent during the month before and the month after PTx. Of 12 patients followed long term, 8 (67%) were receiving AHM before PTx; after PTx; 3 (36%) of 8 discontinued AHM within 1 year, 2 (25%) of 8 required more AHM, while 2 (25%) of 8 continued on their original AHM, and 1 patient who was not on AHM prior to PTx required initiation of AHM after PTx. There was a clinically significant increase in predialysis weight at 1 year after PTx (median 13 lb) and over time (r = 0.7; slope = 0.5; p = 0.07). However, there was neither a clinically nor statistically significant change in either systolic (r = -0.18; slope = -0.01; p = 0.61) or diastolic (r = -0.6; slope = -0.24; p = 0.12) BP over time. We conclude that PTx fails to correct hypertension in hemodialysis patients with 2 degrees HPT.

Anemia following renal transplantation: erythropoietin response and iron deficiency.

To define the etiology of anemia post-renal transplantation, we assessed hematologic parameters and EPO levels in 38 anemic and 16 non-anemic control renal transplant recipients (RTRs) with varying degrees of allograft function at periods > 3 months post-transplantation. Significant differences between the two groups were found for serum creatinine (Cr) 291.7 +/- 26.5 vs. 203.3 +/- 26.5 mumol/l, p < 0.01; iron 9.3 +/- 0.92 vs. 13.6 +/- 1.7 mumol/l, p < 0.05; and ferritin 345.5 +/- 90.8 vs. 91.1 +/- 18.5 micrograms/l, p < 0.01. Serum EPO levels were inappropriately low in anemic patients with no significant correlation between EPO and Cr or hematocrit (Hct) levels. Serum iron was the only predictive factor for anemia on regression analysis (p < 0.05). Ferritin levels did not correlate with serum iron or Hct, and may be falsely elevated in iron deficient RTRs. Iron deficiency, poor renal function and inappropriately low EPO levels are major contributors to the 12% of our outpatient renal transplant population who are anemic.

Unemployment in inner-city renal transplant recipients: predictive and sociodemographic factors.

Studies of dialysis patients report unemployment rates of 60% to 75%; however, it is generally believed that following transplantation, improvement in well-being and removal of time constraints imposed by the dialytic regimen afford improvement in employment status. We studied 58 stable renal transplant recipient attending an outpatient transplant clinic by questionnaire, administered anonymously. Only 25 (43%) of the patients were currently employed. Employed and unemployed patients did not differ when compared for age, gender, race, cause of renal disease, type of transplant or prior dialysis, time on dialysis or time since transplantation, years of education, or prestige score or classification ("blue collar" v "white collar") of prior job. In the employed group, 24 (96%) patients had worked before developing kidney disease compared with 23 (70%) patients in the unemployed group (P < 0.05). While on dialysis, 19 (79%) of the employed patients continued working compared with 10 (30%) of the unemployed patients (P < 0.005). Major reasons for discontinuing work after starting dialysis for both groups were subjective illness (feeling too sick, 51%), followed by interference of the dialysis regimen with time necessary for work (32%). Only 15% of the previously employed patients did not work after transplantation because of feeling too sick. By multiple logistic regression, the strongest predictors of employment posttransplant were being more than 1 year posttransplant (odds ratio, 2.35; 95% confidence interval, 1.01 to 5.5) and having been employed before transplantation (odds ratio, 3.79; 95% confidence interval, 1.60 to 9.02). Over half of the unemployed patients (20 [61%]) expressed interest in job training. Eighty percent to 90% of patients in both groups were insured by Medicare, with the second greatest number insured by Medicaid. Of the 15 unemployed patients insured by Medicaid, 67% reported that their decision not to work was related to fear of losing Medicaid benefits because they could not afford medications without it. Despite no difference in actual type of insurance carried, 17 (51%) of the unemployed patients believed their health insurance coverage was inadequate compared with four (12%) of the employed patients (P = 0.005, chi-squared test). Unemployment remains a significant problem for our population of inner-city renal transplant recipients. Attention to job retention or retraining during the early renal disease and dialysis therapy period may promote better rehabilitation following transplantation. However, for this population, with limited employment opportunities, removal of disincentives to work, including loss of Insurance and Inability to pay for medications, will be necessary before we can provide optimal rehabilitation for renal transplant recipients from all social strata.

Determinants of type of initial hemodialysis vascular access.

Vascular access thrombosis is more common with polytetrafluoroethylene (PTFE) grafts than with native arteriovenous fistulae (AVF). Recent studies report an unexplained excess vascular access morbidity in women on hemodialysis. We studied 92 consecutive end-stage renal disease (ESRD) patients receiving their first permanent hemodialysis vascular access at initiation of hemodialysis to identify variables that determine assignment of either a PTFE graft or a native AVF. Independent variables included: age, gender, race, etiology of ESRD, and whether or not access surgery was electively planned before need for dialytic therapy. The 51 women and 41 men included 65 blacks, 13 Hispanics, 11 whites, and 3 Orientals aged 50 +/- (SD) 16 years. Of the 92 subjects, 54 (59%) received an AVF, while 38 (41%) received a PTFE graft. 36 (94%) of 38 PTFE grafts were placed in the upper arm as compared with 9 (17%) of 54 AVF (p = 0.0001). Also, 45 (83%) of 54 AVF were placed in the forearm as compared with only 2 (6%) of 38 PTFE grafts (p = 0.0001). Women were more likely to receive a PTFE graft - 28 (55%) of 51 - than men - 10 (24%) of 41 (p = 0.003). By contrast, men were more likely to get an AVF - 31 (76%) of 41 - than women - 23 (45 %) of 51 (p = 0.003). The log linear analysis confirmed that this finding was significant (p = 0.0018) for the coefficient of interaction between gender and type of vascular access. No other independent variable had a significant relationship with type of vascular access. We conclude that women with ESRD are more likely to receive a PTFE graft for hemodialysis, while men are more likely to get an AVF. These findings may explain, in part, the reported excess vascular access morbidity in women on hemodialysis.

Influence of the timing of FK 506 (Tacrolimus) administration on recovery of renal function from warm ischemic injury in rats.

The influence of timing of FK 506 (Tacrolimus) administration on renal function and recovery from renal warm ischemia was studied in Sprague-Dawley rats. Animals were administered FK 506 and subjected to 60 min of renal warm ischemia by temporary occlusion of the renal artery and vein. No significant differences in serum creatinine levels among rats subjected to renal ischemia, FK 506, or FK 506 vehicle (methanol and 5% dextrose in water) were demonstrated. In contrast, FK 506 administration (4 mg/kg intraperitoneally) in combination with renal warm ischemia resulted in significant deterioration of renal function with peaking of serum creatinine on day 2. The timing of FK 506 administration relative to renal ischemia did not significantly affect serum creatinine levels. Rats that received FK 506 either 24 hr pre-ischemia, 4 hr pre-ischemia, 4 hr post-ischemia, or 24 hr post-ischemia all showed similar serum creatinine levels on day 2 (3.85 +/- 0.9, 4.7 +/- 0.5, 3.8 +/- 0.9, and 5.1 +/- 0.6 mg/dl, respectively, p = NS). In all animals, serum creatinine returned to baseline values by day 10. Histopathologic examination of kidneys revealed tubular atrophy and dilatation with tubular calcifications at the corticomedullary junction in FK 506 treated animals with or without ischemia. Our data suggest the timing of FK 506 administration in rats subjected to renal warm ischemia does not influence the extent of renal injury with an equally deleterious effect seen when administered within a 24 hr period of an ischemic event. Changes in kidney morphology, however, were seen in all FK 506 treated rats, with or without a period of warm ischemia.