Evolution of renal function and urinary biomarker indicators of inflammation on serial kidney biopsies in pediatric kidney transplant recipients with and without rejection.

Urinary CXCL10 and metabolites are biomarkers independently associated with TCMR. We sought to test whether these biomarkers fluctuate in association with histological severity of TCMR over short time frames. Forty-nine pairs of renal biopsies obtained 1-3 months apart from 40 pediatric renal transplant recipients were each scored for TCMR acuity score (i + t; Banff criteria). Urinary CXCL10:Cr and TCMR MDS were obtained at each biopsy and were tested for association with changes between biopsies in acuity, estimated GFR (ΔeGFR), and 12-month ΔeGFR. Sequential biopsies were obtained 1.8 ± 0.8 months apart. Biopsy 1 was usually obtained under protocol (75%), and 62% percent had evidence of TCMR. Using each biopsy pair for comparison, ΔeGFR did not predict change in acuity. By contrast, change in acuity was significantly correlated with change in urinary CXCL10:Cr (ρ 0.45, P = .003) and MDS (ρ 0.29, P = .04) between biopsies. The 12-month ΔeGFR was not predicted by TCMR acuity or CXCL10:Cr at Biopsy 2; however, an inverse correlation was seen with urinary MDS (ρ -0.35; P = .02). Changes in eGFR correlate poorly with evolving TCMR acuity on histology. Urinary biomarkers may be superior for non-invasive monitoring of rejection, including histological response to therapy, and may be prognostic for medium-term function.

Patient views on the management of rheumatic fever and rheumatic heart disease in the Kimberley: a qualitative study.

OBJECTIVE: To describe, from a patient perspective, factors leading to suboptimal management of individuals with rheumatic fever (RF) and rheumatic heart disease (RHD) among members of the Kimberley population. METHOD: Qualitative in-depth semistructured and repeated interviews of seven Kimberley patients, or parents of children, with rheumatic fever and/or rheumatic heart disease, during 1998. RESULTS: Participants showed variable levels of understanding about RF/RHD, often relating to the need for secondary prophylaxis. Compliance with medication was closely linked with positive patient-staff interactions. From the perspective of health care, living in a remote location was frequently described as a negative influence. Participants desire more accessible and culturally appropriate opportunities for learning about their disease. CONCLUSIONS: Participants focused on issues closely related to effective and ineffective management of RF/RHD. The lessons learned are indicators for health staff attempting to improve the quality of management that people receive.

The quality of management of rheumatic fever/ heart disease in the Kimberley.

OBJECTIVE: To evaluate the quality of management of Kimberley patients with rheumatic fever (RF) and rheumatic heart disease (RHD). METHODS: A retrospective analysis of medical records for 215 residents of the Kimberley region of Western Australia, diagnosed with RF or RHD during the years 1982 to 1996. RESULTS: Among patients prescribed intramuscular penicillin for secondary prophylaxis, 67% of prescribed doses were given, with individuals receiving 8-100% of doses prescribed. Of patients recommended visiting specialist or echocardiographic review, 78% and 64% attended respectively. Only 34% of patients with RHD in 1996 were recommended dental review in 1996 or 1997. Appropriate blood testing occurred in 34% of the months in which people had anticoagulant prescribed. CONCLUSIONS: A clinical audit can be used to evaluate the management received by this population and hence identify areas to improve management. We found much room for improvement if optimal clinical outcomes are to be obtained.