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Background: In 2012, Luxembourg introduced a Referring Doctor (RD) policy, whereby patients voluntarily register with a primary care practitioner, who coordinates patients' health care and ensures optimal follow-up. We contribute to the limited evidence base on patient registration by evaluating the effects of the RD policy., Methods: We used data on 16,775 people with type 2 diabetes on oral medication (PWT2D), enrolled with the Luxembourg National Fund from 2010 to 2018. We examined the utilisation of primary and specialist outpatient care, quality of care process indicators, and reimbursed prescribed medicines over the short- (until 2015) and medium-term (until 2018). We used propensity score matching to identify comparable groups of patients with and without an RD. We applied difference-in-differences methods that accounted for patients' registration with an RD in different years., Results: There was low enrolment of PWT2D in the RD programme. The differences-in-differences parallel trends assumption was not met for: general practitioner (GP) consultations, GP home visits (medium-term), HbA1c test (short-term), complete cholesterol test (short-term), kidney function (urine) test (short-term), and the number of repeat prescribed cardiovascular system medicines (short-term). There was a statistically significant increase in the number of: HbA1c tests (medium-term: 0.09 (95% CI: 0.01 to 0.18)); kidney function (blood) tests in the short- (0.10 (95% CI: 0.01 to 0.19)) and medium-term (0.11 (95% CI: 0.03 to 0.20)); kidney function (urine) tests (medium-term: 0.06 (95% CI: 0.02 to 0.10)); repeat prescribed medicines in the short- (0.19 (95% CI: 0.03 to 0.36)) and medium-term (0.18 (95% CI: 0.02 to 0.34)); and repeat prescribed cardiovascular system medicines (medium-term: 0.08 (95% CI: 0.01 to 0.15)). Sensitivity analyses also revealed increases in kidney function (urine) tests (short-term: 0.07 (95% CI: 0.03 to 0.11)) and dental consultations (short-term: 0.06, 95% CI: 0.00 to 0.11), and decreases in specialist consultations (short-term: -0.28, 95% CI: -0.51 to -0.04; medium-term: -0.26, 95% CI: -0.49 to -0.03)., Conclusions: The RD programme had a limited effect on care quality indicators and reimbursed prescribed medicines for PWT2D. Future research should extend the analysis beyond this cohort and explore data linkage to include clinical outcomes and socio-economic characteristics., (© 2024. The Author(s).)

Background: In recent years, more importance is being given to the assessment of quality of life (QoL) among diabetic patients as a measure of their health and the goal of all health interventions. Other studies have reported a high prevalence of diabetes-related effects on; however, there is a knowledge gap in the region of Sub-Saharan Africa, as is the case for Rwanda, where the prevalence of diabetes is expected to rise over the next decade. The aim of this study is to report on the translation and cultural adaptation of the Diabetes-39 (D-39) questionnaire into the Kinyarwanda and its psychometric properties among diabetic patients in Rwanda., Methods: The D-39 questionnaire-a five-scale, disease-specific QoL questionnaire-was translated from English to Kinyarwanda, then back-translated to English. A consensus meeting discussed discrepancies and agreed on changes. Interviews were conducted with 26 participants before producing a final version. For the psychometric evaluation, the adapted version was administered to 309 patients with diabetes mellitus. Participants either came from a separate cluster-randomised controlled trial or were recruited ad hoc for this study. The evaluation included testing internal consistency, known group validity, and construct validity., Results: Participants' mean age was 51 ± 12.7 years with a predominance of women (64%) in the sample. All five scales of the questionnaire showed a good internal consistency, with composite reliability of above 0.7. The five-factor model of the questionnaire was fitted to the 39 items. Although the fit was not exact, there was a satisfactory approximate fit (CFI = 0.93, TLI = 0.92, RMSEA = 0.05). There was a good discriminant validity except for the "social burden" and "anxiety and worry" scales (inter-factor correlation = 0.80)., Conclusions: Diabetes-39 is a questionnaire developed in English that was adapted and translated into Kinyarwanda. The Kinyarwanda version of D-39 is a reliable and valid instrument to measure QoL among diabetic patients in Rwanda. The questionnaire can be helpful in research and clinical practice improving health outcomes for patients with diabetes in Rwanda and other Kinyarwanda-competent areas in the sub-region. However, certain cross-cultural differences should be considered., (© 2022. The Author(s).)

Background: High prevalence rates in diabetes-related distress have been observed in several studies; however, in the region of Sub-Saharan Africa evidence is lacking as is, for example, the case for Rwanda, where diabetes prevalence is expected to increase over the next decade. The aim of this study is to report on the translation and cultural adaption of the problem areas in diabetes (PAID) questionnaire into Kinyarwanda and its psychometric properties., Methods: The questionnaire was translated following a standard procedure. Interviews were conducted with 29 participants before producing a final version. For the psychometric evaluation, a sample of 266 patients with diabetes mellitus, aged 21-64 years old were examined. Participants either came from a separate cluster-randomised controlled trial or were recruited ad-hoc for this study. The evaluation included testing internal consistency, known groups validity, and construct validity. A series of confirmatory factor analysis were conducted investigating seven previously established factorial structures. An exploratory factor analysis (EFA) was also carried out to examine the structure further., Results: The full scale showed good internal reliability (Cronbach's α = 0.88). A four-factor solution previously tested in Spain with subdimensions of emotional, treatment, food-related and social-support problems demonstrated adequate approximate fit (RMSEA = 0.056; CFI = 0.951; TLI = 0.943). The EFA revealed a four-factor structure; however, two of these factors were not as homogeneous and easily interpretable as those of the Spanish model., Conclusions: The psychometric properties of the Kinyarwanda version of PAID are acceptable. The questionnaire can be helpful in research and clinical practice in Rwanda, however certain cross-cultural differences should be taken into account., (© 2021. The Author(s).)

Objectives: To report on the disease-related quality of life of patients living with diabetes mellitus in Rwanda and identify its predictors., Design: Cross-sectional study, part of the baseline assessment of a cluster-randomised controlled trial., Setting: Outpatient clinics for non-communicable diseases of nine hospitals across Rwanda., Participants: Between January and August 2019, 206 patients were recruited as part of the clinical trial. Eligible participants were those aged 21-80 years and with a diagnosis of diabetes mellitus for at least 6 months. Illiterate patients, those with severe hearing or visual impairments, those with severe mental health conditions, terminally ill, and those pregnant or in the postpartum period were excluded PRIMARY AND SECONDARY OUTCOME MEASURES: Disease-specific quality of life was measured with the Kinyarwanda version of the Diabetes-39 (D-39) questionnaire. A glycated haemoglobin (HbA1c) test was performed on all patients. Sociodemographic and clinical data were collected, including medical history, disease-related complications and comorbidities., Results: The worst affected dimensions of the D-39 were 'anxiety and worry' (mean=51.63, SD=25.51), 'sexual functioning' (mean=44.58, SD=37.02), and 'energy and mobility' (mean=42.71, SD=20.69). Duration of the disease and HbA1c values were not correlated with any of the D-39 dimensions. A moderating effect was identified between use of insulin and achieving a target HbA1c of 7% in the 'diabetes control' scale. The most frequent comorbidity was hypertension (49.0% of participants), which had a greater negative effect on the 'diabetes control' and 'social burden' scales in women. Higher education was a predictor of less impact on the 'social burden' and 'energy and mobility' scales., Conclusions: Several variables were identified as predictors for the five dimensions of quality of life that were studied, providing opportunities for tailored preventive programmes. Further prospective studies are needed to determine causal relationships., Trial Registration Number: NCT03376607., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: In response to the COVID-19 pandemic, the Yale New Haven Health System began rescheduling nonurgent outpatient appointments as virtual visits in March 2020. While Yale New Haven Health expanded its telemedicine infrastructure to accommodate this shift, many appointments were delayed and patients faced considerable uncertainty., Objective: Medical students created the Medical Student Task Force (MSTF) to help ensure continuity of care by calling patients whose appointments were delayed during this transition to telemedicine., Methods: Eighty-five student volunteers called 3765 internal medicine patients with canceled appointments, completing screening for 2197 patients. Volunteers screened for health care needs, assessed preferences for future appointments, and offered emotional support and information about COVID-19. Urgent or emergent patient concerns were triaged and escalated to providers. In this analysis, we used a mixed-methods approach: call information and provider responses were analyzed quantitatively, and patient feedback was analyzed qualitatively via thematic analysis., Results: Ninety-one percent of patients screened found the MSTF calls helpful. Twenty-one percent of patients reported health concerns, with 1% reporting urgent concerns escalated to and addressed by providers. Themes of patient comments included gratitude for outreach and social contact, utility of calls, and well-wishes for health care workers., Conclusions: By calling patients whose appointments had been canceled during a rapid transition to telemedicine, the MSTF helped bridge a potential gap in care by offering patients communication with their care teams, information, and support. We propose that this model could be used in other care systems urgently transitioning to outpatient telemedicine, whether during ongoing outbreaks of COVID-19 or other public health emergencies., Competing Interests: N.R.D. reports grants and personal fees from Amgen, grants and personal fees from Astra Zeneca, grants from Boehringer Ingelheim, grants and personal fees from Cytokinetics, grants and personal fees from Novartis, grants and personal fees from Relypsa, and personal fees from SC Pharmaceuticals, outside the submitted work. No other authors report conflicts of interest., (© Annika Belzer et al., 2021; Published by Mary Ann Liebert, Inc.)

Introduction: In Rwanda, diabetes mellitus prevalence is estimated between 3.1% and 4.3%. To address non-communicable diseases and the shortage of health workforce, the Rwandan Ministry of Health has introduced the home-based care practitioners (HBCPs) programme: laypeople provide longitudinal care to chronic patients after receiving a six-month training. Leveraging technological mobile solutions may also help improve health and healthcare. The D²Rwanda study aims at: (a) determining the efficacy of an integrated programme for the management of diabetes in Rwanda, which will provide monthly patient assessments by HBCPs, and an educational and self-management mHealth patient tool, and; (b) exploring qualitatively the ways the interventions will have been enacted, their challenges and effects, and changes in the patients' health behaviours and HBCPs' work satisfaction., Methods and Analysis: This is a mixed-methods sequential explanatory study. First, there will be a one-year cluster randomised controlled trial including two interventions ((1) HBCPs' programme; (2) HBCPs' programme + mobile health application) and usual care (control). Currently, nine hospitals run the HBCPs' programme. Under each hospital, administrative areas implementing the HBCPs' programme will be randomised to receive intervention 1 or 2. Eligible patients from each area will receive the same intervention. Areas without the HBCPs' programme will be assigned to the control group. The primary outcome will be changes in glycated haemoglobin. Secondary outcomes include medication adherence, mortality, complications, health-related quality of life, diabetes-related distress and health literacy. Second, at the end of the trial, focus group discussions will be conducted with patients and HBCPs. Financial support was received from the Karen Elise Jensens Fond, and the Universities of Aarhus and Luxembourg., Ethics and Dissemination: Ethics approval was obtained from the Rwanda National Ethics Committee and the Ethics Review Panel of the University of Luxembourg. Findings will be disseminated via peer-reviewed publications and conference presentations., Trial Registration Number: NCT03376607; Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The observed structured clinical examination (OSCE) is an important tool to assess clinical competencies; however, there are no reported palliative care OSCEs for medical student assessment., Objective: We aimed to develop, implement, and evaluate the characteristics of a palliative care OSCE for fourth-year medical students., Methods: We created a representative case and a checklist of 14 history items from three core palliative care competency domains. Subjects were fourth-year medical students who had completed our school's longitudinal palliative care curriculum. Measurements were students' scores compiled from the standardized patient's (SP) tally of the checklist results. We determined inter-rater reliability between the SP and a remote observer. Measurements included the difficulty and discrimination index, internal consistency reliability, factor analysis, and relationships between palliative care scores and composite seven station OSCE scores., Results: In the implementation year, 95 students scored an average of 74% (standard deviation [SD] = 13%) on the 14 history items. There was 95% agreement in ratings on items between the SP and the remote observer. The Cronbach's alpha was 0.53, demonstrating moderate internal consistency. The palliative care scores correlated with overall OSCE communication scores (R = 0.29, p = 0.01) and history scores (R = 0.61, p = 0.01)., Conclusions: A new OSCE to assess palliative care competencies was feasible to implement with high inter-rater reliability, evidence supporting validity, and moderate internal consistency. We believe this OSCE would prove useful to assess students' primary palliative care competency and to evaluate curricula in palliative care.

Problem: Meeting the needs of patients with life-limiting and terminal illness requires effectively trained physicians in all specialties to provide skillful and compassionate care. Despite mandates for end-of-life (EoL) care education, graduating medical students do not consistently feel prepared to provide this care., Intervention: We have developed a longitudinal, integrated, and developmental 4-year curriculum in EoL care. The curriculum's purpose is to teach basic competencies in EoL care. A variety of teaching strategies emphasize experiential, skill-building activities with special attention to student self-reflection. In addition, we have incorporated interprofessional learning and education on the spiritual and cultural aspects of care. We created blended learning strategies combining interactive online modules with live workshops that promote flexibility, adaptability, and interprofessional learning opportunities., Context: The curriculum was implemented and evaluated in the 4-year program of studies at Yale School of Medicine., Outcome: A mixed-method evaluation of the curriculum included reviews of student written reflections and questionnaires, graduating student surveys, and demonstration of 4th-year students' competency in palliative care with an observed structured clinical examination (OSCE). These evaluations demonstrate significant improvements in students' self-reported preparedness in EoL care and perceptions of the adequacy in their instruction in EoL and palliative care, as well as competency in primary palliative care in a newly developed OSCE., Lessons Learned: A 4-year longitudinal integrated curriculum enhances students' skills and preparedness in important aspects of EoL care. As faculty resources, clinical sites, and curricular structure vary by institution, proven and adaptable educational strategies as described in this article may be useful to address the mandate to improve EoL care education. Teaching strategies and curricular components and design as just described can be adapted to other programs.

Ethicists and guidelines have suggested that potential living kidney donors who withdraw from evaluation be offered an 'alibi.' We sought to determine what potential living kidney donors are told about their ability to opt out, alibi availability and postwithdrawal confidentiality. We reviewed 148 consent forms for living kidney donor evaluation from US transplant centres that performed >5 living kidney transplants in 2010-2011 (response rate 87%). We found that while 98% of centres used evaluation consent forms that indicated that the donor could withdraw, only 21% of these documents offered an alibi. Another 23% of centres' consent forms indicated that the transplant team would be willing to inform the intended recipient that an individual was not a potential donor. Relatively few consent documents explicitly addressed the confidentiality of the donor's health information (31%), candidacy status (18%), decision (24%) or reasons (23%) following withdrawal. To preserve potential donors' autonomy and relationships, we advocate that all transplant centres offer general alibis in their evaluation consent forms. We conclude by offering recommendations for evaluation consent discussions of opting out, alibis and postwithdrawal confidentiality., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

We sought to assess how written informed consent practices for candidate living kidney donors have changed over the last 5 years and to assess compliance with Centers for Medicare and Medicaid (CMS) and Organ Procurement and Transplantation Network (OPTN) regulations that took effect in 2007. We requested evaluation consent forms from US centers that performed >5 living kidney transplants during the prior year (n = 184). We received 148 consent forms; each was reviewed for information provided and inclusion of CMS- and OPTN-required elements. We found that nearly all transplant centers now obtain written consent for living kidney donor evaluation. However, most centers' evaluation consent forms do not include all CMS and OPTN requirements. Multiple items balancing donor and recipient interests and confidentiality were omitted. In addition, information about payment for routine follow-up care, complications related to surgery and other health problems following surgery were highly variable and frequently ambiguous. As centers revise their consent forms to address the 2013 OPTN policies, our findings may help them identify areas of potential deficiency. We propose that UNOS develop a uniform donor evaluation consent form to improve the clarity, consistency and efficiency of living donor consent., (© Copyright 2013 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Background: To meet the complex needs of patients with serious illness, health professional students require education in basics aspects of palliative care, including how to work collaboratively on an interprofessional team., Objectives: An educational program was created, implemented, and evaluated with students in medicine, nursing, chaplaincy, and social work. Five learning objectives emphasized spiritual, cultural, and interprofessional aspects of palliative care., Design: The program blended two sequential components: an online interactive, case-based learning module, and a live, dynamic simulation workshop., Measurements: Content analysis was used to analyze students' free-text responses to four reflections in the online case, as well as open-ended questions on students' postworkshop questionnaires, which were also analyzed quantitatively., Results: Analysis of 217 students' free-text responses indicated that students of all professions recognized important issues beyond their own discipline, the roles of other professionals, and the value of team collaboration. Quantitative analysis of 309 questionnaires indicated that students of all professions perceived that the program met its five learning objectives (mean response values>4 on a 5-point Likert scale), and highly rated the program and its two components for both educational quality and usefulness for future professional work (mean response values approximately>4)., Conclusions: This innovative interprofessional educational program combines online learning with live interactive simulation to teach professionally diverse students spiritual, cultural, and interprofessional aspects of palliative care. Despite the challenge of balanced professional representation, this innovative interprofessional educational program met its learning objectives, and may be transferable for use in other educational settings.

Multidetector computed tomography (MDCT) angiography is a reliable technique for assessing pre-operative renal anatomy in living kidney donors. The method has largely evolved into protocols that eliminate dedicated venous phase and instead utilize a combined arterial/venous phase to delineate arterial and venous anatomy simultaneously. Despite adoption of this protocol, there has been no study to assess its accuracy. To assess whether or not MDCT angiography compares favorably to intra-operative findings, 102 donors underwent MDCT angiography without a dedicated venous phase with surgical interpretation of renal anatomy. Anatomical variants included multiple arteries (12%), multiple veins (7%), early arterial bifurcation (13%), late venous confluence (5%), circumaortic renal veins (5%), retroaortic vein (1%), and ureteral duplication (2%). The sensitivity and specificity of multiple arterial anomalies were 100% and 97%, respectively. The sensitivity and specificity of multiple venous anomalies were 92% and 98%, respectively. The most common discrepancy was noted exclusively in the interpretation of right venous anatomy as it pertained to the renal vein/vena cava confluence (3%). MDCT angiography using a combined arterial/venous contrast-enhanced phase provides suitable depiction of renal donor anatomy. Careful consideration should be given when planning a right donor nephrectomy whether the radiographic interpretation is suggestive of a late confluence., (© 2010 John Wiley & Sons A/S.)

In response to recently published KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for the care of kidney transplant recipients (KTRs), the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) organized a working group of transplant nephrologists and surgeons to review these guidelines and comment on their relevance and applicability for US KTRs. The following commentaries on the KDIGO guidelines represent the consensus of our work group. The KDIGO transplant guidelines concentrated on aspects of transplant care most important to this population in the posttransplant period, such as immunosuppression, infection, malignancy, and cardiovascular care. Our KDOQI work group concurred with many of the KDIGO recommendations except in some important areas related to immunosuppression, in which decisions in the United States are largely made by transplant centers and are dependent in part on the specific patient population served. Most, but not all, KDIGO guidelines are relevant to US patients. However, implementation of many may remain a major challenge because of issues of limitation in resources needed to assist in the tasks of educating, counseling, and implementing and maintaining lifestyle changes. Although very few of the guidelines are based on evidence that is strong enough to justify their being used as the basis of policy or performance measures, they offer an excellent road map to navigate the complex care of KTRs., (Copyright (c) 2010 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Goals: To determine the efficacy and safety of combination therapy in patients with hepatitis C virus (HCV) and end-stage renal disease (ESRD)., Background: There is little data on the treatment of ESRD patients with pegylated interferon and ribavirin. We designed a pilot study to determine the initial and 12-week posttreatment viral response., Study: A nonrandomized, prospective observational study of adjusted-dose combination therapy. Twenty patients were enrolled and began pegylated interferon at 135 microg/wk SC, and 4 weeks later ribavirin was started at 200 mg PO weekly, increasing gradually to 3 times a week for a total of 48 weeks., Results: Twenty patients: M:F 18:2; mean age 52.4 years; genotype 1: 18, non-genotype 1: 2. Of the 20 patients, 5 withdrew before starting treatment. Of the 11 patients who reached 3 months, 6 had early virologic response, defined as at least a 2-log drop in their HCV count (54.5%). Of the 5 patients who were treated for 1-year, only 1 patient had a response 12 weeks after treatment. Side effects included 4 cases of anemia and 1 patient with headache., Conclusions: The initial response rate in individuals taking 3 months of treatment in our study is comparable with studies in non-ESRD patients with no serious adverse side effects. However, the sustained posttreatment rate was low. This demonstrates that combination therapy is a safe therapeutic option in the ESRD population with HCV infection which needs further testing to determine if increasing the length of treatment and/or the dose of ribavirin will affect posttreatment rates.

Integrating end-of-life care training into the clinical years of medical school has been promoted to enhance education in this area. To assess the effectiveness of an end-of-life care exercise integrated into clinical clerkships, we compared the level of preparedness in end-of-life care reported by students who did or did not complete the exercise. A greater proportion of students who completed the exercise compared with those who did not felt prepared in end-of-life care [50.7% (39/77) vs 35.6% (64/180); P = .02]. Among 5 domains of skills examined, significant differences were seen in interviewing/communicating (3.7 vs 3.5; P = .05) and management of common symptoms (3.3 vs 3.0; P < .01). We conclude that a ward-based integrated end-of-life care exercise may improve graduating students' self-reported preparedness to care for patients at the end of life.

Bone disease is common in recipients of kidney, liver, heart, and lung transplants and results in fractures in 20-40% of patients, a rate much higher than expected for age. Fractures occur because of the presence of bone disease as well as other factors such as neuropathy, poor balance, inactivity, and low body or muscle mass. Major contributors to bone disease include both preexisting bone disease and bone loss post transplant, which is greatest in the first 6-12 months when steroid doses are highest. Bone disease in kidney transplant recipients should be considered different from that which occurs in other solid organ transplant recipients for several reasons including the presence of renal osteodystrophy, which contributes to low bone mineral density in these patients; the location of fractures (more common in the legs and feet in these patients than in spine and hips as in other solid organ recipients); and the potential danger in using bisphosphonate therapy, which may cause more harm than good in kidney transplant recipients with low bone turnover. Evaluation in all patients should preferably occur in the pretransplant period or early post transplant and should include assessment of fracture risk as well as metabolic factors that can contribute to bone disease. Bone mineral density measurement is recommended in all patients even if its predictive value for fracture risk in the transplant population is unproven. Management of bone disease should be directed toward decreasing fracture risk as well as improving bone density. Pharmacologic and nonpharmacologic treatment strategies are discussed in this review. Although there have been many studies describing a beneficial effect of bisphosphonates and vitamin D analogues on bone density, none have been powered to detect a decrease in fracture rate.

The authors developed and implemented a new ward-based end-of-life care experience for third-year medical students at Yale University School of Medicine, which began on a pilot basis in 2005. The primary objectives of the program, which still continues, are to improve students' comfort and skills in communicating with and assessing patients facing the end of life and to reflect on their experiences. Students interview a hospitalized patient, family, and caregivers; assess specified end-of-life domains and management plans; reflect on the experience; and then prepare a report for presentation at a case conference facilitated by dedicated multidisciplinary faculty. Many students interview patients while rotating on psychiatry consults, and the case conference occurs during the psychiatry clerkship. A total of 45 students in the pilot year (2005), 76 students in the following year, and 48 thus far in the current year have completed the program. An assessment of the personal impact of the exercise on the students who completed the program in 2005 and 2006 revealed six themes, including students' recognition of the complexity of patients' reactions to dying, students' appreciation of the value of the clinicians' presence, and students' personal reflections. This experience suggests that a hands-on end-of-life exercise is feasible and will be well received in the acute inpatient setting. Key features for success include separate, dedicated faculty for the case conference (which is integrated into a single clerkship), emphasis on student self-reflection, and a requirement that the written component become part of the student's portfolio.

Loss of bone is a significant problem after renal transplant. Although bone loss in the first post transplant year has been well documented, conflicting data exist concerning bone loss after this time. It is equally unclear whether bone loss in long-term renal transplant recipients correlates with bone turnover as it does in postmenapausal osteoporosis. To examine these issues, we conducted a cross-sectional study to define the prevalence of osteoporosis in long-term (> 1 year) renal transplant recipients with preserved renal function (mean creatinine clearance 73 +/- 23 ml/min). Bone mineral density (BMD) was measured at the hip, spine and wrist by DEXA in 69 patients. Markers for bone formation (serum osteocalcin) and bone resorption [urinary levels of pyridinoline (PYD) and deoxypyridinoline (DPD)] were also measured as well as parameters of calcium metabolism. Correlations were made between these parameters and BMD at the various sites. The mean age of the patients was 45 +/- 11 years. Eighty eight percent of patients were on cyclosporine (12% on tacrolimus) and all but 2 were on prednisone [mean dose 9 +/- 2 mg/day)]. Osteoporosis (BMD more than 2.5 SD below peak adult BMD) at the spine or hip was diagnosed in 44% of patients and osteopenia was present in an additional 44%. Elevated levels of intact parathyroid hormone (i PTH) were observed in 81% of patients. Elevated urinary levels of PYD or DPD were present in 73% of patients and 38% had elevated serum levels of osteocalcin. Levels of calcium, and of 25(OH) and 1,25(OH)2 vitamin D were normal. In a stepwise multiple regression model that included osteocalcin, PYD, DPD, intact PTH, age, years posttransplant, duration of dialysis, cumulative prednisone dose, smoking, and diabetes: urinary PYD was the strongest predictor of bone mass. These results demonstrate that osteoporosis is common in long-term renal transplant recipients. The data also suggest that elevated rates of bone resorption contribute importantly to this process.

Objective: To recommend practice guidelines for transplant physicians, primary care providers, health care planners, and all those who are concerned about the well-being of the live organ donor., Participants: An executive group representing the National Kidney Foundation, and the American Societies of Transplantation, Transplant Surgeons, and Nephrology formed a steering committee of 12 members to evaluate current practices of living donor transplantation of the kidney, pancreas, liver, intestine, and lung. The steering committee subsequently assembled more than 100 representatives of the transplant community (physicians, nurses, ethicists, psychologists, lawyers, scientists, social workers, transplant recipients, and living donors) at a national conference held June 1-2, 2000, in Kansas City, Mo., Consensus Process: Attendees participated in 7 assigned work groups. Three were organ specific (lung, liver, and kidney) and 4 were focused on social and ethical concerns (informed consent, donor source, psychosocial issues, and live organ donor registry). Work groups' deliberations were structured by a series of questions developed by the steering committee. Each work group presented its deliberations to an open plenary session of all attendees. This information was stored and shaped into a statement circulated electronically to all attendees for their comments, and finally approved by the steering committee for publication. The term consensus is not meant to convey universal agreement of the participants. The statement identifies issues of controversy; however, the wording of the entire statement is a consensus by approval of all attendees., Conclusion: The person who gives consent to be a live organ donor should be competent, willing to donate, free from coercion, medically and psychosocially suitable, fully informed of the risks and benefits as a donor, and fully informed of the risks, benefits, and alternative treatment available to the recipient. The benefits to both donor and recipient must outweigh the risks associated with the donation and transplantation of the living donor organ.

Essential hypertension is a common multifactorial trait. The molecular basis of a number of rare diseases that after blood pressure in humans has been established, identifying pathways that may be involved in more common forms of hypertension. Pseudohypoaldosteronism type II (PHAII, also known as familial hyperkalaemia and hypertension or Gordon's syndrome; OMIM #145260), is characterized by hyperkalaemia despite normal renal glomerular filtration, hypertension and correction of physiologic abnormalities by thiazide diuretics. Mild hyperchloremia, metabolic acidosis and suppressed plasma renin activity are variable associated findings. The pathogenesis of PHAII is unknown, although clinical studies indicate an abnormality in renal ion transport. As thiazide diuretics are among the most efficacious agents in the treatment of essential hypertension, understanding the pathogenesis of PHAII may be of relevance to more common forms of hypertension. Analysis of linkage in eight PHAII families showing autosomal dominant transmission demonstrates locus heterogeneity of this trait, with a multilocus lod score of 8.1 for linkage of PHAII to chromosomes 1q31-q42 and 17p11-q21. Interestingly, the chromosome-17 locus overlaps a syntenic interval in rat that contains a blood pressure quantitative trait locus (QTL). Our findings provide a first step toward identification of the molecular basis of PHAII.

In order to precise the different prognosised factors of the acute intestinal invagination of the nursling, authors hereby report results of a prospective study lead in the department of general surgery during the period of January 1989 to August 1990. Eleven nursling have been operated during that period. The study of their files showed that the standard clinical triad of the acute intestinal invagination theoretically taught in the schools of health sciences, is never definitive. The diagnostic lateness and indeed therapeutic and the lack of adequate means of pediatric resuscitation constituted the main prognosised factors of this affection. The clinical board of the patients is that of an advanced occlusion or that of a serious peritonis. The surgical operation often consisted in an intestinal resection. The immediate mortality was heavy: 55%. The authors hereby stress the necessity of a training-informing-sensitizing of the health staff in the primary sanitary facilities and the populations.

The analysis of a mixed acid-base disturbance begins with the history and physical examination from which data can be derived that make the clinician suspect a specific disturbance(s). The electrolytes are then evaluated with emphasis on the meaning of the values for serum bicarbonate, potassium and chloride concentration and on the level of the anion gap. Other laboratory data such as serum creatinine or glucose concentrations, blood cultures, and so forth, should also be reviewed for further clues to a possible disturbance(s). When it is clinically indicated, values for pH and Pco2 are obtained by blood gas determination. If the evidence up to this point indicates the presence of at least one disturbance, the data are examined to see if compensation for this disturbance is appropriate. If not, a mixed disturbance must be present. A normal pH in the setting of an abnormal serum HCO3(-) concentration or Pco2 also suggests a mixed disturbance since compensation rarely corrects the pH back to normal. Of course, a pH deviated in the opposite direction than that expected for a known primary disturbance makes the diagnosis of a mixed disturbance certain. The diagnosis of a mixed acid-base disturbance is therefore based on an analysis of all the clinical data and not just the blood gas measurements. Treatment of the disorders should be directed at maintaining a normal or near normal pH. Some combined acid-base disorders are important to recognize because they can result in a severe deviation in blood pH that demands immediate, specific therapy. Other mixed disturbances result in a pH which is near normal but are important to recognize since they can alert the clinician to the possibility of certain clinical derangements such as septic shock or drug ingestion. Careful analysis of mixed acid-base disturbances in this way is not peutic information to be used in caring for his (her) patients.

Quantitative duplex Doppler sonography was performed in 55 renal transplant patients during 54 independent episodes of acute rejection, three episodes of chronic rejection, three episodes of acute tubular necrosis (ATN), and 23 occasions of normal graft function. Doppler signals were obtained from four arterial sites in each kidney. Nine patients, in whom signals were absent, were subsequently shown at nephrectomy to have absence of perfusion resulting from severe acute vascular rejection. In each patient with graft dysfunction, biopsy or nephrectomy was performed within 24 hours of the Doppler study. Arterial Doppler signals were quantified using a pulsatility index (PI). Acute rejection produced a significantly higher PI at each arterial site. Receiver-operator characteristics suggest that signals obtained from the segmental arteries are most sensitive to these changes. With a threshold PI of 1.5, the sensitivity of this technique for detection of acute renal allograft rejection is 75%; the specificity is 90%. In acute vascular rejection, the same PI yields a sensitivity of 79% and specificity of 90%. With a cutoff PI of 1.8, a specificity of 100% can be achieved.

We evaluated demeclocycline and lithium therapy in 10 patients with the syndrome of inappropriate secretion of antidiuretic hormone. Despite severe water restriction, all patients had hyponatremia (mean +/- S.E.M. serum sodium of 122 +/- 1.1 meq per liter) and elevated urine osmolality (744 +/- 59 mOsm per kilogram) before treatment. Demeclocycline (600 to 1200 mg daily) restored serum sodium concentration to 139 +/- 1.1 meq per liter within five to 14 days, permitting unrestricted water intake in all patients. In three patients given lithium carbonate (900 mg daily) the serum sodium concentration, urine osmolality and urine volume were unchanged; since two patients had adverse central-nervous-system symptoms during lithium therapy, further study of this agent was abandoned. A patient with an unusual 22-year history of the syndrome was unresponsive to lithium, whereas long-term treatment with demeclocyline was markedly effective. Demeclocycline is superior to lithium in the treatment of the syndrome and may obviate the need for severe water restriction.

The effect of epinephrine on potassium metabolism was examined in six subjects. Each subject participated in four studies as follows: (1) potassium chloride infusion (0.75 mEq/kg, i.v.) given over 2 hours, (2) epinephrine (0.05 micrograms/kg.min) plus potassium chloride, (3) propranolol (1.43 micrograms/kg.min) plus epinephrine plus potassium chloride, and (4) propranolol plus potassium chloride. The epinephrine infusion with potassium chloride led to a marked improvement in potassium tolerance, which was due to a greater than twofold increase in the extrarenal disposal of potassium (P less than 0.001). The enhancing effect of epinephrine on extrarenal potassium uptake was completely reversed with the beta-blocking agent propranolol. When propranolol alone was infused with potassium chloride, a significant decrease in the extrarenal disposal of potassium was observed. When potassium chloride was infused alone, 47% of the administered potassium load was excreted in the urine. Epinephrine infusion with potassium chloride markedly inhibited the urinary excretion of potassium (UkV) to rates that were actually below the basal potassium excretion rate (P less than 0.001). Propranolol almost completely reversed this effect of epinephrine on UkV, and when propranolol was infused alone, an enhancement in UkV (P less than 0.005) was observed. Insulin adds only a minor contribution to the enhancing effect of epinephrine on extrarenal potassium disposal and dose not contribute at all to the inhibitory effect of epinephrine on renal potassium excretion. These results demonstrate that epinephrine ameliorates the rise in plasma potassium concentration following potassium chloride infusion. Because none of the infused potassium was excreted during the 4-hour study period, the improvement in potassium tolerance must result from an enhancement in extrarenal potassium disposal. The ability of propranolol to reverse both the extrarenal and renal effects indicates that the action of epinephrine is mediated via stimulation of the beta receptor.

The metabolic and hormonal response to acute moderate intensity (40% of VO2 max) bicycle exercise was examined in eight uremic subjects maintained on chronic dialysis and in 12 age- and weight-matched controls before and after the administration of low dose, selective (metoprolol) and nonselective (propranolol), beta adrenergic antagonists. The fasting plasma glucose concentration and basal rates of hepatic glucose production (HGP) and tissue glucose disappearance (Rd) were similar in control and uremic subjects. In both groups HGP and Rd increased in parallel during exercise, and the plasma glucose concentration remained constant at the fasting level. However, the increments in Rd (2.27 +/- 0.27 vs. 0.87 +/- 0.31 mg/kg.min, P less than 0.01) and HGP (2.47 +/- 0.22 vs. 0.92 +/- 0.19 mg/kg.min, P less than 0.01) were 2.5-3 fold greater in the control compared to uremic subjects. Although the VO2max was decreased by 50% (39 +/- 2 vs. 20 +/- 2 ml/min.kg; P less than 0.01), the correlation between Rd and VO2max was weak (r = 0.33, P less than 0.10), suggesting that factors other than diminished physical fitness contribute to diminished tissue uptake of glucose in the dialyzed uremic patients. Following the cessation of exercise, HGP and Rd promptly returned toward basal levels in both uremic and control subjects. The glucose homeostatic response to exercise was not significantly altered by either propranolol or metoprolol. In the postabsorptive state fasting levels of insulin, glucagon, epinephrine, and norepinephrine all were significantly increased in the uremic group (P less than 0.01 to 0.05). During exercise in the healthy young controls the plasma insulin concentration declined and plasma epinephrine and norepinephrine levels rose three- to fourfold. In contrast, in uremics plasma insulin failed to fall (P less than 0.05) and the increase in circulating epinephrine and norepinephrine levels was markedly impaired (P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Renal allografts are subject to many vascular complications. Over a 2-year period, 334 duplex Doppler ultrasonographic (US) examinations were performed in 88 renal allograft recipients. Vascular occlusion on the basis of severe vascular rejection was documented in ten patients (11.4%) for a sensitivity and specificity of 100%. Seven patients, for whom there was clinical and Doppler US evidence for renal artery stenosis, underwent angiography. A significant stenosis was confirmed and treated by angioplasty in four patients; one had an insignificant stenosis in an accessory artery, one had kinking of the renal vessels, and another had normal findings. The most reliable criteria for stenosis were a high-velocity jet exceeding 7.5 kHz and distal turbulence. One arteriovenous fistula was diagnosed by the presence of an intrarenal high-velocity jet. Duplex Doppler US is a useful, noninvasive, and portable initial procedure with which to screen patients for vascular complications of renal transplantation.

Sixty-nine duplex sonographic studies were performed in 24 patients who had received renal allografts. After a prospective qualitative analysis of the Doppler waveforms, results were correlated with biopsy material and each patient's clinical course. Increased pulsatility of the Doppler waveform of intrarenal arterial flow constituted an abnormal study, indicating acute rejection. Overall sensitivity varied with the histologic form of rejection, with a 60% sensitivity for acute interstitial rejection with or without vascular rejection and an 82% sensitivity for acute vascular rejection. Overall specificity was 95% and 96%, respectively. Early rejection was also accurately detected in three patients less than 48 hours following kidney transplantation. Duplex sonography has a useful role in evaluating posttransplantation renal failure. Abnormal study results may obviate the need for biopsy and help in guiding clinical management.