Prognostic role of mesangial IgM deposition in IgA nephropathy: a long-term cohort study

BACKGROUND

The clinical significance of mesangial immunoglobulin (Ig) M deposition in IgA nephropathy (IgAN) has been less explored and remains a topic of debate. Therefore, our study aimed to investigate the prognostic value of mesangial IgM deposition in a long-term follow-up cohort of IgAN patients.

METHODS

A unicentric retrospective study was conducted on 93 consecutive IgAN patients (median age 41 years, 68% male, eGFR 48.7 mL/min, proteinuria 1.1 g/g) from 2010 to 2015. They were followed until end-stage kidney disease (ESKD), death, or until the end of the study in January 2021, with a median follow-up of 7 years. An independent pathologist evaluated the IgM immunofluorescence pattern, Oxford MEST-C score, and transmission electron microscopy (TEM) lesions following a comprehensive protocol.

RESULTS

In our cohort, 70% had mesangial IgM-positive deposits, while 30% were IgM-negative. Both groups were similar in age, sex, prevalence of arterial hypertension, Charlson comorbidity scores, kidney function (eGFR and proteinuria), pathology findings (Oxford MEST-C score, IgG and C3 immune deposition), and TEM analysis. Treatment with RASI and immunosuppression, and death rates were also comparable. However, 37% of IgM-positive patients progressed to ESKD, significantly higher than the 11% in the IgM-negative group. Univariate and multivariate Cox proportional hazards regression analyses identified lower eGFR, higher Oxford MEST-C score, and mesangial IgM deposits as independent factors associated with shorter kidney survival.

CONCLUSIONS

Our study highlights mesangial IgM deposition as a potential risk factor for ESKD in patients with advanced IgAN, laying a foundation for further research in this area.

Glasgow prognostic score as an outcome predictor for patients initiating hemodialysis

INTRODUCTION

This retrospective study examined the relationship between the Glasgow Prognostic Score (GPS) at hemodialysis (HD) initiation and overall/cardiovascular mortality.

METHODS

A total of 264 patients starting HD between 2014 and 2015 at a single center were studied. Follow-up persisted until therapy change, death, or study end (December 31, 2021), with a median of 6.8 years.

RESULTS

Patients with a higher GPS more frequently had emergent HD initiation and showed increased eGFR at initiation. During follow-up, 60% of patients died, with cardiovascular disease being the leading cause. Univariate analysis revealed a significant difference in median survival time across GPS classes. Cox proportional hazard models confirmed a significant association between GPS and mortality.

CONCLUSIONS

We report a significant association between GPS at HD initiation and mortality. GPS may prove useful as a prognostic tool for identifying high-risk patients, underscoring the need for future research to validate these findings and explore the potential of GPS-based interventions.

Mortality in IgA Nephropathy: A Long-Term Follow-Up of an Eastern European Cohort

Background and Objectives: IgA nephropathy (IgAN), the most common primary glomerulonephritis, has been extensively studied for renal outcomes, with limited data on patient survival, particularly in Eastern Europe. We aimed to investigate the long-term survival rate of patients with IgAN and the associated risk factors in an Eastern European cohort. Materials and Methods: We conducted a retrospective analysis of 215 IgAN patients (median age 44, 71% male) diagnosed at a Romanian tertiary center between 2010 and 2017. We assessed clinical and pathological attributes, including the Charlson comorbidity index, the prevalence of diabetes, renal function, and treatment with renin-angiotensin-system inhibitors (RASIs). Results: Over a median 7.3-year follow-up, 20% of patients died, mostly due to cardiovascular diseases. Survival rates at 1, 5, and 10 years were 93%, 84%, and 77%, respectively. Deceased patients had higher Charlson comorbidity index scores, greater prevalence of diabetes, and poorer renal function. They were less frequently treated with RASIs and more frequently reached end-stage kidney disease (ESKD). Conclusions: We report a 20% mortality rate in our Eastern European IgAN cohort, primarily due to cardiovascular diseases. Death correlates with increased age, comorbidity burden, decreased renal function at diagnosis, and the absence of RASI use. RASI treatment may potentially improve survival, highlighting its importance in managing IgAN.

Prognostic role of glomerular electron microscopy lesions in IgA nephropathy: "the devil is in the details"

INTRODUCTION

Transmission electron microscopy enables examination of ultrastructural glomerular changes; while this tool has already been applied in IgA nephropathy (IgAN), limited information exists on the prognostic value in this disease. We aimed to systematically investigate ultrastructural lesions and assess their role in predicting the evolution of IgA nephropathy to end-stage kidney disease.

METHODS

A single-center retrospective study was performed on 107 consecutive IgAN patients (median age 42 years, 67% male, estimated glomerular filtration rate 46 mL/min, proteinuria 1.0 g/g) between 2010 and 2015, who were followed-up until end-stage kidney disease, death, or end of study (January 2021). A pathologist evaluated the Mesangial hypercellularity (M), Endocapillary hypercellularity (E), Segmental glomerulosclerosis (S), and Tubular atrophy/interstitial fibrosis-Crescents (C) (MEST-C) score and transmission electron microscopy lesions according to a comprehensive protocol that encompassed all glomerular structures.

RESULTS

Patients were followed up for a median of 7.1 years; 32 (43%) reached end-stage kidney disease. Patients who reached kidney failure had higher comorbidity score, more frequent arterial hypertension, lower estimated glomerular filtration rate, and higher MEST-C score. In terms of transmission electron microscopy lesions, patients who progressed to end-stage kidney disease had more frequent podocyte activation, effacement, and presence of microvilli; more frequent signs of endothelial cell activation and fenestration; higher mesangial cell proliferation. In the univariate Cox proportional hazard regression, higher MEST-C score and lesions detected by transmission electron microscopy in podocytes, endothelial cells, and mesangial cell proliferation were associated with shorter kidney survival time. In the multivariate Cox proportional hazard regression, only higher MEST-C score, presence of podocytes with microvilli, and mesangial cell proliferation were associated with end-stage kidney disease.

CONCLUSION

This study shows that, besides the MEST-C score, the presence of podocytes with microvilli and mesangial cell proliferation are associated with poor kidney survival in IgAN patients, highlighting the prognostic value of lesions detected by transmission electron microscopy.

Anti-phospholipase A2 receptor positive membranous nephropathy: investigating the link between electron microscopy stages and clinical outcome

This retrospective, observational study sought to examine the relationship between Ehrenreich-Churg electron microscopy (EM) stages and long-term outcomes in anti-PLA2R membranous nephropathy (MN). Seventy-one patients with anti-PLA2R MN (median titer 185.7RU/mL) were followed for a median of 46 months, with end-stage kidney disease (ESKD) as the primary endpoint, and response to treatment as a secondary endpoint. Patients were grouped into stages I-II (41 patients) and stages III-IV (30 patients) for analytical purposes. Notably, the III-IV group demonstrated a lower eGFR, lower anti-PLA2R titer, but a higher chronicity score. Kaplan-Meier analysis showed shorter mean kidney survival time in stages III-IV compared to I-II (p 0.03). However, multivariate analysis using Cox regression indicated that Ehrenreich-Churg stages did not significantly influence kidney survival, but lower eGFR at diagnosis and higher histopathological chronicity score did. Remission was achieved by 64% of patients and no relationship between Ehrenreich-Churg stages and treatment response was found. The only identified risk factor for not achieving remission was the severity of hyposerinemia at diagnosis. In conclusion, while EM stages III-IV are associated with more chronic lesions and stages I-II with more active immunologic disease, the histological chronicity score seems to be a stronger predictor of long-term outcomes.

Budd-Chiari syndrome: An unusual complication of an internal jugular tunneled dialysis catheter

Budd-Chiari syndrome due to the tip of an internal jugular tunneled dialysis catheter malposition in inferior vena cava or hepatic vein is a rare complication. We aimed to present our experience and compare it with the previous reports to highlight the clinical features and the optimal management. A 57-year-old female with history of ANCAp vasculitis, treated by hemodialysis in the last 2 years on a right internal jugular vein tunneled catheter was admitted for pain in the right upper quadrant. A subacute Budd-Chiari syndrome due to catheter malposition was diagnosed. The catheter was removed, and a new tunneled hemodialysis line was inserted in the right internal jugular vein with the tip at the junction of right atrium with superior vena cava. Anticoagulation with apixaban 2.5 mg twice daily was started after catheter replacement and the patient was discharged. At 1 month follow-up the patient had no symptoms, and the ultrasound revealed the absence of the thrombus in the inferior vena cava. Imagining monitoring for malposition after insertion or in a clinical context suggestive for Budd-Chiari syndrome is essential for early diagnosis and treatment. In our case, anticoagulation with apixaban and prompt catheter replacement resulted in Budd-Chiari syndrome resolution.

Multiple Myeloma and Kidney Impairment at Diagnosis: A Nephrological Perspective from an Eastern European Country

Background and Objectives: The clinical presentation and survival factors in patients with myeloma-related kidney impairment (MRKI) at diagnosis remain a topic of ongoing research, given the complex interplay between nephrology and hematology. To date, no studies have specifically reported outcomes for these patients in Eastern Europe. Materials and Methods: We conducted a retrospective, unicentric study of consecutive newly diagnosed patients with MRKI in our tertiary nephrology service in Romania between 2015 and 2020; follow-up extended until 1 September 2022, covering a study period of 90 months. Results: We identified 89 consecutive patients with MRKI (median age 66 years, 38% male, median eGFR 5 mL/min). The majority of patients had arterial hypertension (71%) and systemic atherosclerosis (58%), and the most frequent clinical features at presentation were asthenia (75%) and bone pain (51%). Light-chain-restricted myeloma was the most common type (55%), with kappa free light chain being more frequent (53%). Among the patients, 81% presented with acute kidney injury (AKI), and 38% required hemodialysis at diagnosis. During the study period, 65% of the patients died, and hypoalbuminemia and the need for hemodialysis at diagnosis were significantly associated with mortality in multivariate analysis. Conclusions: Patients with MRKI who present to the nephrologist more frequently exhibit light chain restriction and most often present with AKI, with one-third requiring hemodialysis at diagnosis. Moreover, hypoalbuminemia and the initiation of hemodialysis at diagnosis were significantly associated with increased mortality.

Nephrotic Syndrome and Statin Therapy: An Outcome Analysis

Background and Objectives: Hypercholesterolemia in patients with nephrotic syndrome (NS) may predispose to cardiovascular events and alter kidney function. We aimed to evaluate statins efficiency in NS patients under immunosuppression using four endpoints: remission rate (RR), end-stage kidney disease (ESKD), major cardiovascular events (MACE), and thrombotic complications (VTE). Materials and Methods: We retrospectively examined the outcome at 24 months after diagnosis of 154 NS patients (age 53 (39–64) years, 64% male, estimated glomerular filtration rate (eGFR) 61.9 (45.2–81.0) mL/min). During the follow-up, the lipid profile was evaluated at 6 months and at 1 and 2 years. Results: The median cholesterol level was 319 mg/dL, and 83% of the patients received statins. Patients without statins (17%) had similar age, body mass index, comorbidities, blood lipids levels, NS severity, and kidney function. The most used statin was simvastatin (41%), followed by rosuvastatin (32%) and atorvastatin (27%). Overall, 79% of the patients reached a form of remission, 5% reached ESKD, 8% suffered MACE, and 11% had VTE. The mean time to VTE was longer in the statin group (22.6 (95%CI 21.7, 23.6) versus 20.0 (95%CI 16.5, 23.5) months, p 0.02). In multivariate analysis, statin therapy was not associated with better RR, kidney survival, or fewer MACE; however, the rate of VTE was lower in patients on statins (HR 2.83 (95%CI 1.02, 7.84)). Conclusions: Statins did not improve the remission rate and did not reduce the risk of MACE or ESKD in non-diabetic nephrotic patients. However, statins seemed to reduce the risk of VTE. Further randomized controlled studies are needed to establish statins’ role in NS management.

Immunosuppressive therapy versus supportive care in IgA nephropathy patients with stage 3 and 4 chronic kidney disease

The use of immunosuppressive therapy for immunoglobulin A nephropathy (IgAN) patients with stage 3 or 4 chronic kidney disease (CKD) is controversial. We performed a monocentric retrospective study on 83 consecutive IgAN patients with stage 3 or 4 CKD and proteinuria ≥0.75 g/d (age 41 [33-56] years, 72% male, estimated glomerular filtration rate 36.1 [25.4-47.5] mL/min/1.73 m2) who received uncontrolled supportive care (Supp) (n = 36), corticosteroids/corticotherapy (CS) (n = 14), or CS combined with monthly pulses of cyclophosphamide (CS + CFM) (n = 33) between 2010 and 2017. Patients were followed until composite endpoint (doubling of serum creatinine, end-stage kidney disease (dialysis or kidney transplant) or death, whichever came first) or end of study (January 2020). Patients were followed for a median of 29 (95% confidence interval = 25.2-32.7) months, and 12 (15%) patients experienced the composite endpoint. Within the limitation of a retrospective study, our results suggest no benefit from immunosuppressive therapy in patients with IgAN with stage 3 and 4 CKD as compared with supportive care. There were no differences between the 3 studied groups regarding age, estimated glomerular filtration rate, proteinuria, Oxford classification score, arterial hypertension, and therapy with renin-angiotensin system inhibitors. Mean kidney survival time for the entire cohort was 81.0 (95% confidence interval = 73.1-89.0) months, without significant differences between the 3 groups. In univariate and multivariate Cox regression analysis adjusted for IgAN progression factors, immunosuppressive therapy was not associated with better kidney survival when compared with supportive therapy.

Negative anti-phospholipase A2 receptor antibody status at three months predicts remission in primary membranous nephropathy

Background

The value of anti-phospholipase A2 receptor antibody (anti-PLA2R ab) monitoring at 3 months after diagnosis in membranous nephropathy (MN) remains uncertain.

Methods

We retrospectively examined the outcome on 1 August 2020 of 59 adult patients (age 54 (44, 68) years, 69% male, SCr 1.0 (0.9, 1.3) mg/dL) diagnosed with MN (kidney biopsy, positive serum anti-PLA2R ab). The outcomes were: kidney survival; partial and/or complete remission.

Results

Most of the studied patients (97%) received immunosuppression, cyclophosphamide regimens were the most frequent (87%), followed by cyclosporine (10%). The median time to remission was 12.0 months and the cumulative remission rates were 34% at 6, 54% at 12, and 73% at 24 months. Forty (69%) patients had negative anti-PLA2R ab at 3 months, they had similar age, serum creatinine, albumin, proteinuria, and treatment with the group with positive ab at 3 months. In the Cox proportional hazard model, three months anti-PLA2R ab negativization (HR 0.4 (95%CI 0.1, 0.9)) was an independent predictor for remission, while baseline hypoalbuminemia (HR 3.0 (95%CI 1.5, 5.7)) was associated with absence of remission. Six (10%) patients died, mostly due to cardiovascular disease and infections. A total of five (9%) patients started dialysis. Mean kidney survival time was 50.3 months and there was no survival difference in relation to baseline anti-PLA2R ab titer (p .09) or 3 months negativization (p .8).

Conclusions

Three months anti-PLA2R ab negativization seems to be a late predictor of remission, and lower serum albumin at diagnosis is an early marker for remission absence. Abbreviations: anti-P LA2R ab, anti-phospholipase A2 receptor antibody; eGFR, estimated glomerular filtration rate; ESKD, end stage kidney disease; MN, membranous nephropathy; NELL-1, neural epidermal growth factor-like 1 protein; RAAS: renin–angiotensin–aldosterone system; RBC: red blood cells; RRT, renal replacement therapy; T HSD7A, thrombospondin type-1 domain containing 7A

Diffuse calcification of a nonfunctioning kidney allograft

Diffuse calcification of nonfunctioning kidney graft may rarely occur in clinical practice, and it is generally benign and does not require transplant removal in most cases.

IgA nephropathy with serum ANCA positivity: case series and literature review

The co-occurrence of IgA nephropathy (IgAN) and positive anti-neutrophil cytoplasmic autoantibodies (ANCA) serology is uncommon. In the present case series and literature review, we aimed to clarify the impact of ANCA on pathogenesis, clinical and histopathology presentation, and outcome in IgAN patients. We report four patients with an overlap lesion of IgAN-ANCA positive. Also, we performed a narrative review of all biopsy-proven published case series. Only 1.2% patients had ANCA in our 330-biopsy-proven IgAN cohort. We compared our data with previous reports-6 case series and 3 small retrospective studies-a total of 103 patients. All patients but one had eGFR below 15 mL/min at diagnosis. Besides rapidly decreasing eGFR, all presented with proteinuria around 1.5 g/day and dysmorphic microhematuria, suggesting glomerular inflammation. Systemic symptoms suggestive for ANCA vasculitis were seen in half of our patients, but only one patient had hemorrhagic alveolitis. Patients from our cohort responded to the intensive immunosuppressive regimens used in ANCA-positive vasculitis with renal involvement. However, in the follow-up, one patient had a relapse followed by septic shock related to immunosuppression and one patient started hemodialysis. In the review, we found that IgAN-ANCA -positive patients are characterized by vasculitis-like lesions and clinically by a rapidly progressive decline in kidney function, which was reversed by an aggressive induction immunosuppressive protocol used in ANCA vasculitis. Checking ANCA serology seems useful in patients with rapidly progressive IgAN for therapeutic and prognostic reasons.

Inflammation-based modified Glasgow prognostic score and renal outcome in chronic kidney disease patients: is there a relationship?

BACKGROUND

Chronic kidney disease (CKD) progression is presumably related to inflammatory response. The modified Glasgow prognostic score (mGPS), based on combination between albumin and C-reactive protein, has been derived from oncology and validated in multiple diseases.

AIMS

We aimed to evaluate the relationship between the mGPS and CKD progression.

METHODS

The present retrospective unicentric cohort study included 547 CKD patients (age 60.2 years, 53% male, eGFR 42.0 mL/min, mean change -2 mL/min/year) admitted between January 1, 2007 and December 31, 2012. Patients records were reviewed from the CKD diagnosis to one of the four outcomes: end-stage kidney disease (ESKD), death, loss to follow-up, or until July 31, 2017.

RESULTS

The mGPS score was 0 for 420 (78%), 1 for 110 (19%), and 2 for 17 (3%) patients. More patients with rapid CKD progression were found in the group with the highest mGPS (p=0.05). mGPS was negatively correlated with baseline eGFR and positively with albuminuria. In the multivariate analysis, mGPS was associated with the eGFR slope. During the study period, 130 patients (24%) died and 109 (20%) reached ESKD. The mean kidney survival time was 8.1 (95%CI 7.9 to 8.4) years. Patients with zero mGPS had better kidney survival than those with the score of one and two (Kaplan-Meier, p=0.02). However, the kidney survival differences were not present after adjusting for CKD progression risk factors.

CONCLUSION

The inflammation-based mGPS score was associated with eGFR decline in CKD patients. Therefore, could prove useful in improving risk stratification of CKD patients. This article is protected by copyright. All rights reserved.

Atheroembolic kidney disease: The under-recognized silent killer

While kidney biopsy demonstrating cholesterol crystal emboli is the method of definitive diagnosis; the triad of acute to subacute renal failure with skin findings in the setting of recent precipitating event should raise clinical suspicion for atheroembolic kidney disease.

Is There a Role for IgA/C3 Ratio in IgA Nephropathy Prognosis? An Outcome Analysis on An European Population

INTRODUCTION

Serum immunoglobulin A (IgA)/C3 ratio has been reported as a predictor of histological lesions and prognosis in asian patients with IgA nephropathy (IgAN). Since its validity in other populations is unclear, we aimed to evaluate the relationship between IgA/C3 ratio and renal outcome in Caucasian European patients with biopsy-proven IgAN.

METHODS

We conducted a retrospective, observational study on 95 patients with primary IgAN patients diagnosed between 2010 to 2017 (70% male, age 41 (34 to 49) years, eGFR 39.4 (25.2 to 56.5) mL/ min, proteinuria 1.7 (0.8 to 3.0) g/g). The primary study composite end-point was doubling of serum creatinine, ESRD (dialysis or renal transplant) or death, whichever came first.

RESULTS

Median follow-up was 30 (95% CI: 27.5 to 32.4) months; 11% developed ESRD, 10% experienced serum creatinine doubling, and 1% died. The endpoint was reached by 21% of the patients. They had lower eGFR, higher proteinuria and hematuria, and lower serum albumin. The distribution in Oxford classes was alike. The AUROC for IgA/C3 ratio was 0.60 (95% CI: 0.45 to 0.74) and generated an optimal cut-off of 2.91 (sensitivity 68%, specificity 55%). The mean event-free survival of the whole cohort was 5.2 (95% CI: 4.7 to 5.8) years. Patients with IgA/C3 ratio < 2.9 had a tendency to better renal survival (P > .05). In Cox proportional hazard ratio model, the independent predictors of a poorer eventfree survival were higher serum creatinine, higher proteinuria and increased IgA/C3 ratio, while renin angiotensin system inhibitors predicted better outcome.

CONCLUSION

Our study reports evidence that supports IgA/C3 ratio as a reasonable predictor of IgAN prognosis in European patients.

Adult-onset minimal change disease: the significance of histological chronic changes for clinical presentation and outcome

INTRODUCTION

Data on pathologic features with prognostic utility in adults with minimal change disease (MCD) are limited. We assessed the relationship between histologic chronic changes and clinical presentation and outcomes.

METHODS

The consecutive records of 79 patients with MCD and minimum of 6 months follow-up were retrospectively reviewed. Kidney survival was the primary endpoint (doubling serum creatinine or dialysis initiation). Secondary endpoints were time to remission and relapse. Total chronicity score was the sum of glomerulosclerosis (0-3), interstitial fibrosis (0-3), tubular atrophy (0-3), and arteriolosclerosis (0/1).

RESULTS

The median renal chronicity score was 1; 77% had minimal (0-1), 18% mild (2-4), and 5% moderate (5-7) chronicity. Fifty percent had a null score; they were younger, had higher eGFR, similar proteinuria, better renal survival, and lower mortality. Mean kidney survival time was 5.7 (95% CI 5.2-6.2) years; 89% reached a form of remission at a median of 8 weeks; 31% relapsed at a mean of 26 months. Chronic changes severity predicted both relapses and kidney survival, each one-point increase in score raised with 27% the risk of relapse and with 31% the risk of dialysis initiation. Acute kidney injury (AKI) was present in 42% of the patients; they had more often mesangial proliferation, interstitial inflammation, tubular atrophy, arteriosclerosis, podocyte villous hypertrophy, and higher chronicity score.

CONCLUSION

Standardized grading of chronicity was a predictor of kidney survival and disease relapse and was related to AKI. Older patients with severe nephrotic syndrome and with increased chronicity score could represent a high-risk category.

Histologic predictors of renal outcome in diabetic nephropathy: Beyond renal pathology society classification

The prognostic utility of histologic features in patients with diabetic nephropathy (DN) classified according to the Renal Pathology Society (RPS) classification is controversial. Therefore, we aimed to evaluate the relationship between histologic changes and renal outcome in DN patients.We examined the renal outcome at November 30, 2017 of 74 adult patients (median age of 54.6 years, 69% male, 81% diabetes mellitus (DM) type 2, estimated GFR (eGFR) 29.6 mL/min) with biopsy proven DN between 2010 and 2015. The primary endpoint was renal replacement therapy (RRT) initiation.Half of the patients progressed to end stage renal disease (ESRD) during follow-up; they had lower eGFR, increased proteinuria, hematuria and serum cholesterol. Regarding the pathologic features, they were more frequently in class III and IV, had higher interstitial fibrosis and tubular atrophy score (IFTA), increased interstitial inflammation, more frequent arteriolar hyalinosis and higher glomerular basement membrane (GBM) thickness. The mean kidney survival time was 2.7 (95%CI 2.1, 3.3) years. In univariate time-dependent analyses, higher RPS DN class, increased IFTA, the presence of arteriolar hyalinosis and arteriosclerosis were associated with RRT initiation.In the fully adjusted model, the clinical characteristics associated with poor renal survival were longer duration of DM, lower eGFR, increased proteinuria and higher hematuria and the only pathologic lesions to remain significant were the GBM thickness and the IFTA.In conclusion, in this European cohort, the severity of glomerular lesions evaluated with the RPS DN classification had limited utility in predicting RRT initiation. However, IFTA and GBM thickness were significantly associated with renal survival.

Validation study of Oxford Classification of IgA Nephropathy: the significance of extracapillary hypercellularity and mesangial IgG immunostaining

The Oxford classification (OC) of IgA Nephropathy (IgAN) identified mesangial hypercellularity (M), endocapillary hypercellularity (E), segmental glomerulosclerosis (S), and tubular atrophy/interstitial fibrosis (T) as predictors of outcome. We aimed to validate the OC and to investigate the clinical significance of extracapillary hypercellularity and IgG immunostaining. We examined the renal outcome at December 31, 2014, of 121 adult patients with biopsy proven primary IgAN between 2003 and 2013. The primary endpoint was doubling of serum creatinine or renal replacement therapy initiation. The mean observation period was 59.7 months. Thirty-one percent of the patients presented with a grade of extracapillary hypercellularity. In comparison with the group with no crescents, they had higher grade of inflammation, lower eGFR and increased proteinuria. There were no differences between the IgA and IgA&IgG immunostaining groups regarding the disease progression risk factors. Mean kidney survival time for the entire cohort was 10.6 (9.1, 12.0) years. In the Cox regression model, the independent predictors of decreased renal survival were eGFR at time of biopsy, S1 and the presence of crescents. Our study showed that extracapillary proliferation and S1 had the greatest importance in establishing the renal prognosis of patients with IgAN.

Bone marrow iron, iron indices, and the response to intravenous iron in patients with non-dialysis-dependent CKD

BACKGROUND

Information about iron stores and their relationship with transferrin saturation (TSAT), serum ferritin, and the erythropoietic response to iron therapy is scarce in anemic non-dialysis-dependent patients with chronic kidney disease (CKD). We examined the diagnostic utility of peripheral-iron indices and the erythropoietic response to intravenous iron as indices of iron store depletion using bone marrow iron as a reference test in anemic non-dialysis-dependent patients with CKD.

STUDY DESIGN

Diagnostic test study.

SETTING & PARTICIPANTS

100 anemic (hemoglobin <11 g/dL) patients with CKD stages 3-5, not receiving epoetin and iron.

INDEX TESTS

TSAT index and serum ferritin level at baseline and increase in hemoglobin level 1 month after 200 mg of iron sucrose daily for 5 days.

REFERENCE TEST

Bone marrow iron (assessed using aspiration and Perls' stain), depleted versus replete, at baseline.

MEASUREMENTS

Area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity of peripheral-iron indices and erythropoietic response to describe bone marrow iron stores.

RESULTS

Bone marrow iron stores were depleted in 48% of patients at baseline. In iron-depleted versus -replete subjects, mean hemoglobin level, median TSAT index, median serum ferritin level, and hemoglobin level increase after iron sucrose administration were 8.74 +/- 1.1 (SD) versus 9.22 +/- 0.9 g/dL (P = 0.02), 19% (interquartile range [IQR], 15%) versus 28% (IQR, 12%; P < 0.001), 100 (IQR, 131) versus 220 ng/mL (IQR, 213; P < 0.001), and 1.2 +/- 0.4 versus 0.8 +/- 0.3 g/dL (P < 0.001), respectively. TSAT, ferritin level, and increase in hemoglobin level AUROCs were similar: 0.75 (95% CI, 0.66-0.85), 0.76 (95% CI, 0.66-0.85), and 0.74 (95% CI, 0.65-0.84), respectively.

LIMITATIONS

Bone marrow iron as the index of iron stores.

CONCLUSIONS

Half the anemic patients with CKD stages 3-5 had depleted iron stores. Peripheral-iron indices and erythropoietic response had equivalent, but limited, utility in identifying depletion of bone marrow iron stores. Use of these indices to indicate depletion of iron stores should be reconsidered.

The analgesic effect of gemcitabine in mice

The analgesic effect of gemcitabine was analyzed in two experimental tests in mice. In the first test gemcitabine produced a dose-dependent decrease of the number of torsions produced by i.p. acetic acid in mice proving an analgesic effect. In the hot plate test the gemcitabine produced a non-statistical significant increase of the latency of the leakage, but a statistically significant increase of the latency of the salt proving an analgesic effect produced especially by a nervous central mechanism like morphine. The association of the gemcitabine and morphine proved that an inactive dose of gemcitabine increased statistically significant the effect of morphine proving a potentiation of the effect of morphine by gemcitabine. A same potentiation was demonstrated also by an effective analgesic dose of gemcitabine. The analgesic effect of the gemcitabine was antagonized by aminophiline, an inhibitor of the phosphodiesteraze, proving that the analgesic effect of the gemcitabine could be produced by a decrease of the intracellular cAMP. According to the chemical structure of gemcitabine it is possible that gemcitabine decrease the velocity of the degradation of the GMP fixed on the alpha subunit of the Gi protein and so increase the effect of the activated a subunit of the Gi protein to inactivate the adenylatecyclase. The analgesic effect of gemcitabine could be important in clinical management of antineoplastic patient by increasing the quality of life of these patients and the property of gemcitabine to potentiate the analgesic effect of morphine could be important by decreasing the needs of morphine of the antineoplastic patients. More researches will be necessary for evaluating also other nervous central effects of gemcitabine, for evaluation if other antineoplastic drugs have the same effect and for establishing a possible chemical structure-analgesic effect relationship and maybe also for evaluation if other effects of morphine are potentiated by gemcitabine and other antineoplastic drugs.

Effect of kanamycin and gentamicin on frog n. sciatic--m. gastrocnemian preparation

The effect of kanamycin and gentamicin on frog n.sciatic-m.gastrocnemian preparatus was analyzed. Both substances decreased the muscular contraction in both after direct electrical stimulation of the muscle and electrical nerve stimulation, in a dose-dependent manner. Both substances were used at a concentration near the therapeutical concentration in human. The effect of kanamycin was more important than the effect of gentamicin. These data obtained in presented experimental condition are in accord with clinical observation but are not in accord with the possibility that aminoglycoside antibiotics block presynaptic Ca2+ channels.

Liquid chromatographic determination of total celiprolol or (S)-celiprolol and (R)-celiprolol simultaneously in human plasma

A method has been developed for the determination of total celiprolol (sum of enantiomers) or the enantiomers (R)-celiprolol and (S)-celiprolol in plasma by high-performance liquid chromatography with UV and fluorescence detection. After extraction from alkalinized plasma with methyl-tert.-butyl ether and back-extraction into 0.01 M HCl (for total celiprolol determination) or after evaporation of the organic phase and derivatisation with R(-)-1-(1-naphthyl)ethyl isocyanate (enantiomer determination), total celiprolol or its diastereomeric derivatives were chromatographed on a reversed-phase HPLC column with a mixture of acetonitrile and phosphate buffer pH 3.5 (+0.05% triethylamine). Acebutolol was used as internal standard. Linearity was obtained in the range of 5 to 2000 ng/ml for total and 2.5 to 500 ng/ml for enantiomer determination. Intra-day and inter-day variation was lower than 10%. The method can be applied for analysis of plasma samples obtained from patients treated with oral racemic celiprolol doses.