Higher summer temperatures increase the likelihood of being hospitalized for acute renal failure (ARF), according to an analysis of data collected in New York State.

Overall, the odds of hospitalization for ARF increased 9% for each 5° F increment in temperature based on the mean temperature a day prior to hospitalization (lag 1). The risk was greater for blacks, Hispanics, individuals aged 25-44 years, and those in the lowest income quartile, the investigators, led by Shao Lin, MD, PhD, of the New York State Department of Health's Center for Environmental Health in Troy, reported online ahead of print in the American Journal of Epidemiology.

Hispanics had a significant 20% increased risk per 5° F increment in temperature while compared with non-Hispanics (9%). Compared with whites (8%), blacks had a 14% increased risk for each 5° F, whereas Asians had a significant 12% decreased risk. Individuals aged 25-44 years had a significant 18% increased risk for each 5° F compared with those aged 45-64 years (9%). Individuals in the lowest income quartile ($31,406 per year or less) had a 13% increased odds of ARF hospitalization per 5° F compared with those in the highest quartile (more than $55,869 per year [7%]).

The odds of an ARF hospitalization varied geographically within the state, with the largest associations observed in more urban regions.

Additionally, Dr. Lin's group found increased odds of hospitalization for urinary tract infections, kidney stones, and other lower urinary tract disorders.

“Our findings add to a growing body of work that documents the association of high temperature and morbidity, particularly hospital admissions for renal diagnoses,” the authors concluded.

The investigators noted that most previous studies considered only heat waves, but their study is one of only a few to examine the effect of all summer temperatures on renal admissions.

They noted that their findings “can be useful in developing adaptation strategies and heat-warning policies.”

Dr. Lin's team pointed out that the biologic mechanism underlying the relationship between heat and renal disease is unclear. Previous studies have found an increased incidence of renal calculi associated with exposure to hot conditions, presumably the result of disrupted fluid balance, the researchers explained.

In a discussion of study limitations, the investigators pointed out that they relied on ecologic-level exposure data. “Exposure temperature was assigned on the basis of residential address and took no account of personal activity,” they wrote. “Similarly, we do not know which individuals had access to air conditioning or other mitigation resources, another source of exposure misclassification.”

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Merck’s Januvia has had its licence extended in the UK for patients with moderate to severe renal impairment.

The drug is already one of the biggest selling diabetes pills in the world, achieving global sales of $3.3 billion last year.

Januvia (sitagliptin) is the leader in the DPP-4 inhibitor class, a new generation of oral diabetes treatments.

Many diabetes patients have renal impairment, making drug treatment of the diabetes more difficult, with some medicines contraindicated in these patients. Januvia has been one of these contraindicated treatments until now, but lower dose forms of the drug can now be used in these patients in the UK.

Professor John Wilding, head of the department of obesity and endocrinology at the University of Liverpool, said: “One of the main complications of diabetes is kidney disease, or diabetic nephropathy, and this unfortunately develops in up to one third of all people with diabetes.

“Treatment choices for glucose-lowering treatments are limited because some drugs cannot be used in people with kidney disease, or may increase the risk of hypoglycaemia.

“Physicians around the world have been prescribing sitagliptin at 25mg and 50mg in this large patient population for a number of years, so it is pleasing that in the UK we now have the option for dosage adjustment to improve glycaemic control, in renally compromised patients with a low risk of hypoglycaemia,” he added.

This opens up the drug to more diabetes patients, which is likely to help its already strong growth in the UK.

GP prescribing data shows spending on the drug in England jumped from £27 million in 2010 to £45 million last year. This was the biggest increase in spend of any new drug, putting it on track to be a big earner for MSD (Merck) in the UK.

The update means Januvia has the same licence as Boehringer’s rival DPP-IV diabetes treatment Trajenta, launched in the UK last September.

Trajenta (linagliptin) is also licensed in type II patients with renal impairment, and works in much the same way as Januvia.

Januvia’s new licence will help it maintain its lead in the DPP-IV diabetes market, in which Novartis’ Galvus (vildagliptin) is another competitor.   

Ben Adams

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A t 87, Lochan Bakshi's sharp mind has decided when to free his failing body.

The retired biology professor has thought hard about death and about the way he wants it to arrive. After all, he's seen men like himself hunched over in chairs in long-term-care centres, their minds absent, unaware there hasn't been a visitor for years.

His cousin had a massive stroke that stole his memory and his mind. He would sit in his own mire until the next nursing visit, bathed by his caring wife. "It struck me: why should he be like this? Why not just finish it?

He's just a vegetable," Bakshi said to her. "'You mean kill my husband? I can't kill him,'" she responded.

"Nobody should be in that situation," Bakshi says, his cheeks apple-flushed, his sharp eyes framed with straying silver eyebrows and wire-rimmed bifocals. "I am convinced that I don't want to be like that."

So in about two months, give or take, he'll refuse his thrice-weekly dialysis treatments, he says, then wait seven to 10 days for his kidneys and the rest of his body to fail. He'd prefer an injection to put him to sleep peacefully.

Bakshi wants to open the debate on euthanasia in Alberta following a landmark report released last month in Quebec that suggested the province legalize doctor-assisted euthanasia in "exceptional circumstances" for those who are terminally ill.

The Dying with Dignity Commission, made up of nine members from all political parties, studied the issue for two years before rejecting the idea of legalizing assisted suicide - performed by a family member - but recommending people should be able to seek aid to die in a medical environment.

"Some sufferings can't be relieved satisfactorily and the seriously ill who want to put an end to their sufferings (that) they deem senseless, come up against a refusal that isn't in line with Quebec's values of compassion and solidarity," reads the report, released March 21.

But the provinces can do little when the federal criminal code makes it illegal to counsel, aid or abet someone to commit suicide, says Erin Nelson, a professor in the University of Alberta's law faculty who specializes in healthcare ethics.

"I think it's going to become inevitable that more and more people will wish to be able to make decisions like this, about dying with dignity as they perceive it, if their life is no longer what they wish to live."

Nelson said the government should start the conversation, rather than leave it to individuals and families. "One of the arguments that Joe Arvay made is, it's unfair to burden those people with that responsibility.

It's not just an individual thing. It actually is a bit of a societal discussion that needs to take place."

But governments are unlikely to take the lead, he says. "There's just not a lot of political gain to be made by getting into this."

If governments did instigate public debate on euthanasia, they would be inevitably and unfairly accused of trying to save health dollars by letting people die, says Nelson.

That, even though an Angus Reid poll conducted in late 2010 found 63% of Canadians generally support euthanasia. It goes up to 78% in Quebec. In Alberta, support dips to 48%.

Bakshi said he easily can reconcile his belief system with the right to die through injection. He doesn't like the idea of refusing dialysis, then awaiting death for one week while on pain killers.

"I absolutely believe that God does not want you to be miserable and, if that is so, why do we keep hanging on to the little thread of life at the very end?" Bakshi said.

"God did not want us to suffer and I'm helping God."

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