Automated and continuous ambulatory peritoneal dialysis have similar outcomes.

We compared survival and death-censored technique survival in patients on automated peritoneal dialysis (automated dialysis) or on continuous ambulatory peritoneal dialysis. All 4128 patients from the Australia and New Zealand Dialysis and Transplant Registry who started peritoneal dialysis over a 5-year period through March 2004 were included. Times to death and death-censored technique failure were analyzed by Cox proportional hazards models while a conditional risk set model computed technique failure. Compared to patients treated entirely with continuous ambulatory peritoneal dialysis, automated peritoneal dialysis patients were more likely to be young, Caucasian, have marginally lower body mass index, and were less likely to have baseline cardiovascular disease or diabetes. Using univariate and multivariate analysis, our study showed there were no significant differences in patient survival and death-censored technique failure between the two types of peritoneal dialysis modalities.

Metastatic insulinoma in an adult patient with underlying nesidioblastosis.

OBJECTIVE: To report a case of metastatic insulinoma presenting 11 yr after enucleation of an isolated insulinoma, and 5 yr after distal pancreatectomy for nesidioblastosis. METHODS: We present the clinical, laboratory, radiological and pathological findings in a 34 yr-old-man with recurrent hypoglycemia. The pertinent literature is reviewed. RESULTS: A 34- yr-old man presented in 1992 with symptoms of recurrent hypoglycemia. Laboratory and imaging findings were consistent with insulinoma. After enucleation of the tumor, his symptoms resolved. In 1998 hypoglycemia recurred and biochemical work-up was consistent with endogenous hyperinsulinism. Imaging for recurrent or metastatic insulinoma revealed no mass. He underwent a distal pancreatectomy and pathology revealed islet cell hyperplasia, or nesidioblastosis. However, the patient reported minimal symptomatic improvement. He was started on diazoxide but was poorly compliant and ate frequently to avoid hypoglycemic symptoms. In 2003 he presented with hypoglycemia-induced seizure activity. Imaging showed hepatic and pulmonary lesions, but no pancreatic mass. An octreotide scan revealed increased hepatic uptake and fine needle aspiration of a liver lesion confirmed metastatic insulinoma. Arterial-stimulation venous sampling revealed increased insulin output from the liver and normal insulin output from the pancreas. After failure of medical therapy, radiofrequency ablation of hepatic lesions was performed with subsequent improvement in clinical symptoms. The patient was discharged on a low dose of dexamethasone. CONCLUSION: Although this patient had nesidioblastosis, his recurrent hyperinsulinism was most likely secondary to metastatic insulinoma. Radiofrequency ablation was successfully used for palliative purposes in managing metastatic insulinoma refractory to medical therapy.

Increased end-stage diabetic nephropathy in Indo-Asian immigrants living in the Netherlands.

AIMS/HYPOTHESIS: We aimed to investigate the risk of end-stage diabetic nephropathy due to Type II (non-insulin-dependent) diabetes mellitus in Indo-Asian immigrants from Surinam. METHODS: A demographically based case-control study was carried out in Surinamese Indo-Asian immigrants and Dutch Caucasian subjects. All patients with end-stage diabetic nephropathy who had started dialysis between 1990 and 1998 were identified through a national registry of all patients entering a renal replacement program in the Netherlands. The general population of native Dutch and Surinamese Indo-Asians were considered the control subjects. RESULTS: Among Indo-Asian immigrants, the age adjusted relative risk of end-stage diabetic nephropathy was 38 (95 % CI 16 to 91) compared with the native Dutch population. The duration of diabetes until the start of dialysis treatment was similar in both ethnic groups, about 17 years. CONCLUSION/INTERPRETATION: The Indo-Asian subjects had a nearly 40-fold increase in the risk for end-stage diabetic nephropathy due to Type II diabetes, compared with the native Dutch population. This was higher than expected on the basis of the eightfold higher prevalence of diabetes in the Indo-Asian population. The similar duration of diabetes until the start of dialysis treatment in both ethnic groups supports the hypothesis of a higher incidence of diabetic nephropathy in the Indo-Asian diabetic population. Early and frequent screening for diabetes and microalbuminuria is recommended in Indo-Asian subjects.

Adequacy targets can be met in anuric patients by automated peritoneal dialysis: baseline data from EAPOS.

OBJECTIVE: Conventional continuous ambulatory peritoneal dialysis (CAPD) in patients without residual renal function and with high solute transport is associated with worse clinical outcomes. Automated peritoneal dialysis (APD) has the potential to improve both solute clearance and ultrafiltration in these circumstances, but its efficacy as a treatment modality is unknown. The European Automated Peritoneal Dialysis Outcomes Study (EAPOS) is a 2-year, prospective, European multicenter study designed to determine APD feasibility and clinical outcomes in anuric patients. The present article describes the baseline data for patients recruited into the study. DESIGN: All PD patients treated in the participating centers were screened for inclusion criteria [urinary output < 100 mL/24 h, or residual renal function (RRF) < 1 mL/min, or both]. After enrollment, changes were made to the dialysis prescription to achieve a weekly creatinine clearance above 60 L per 1.73 m2 and an ultrafiltration rate above 750 mL in 24 hours. SETTING: The study is being conducted in 26 dialysis centers in 13 European countries. BASELINE DATA COLLECTION: The information collected includes patient demographics, dialysis prescription, achieved weekly creatinine clearance, and 24-hour ultrafiltration (UF). RESULTS: The study enrolled 177 anuric patients. Median dialysis duration before enrollment was 22.5 months (range: 0-285 months). Mean solute transport measured as the dialysate-to-plasma ratio of creatinine (D/P(Cr)) was 0.74 +/- 0.12. Patients received APD for a median of 9.0 hours overnight (range: 7-12 hours) using a median of 11.0 L of fluid (range: 6-28.75 L). Median daytime volume was 4.0 L (range: 0.0-9.0 L). Tidal dialysis was used in 26 patients, and icodextrin in 86 patients. At baseline, before treatment optimization, the weekly mean total creatinine clearance was 65.2 +/- 14.4 L/1.73 m2, with 105 patients (60%) achieving the target of more than 60 L/1.73 m2. At baseline, 81% of patients with high transport, 69% with high-average transport, and 40% with low-average transport met the target. At baseline, 70% of patients with a body surface area (BSA) below 1.7 m2, 60% with a BSA of 1.7-2.0 m2, and 56% with a BSA above 2.0 m2 achieved 60 L/1.73 m2 weekly. Median UF was 1090 mL/24 h, and 75% of patients achieved the UF target of more than 750 mL/24 h. CONCLUSION: This baseline analysis of anuric patients recruited into the EAPOS study demonstrates that a high proportion of anuric patients on APD can achieve dialysis and ultrafiltration targets using a variety of regimes. This 2-year follow-up study aims to optimize APD prescription to reach predefined clearance and ultrafiltration targets, and to observe the resulting clinical outcomes.

Forensic aspects of sexual harassment.

Sexual harassment law presents a complex set of issues not only for lawyers but also for psychiatrists in their roles both as evaluators and clinicians. Judge Reinhardt of the US Court of Appeals for the 9th Circuit, summed up these complexities: "We tend these days, far more than in earlier times, to find our friends, lovers, and even mates in the workplace. We ... often discover that our interests and values are closer to those of our colleagues or fellow employees than to those of people we meet in connection with other activities. In short, increased proximity breeds increased volitional sexual activity." On the other hand, he notes that Title VII "entitles individuals to a workplace that is free from the evil of sexual intimidation or repression. It is frequently difficult to reconcile the two competing values." He goes on to ask, "When does a healthy constructive interest in romance become sexual harassment? To what extent is pursuit of a co-worker proper but of a subordinate forbidden? Is wooing or courting a thing of the past? Must a suitor cease his attentions at the first sign of disinterest or resistance? Must there be an express agreement before the person seeking romance may even hold the hand of the subject of his affection? Is it now verboten to steal a kiss? In the workplace? Everywhere? Under all circumstances or only some? Has the art of romantic persuasion lost its charm? Questions relating to love and sex are among the most difficult for society to answer." The US Supreme Court has stressed the need for common sense in evaluating cases of sexual harassment. Perhaps psychiatrists can play a sobering role in developing answers to these questions.

Quantitative neuronal c-fos and c-jun expression in Alzheimer's disease.

Apoptosis, or programmed cell death, has been proposed as a mechanism of neuropathology in Alzheimer's disease (AD). Activation of immediate early genes (IEG) c-jun and c-fos appears to be required for the initiation of apoptosis. Furthermore, the expression of c-jun is induced in cultured neurons that undergo beta-amyloid-mediated apoptosis suggesting a direct role for c-jun in the apoptosis of AD neurons. Using immunohistochemical methods, we calculated the average number of neuronal profiles per unit area expressing c-Jun and c-Fos within hippocampal regions CA1, CA2/3, and CA4 in postmortem brain samples from AD patients and age-matched non-AD patients. There was an increase in c-Jun-positive and c-Fos-positive neuronal profile density in nearly all AD hippocampal regions examined. In cerebellum there was no evidence of apoptosis as determined by using TUNEL technique, and negligible c-Jun labeling.

EEOC guidance on psychiatric disabilities: many problems, few workable solutions.

The EEOC recently issued "Enforcement Guidance" on psychiatric disabilities under the Americans with Disabilities Act. Although the Guidance provides clarification of a few issues involving mental disabilities under the ADA, in most respects the Guidance is problematic. For example, the Guidance suggests that the inability to get along with a supervisor or coworkers may constitute a disability under the ADA, that an employer may have to "accommodate" a disabled employee's misconduct, that an employer cannot require an employee to follow doctor's orders as a condition of employment, and that an employer may be obligated to modify work rules and procedures to accommodate a mentally disabled employee but is prohibited from explaining to coworkers why it is making such modifications. As the EEOC's Guidance exceeds or conflicts with the ADA in some respects and is largely unworkable in many respects, it remains to be seen how many courts will actually follow it.

High frequency of marked hyperphosphatemia during intravenous calcitriol therapy in hemodialysis patients with refractory hyperparathyroidism.

Efficacy and safety of intermittent intravenous calcitriol therapy were studied in 8 chronic hemodialysis patients with marked hyperparathyroidism refractory to oral therapy with calcium salts and daily vitamin D. They were followed for 20 weeks (32 weeks for 2 patients). At the start of the study, serum calcium was < 2.65 mmol/l and phosphate levels were controlled with calcium-based binders only. The phosphate content of the prescribed diet (< 1 g/day) remained unchanged during the study, and a low-calcium dialysate was used (1.38 mmol/l). The initial postdialysis calcitriol dose was 1 microgram and was increased to 2 micrograms in 6 patients. Intravenous calcitriol effectively improved hyperparathyroidism in 7 patients, with a significant decrease of the intact parathyroid hormone level from 650 +/- 433 to 195 +/- 208 pg/ml (p < 0.05). Hypercalcemia > 2.7 mmol/l occurring in 3 patients was observed in only 11% of the weekly laboratory controls and always resolved rapidly. In contrast, hyperphosphatemia > or = 2.0 mmol/l was observed in 7 patients and in 40% of the weekly laboratory controls. In 15% of the cases the phosphate values even exceeded 2.4 mmol/l. The phosphate binder therapy had to be intensified accordingly, not only by increasing the dose of calcium-based binders, but also by introducing aluminum salts in 6 patients. In summary, our data show that intravenously administered calcitriol is effective in the treatment of severe hyperparathyroidism in most hemodialysis patients resistant to oral therapy. However, its usefulness seems to be limited by frequency and severity of hyperphosphatemia, frequently necessitating additional prescription of aluminum-based binders. These undesirable secondary events may thus limit the long-term utility of intravenously administered calcitriol.

[Protein restriction in diet therapy in chronic kidney insufficiency]. / Proteineinschränkung in der Ernährung bei chronischer Niereninsuffizienz.

Dietary protein restriction represents an important new development in the treatment of chronic kidney disease during the last ten years. The dogma that chronic renal failure is always progressive appears to be broken. In clinical practice this mode of therapy is now established in early stages of renal failure. The precise indications, however, remain to be discussed ['Are all patients with chronic renal failure candidates for low-protein diets?']. The pathophysiological background of the diets is only partly elucidated. The main problem with low-protein diets is the compliance of the patients which is frequently insufficient. Studies are underway to answer some of these remaining open questions. This review summarises the current views on practical aspects of low-protein diets in chronic renal failure, and arguments for a more widespread application of this physiologic therapy are presented.

[Systematic use of a "swan neck" catheter for peritoneal dialysis: first evaluation]. / Emploi systématique du cathéter arqué en col de cygne "swan neck" pour dialyse péritonéale: première appréciation.

We inserted a "swan neck" peritoneal dialysis catheter in 26 patients between January 1991 and December 1992. We report our results in the 24 patients that we were able to follow: they were satisfactory but the exit-site infection rate was too high. Postoperative care of the catheter is of paramount importance to prevent such complications.

[C-reactive protein and early diagnosis of kidney transplant rejection]. / C-reaktives Protein und Früherfassung der Nierentransplantatabstossung.

C-reactive protein (CRP), which is known to rise rapidly in the serum after tissue injuries or inflammation, was measured daily after renal transplantation during hospitalization up to day 28 in 45 consecutive patients. In 16 patients who developed neither an infection nor rejection the CRP level normalized within 3 to 5 days. In 7 out of 14 patients with graft rejection the CRP level rose 1 to 3 days before the clinical signs of rejection. 11 patients with overt infection all had a CRP rise. 6 other patients had a CRP rise: in 5 the clinical situation explained this rise but in the sixth no explanation was found. We conclude from our results that periodic measurement of CRP (for example twice a week), even under aggressive immunosuppression, can help in the early diagnosis of graft rejection after renal transplantation. In the event of infection CRP loses its usefulness with respect to graft rejection and the daily measurements have no further point.

[Rhabdomyolysis, acute renal insufficiency and hypercalcemia]. / Rhabdomyolyse, insuffisance rénale aiguë et hypercalcémie.

Acute renal failure is a severe and frequent complication of rhabdomyolysis. During the early polyuric phase, hypercalcemia is observed in around 30% of cases. The principal mechanism is the liberation of calcium from areas of muscular necrosis. Two cases of toxic rhabdomyolysis with secondary hypercalcemia are described.

Cyclosporin A has no impact on alterations of the lipid profile after renal transplantation.

The literature contains conflicting ideas regarding the role of cyclosporin A (CyA) in the induction of posttransplant dyslipidemia. The available studies contain small numbers of patients, especially on CyA monotherapy. We compared 65 patients on conventional azathioprine-prednisone therapy (AP) with 85 patients on CyA monotherapy, 19 on CyA-azathioprine therapy (CA), 20 on CyA-prednisone therapy (CP), and 52 on a triple therapy with CyA, azathioprine, and prednisone (CAP). From the results, it is concluded that patients on CyA monotherapy had lower serum cholesterol levels, with a lower high-density lipoprotein (HDL)-cholesterol level, probably due to the lower total cholesterol, compared with AP patients. From all groups, the CyA monotherapy group showed the most beneficial lipid profile. No additive negative influences of CyA when combined with other immunosuppressive drugs were noted. Thus, a correlation between derangements of the lipid profile and CyA therapy could not be confirmed. Further analysis of our data showed negative influences of antihypertensive treatment on lipid metabolism, particularly in the case of treatment with beta-blockers or diuretics. It cannot be excluded that studies showing a negative influence of CyA therapy on lipid homeostasis were biased by secondary factors like antihypertensive therapy, which was often not taken into account.