MO647: Novel Medium Cut-Off Membranes in Larger Medium Molecules Removal, How Far Can We Go?

BACKGROUND AND AIMS

Dialysis with medium cut-off membranes (MCO) are growing fast during the last years thanks to the availability of an always-increasing number of membranes capable of reaching elevated clearance levels of medium molecules without significant loss of albumin. These achievements made MCO membranes an appropriate alternative to mixed diffusive-convective techniques which are frequently limited by clinical (low-performance vascular accesses) or social reasons (costs, availability). However, the term ‘medium molecules’ includes a wide spectrum of molecules with major differences in molecular weight (MW–from 0.5 to 60 KDa). Considering the human serum albumin's (HSA) MW of 64.5 KDa as the insuperable cut-off for avoiding unwanted protein loss, whereas there are many studies about clearance of medium molecules with dimensions below 25–30 KDa, fewer data are available about those with MW from 40 to ˃ 60 KDa. In this study, we evaluated the clearance proprieties of a new MCO membrane (Asahi Kasei's ViE-21X®), compared with both haemodiafiltration and hemodialysis (HD) with a well-known medium cut-off membrane (Baxter's Theranova 400®-Th400), of three medium molecules with increasing MW: free kappa chains (K-FLC 22.5 KDa), free lambda chains (L-FLC 45 KDa) and alpha-1 antitrypsin (A1AT 52–54 KDa) and measured albumin loss amount.

METHOD

We evaluated 12 patients chronically dialyzed three times a week in our Centre with mixed or post-dilutional haemodiafiltration (HDF) with various membranes. We collected blood samples before and after a common HDF session after a short interdialytic period for K-FLC, L-FLC, A1AT and HSA. Then, we collected the same data for two more sessions after a short interdialytic period conducted only with diffusive techniques, one using Th 400 and another with ViE-21X. For all molecules, we evaluated reduction ratio ± standard deviation (RR ± SD) while statistical significance (P < .05) was examined with Student's t-test. All data were adjusted by dialysis length, membranes surface area, blood flow rate and ultrafiltration rate avoiding any significant difference.

RESULTS

ViE-21X demonstrated an increased RR of K- and L-FLC compared with HDF and Th 400 even without reaching a statistical significance (38.82 ± 14.53% for K-FLC versus 32.36 ± 22.62% and 30.58 ± 24.10% respectively for HDF and Th400; P = .10 versus HDF, P = 0.13 versus Th 400. 35.63 ± 14.30% for L-FLC versus 30.48 ± 22.51% and 29.36 ± 24.91% respectively of HDF and Th 400; P = .19 versus HDF, P = 0.18 versus Th 400). Both ViE-21X and Th 400 showed higher RR for the largest molecule, A1AT, compared with HDF, reaching statistical significance (24.66 ± 19.98% for ViE-12X and 24.67%±20.15% for Th 400 versus 18.46% ± 21.73% for HDF, P < .05 for both). None of the techniques showed a significant loss of albumin, even if Th 400 showed a slightly greater loss compared to HDF and ViE-21X (2.59%±5.40% for HDF, 6.31%±23.61% for Th 400, 2.58%±24.24% for ViE-21X P = NS) (Figure).

CONCLUSION

Our data confirmed that studied MCO membranes can be an effective alternative to HDF in the clearance of medium molecules without any remarkable loss of albumin. Indeed, compared with HDF, they showed non-inferiority clearance levels for K- and L-LFC and a statistically significant benefit in the clearance of the studied largest one, A1AT, which has a close MW to HSA. Furthermore, according to our data, novel MCO membrane ViE-21X seems to show further benefits compared to other membranes. More studies with larger populations need to be conducted to confirm these data.

MO377HOW THE ITALIAN COVID-19 LOCKDOWN AFFECTED NEFROLOGICAL ACTIVITY IN A LOMBARD CENTER

Background and Aims

Italy and Lombard hospitals particularly, were hard affected by Covid-19 pandemic, mostly during spring and autumn, seasons characterized by two lockdown periods which were however, partly different as rules. During first lockdown in fact, by hospital decision, all ambulatorial activity was closed, including nephrological one. This did not happen during second lockdown period. How the different choices about hospital activity affected nephrological patients is the aim of this study.

Method

we evaluated all nephrological advices requested by first aid units of our 3 hospitals, all located in Lombardy, to our Nephrology Unit, splitting out data in 3 periods (I lockdown, summer and II lockdown) and comparing with 2019. Data collected were: number of advices requested by day, age, sex, previous regular nephrological follow-up, Covid-19 diagnosis, nephrological diagnosis after nephrological advice and outcome.

Results

as shown in table 1, during I lockdown period, with hospital decision of suspending our nephrological ambulatorial activity, we suffered an incremented rate of patients approaching local first aid units compared to 2019 same period with an increased rate of acute kidney injury, mostly for dehydration, and with a higher rate of patients requiring hospitalization. All these differences resulted statistically significant vs 2019 same period (figure 1). On the other side, no statically significant difference was found during the other two examined periods, including the II lockdown, while all our ambulatories were fully operating.

Conclusion

Covid-19 pandemic affected also the nephrological population with an increased rate of first aid units’ accesses, acute kidney injury events and hospitalization comparing to 2019. However, these differences were detectable only during the I lockdown period characterized by the suspension of all ambulatorial activity, including our Unit. The absence of statistically significant differences during summer and primarily during II lockdown period demonstrates the importance of nephrological ambulatorial activity in management of renal diseases and in prevention of acute events.

P0214THE IMPORTANCE OF POINT-OF-CARE ULTRASOUND FOR NEPHROLOGIST IN EMERGENCY ROOM: A MONOCENTRIC STUDY

Background and Aims

ultrasound is progressively expanding beyond Radiology Units getting a key role for the main part of medical and surgical specializations. Nephrology proves how a good mastery in ultrasound is critical for studying many aspects of renal disease such as acute kidney injury (AKI), chronic kidney disease (CKD), secondary causes of hypertension, kidney transplant, hemodialysis vascular accesses, hyperparathyroidism and so on. A place where is important for the Nephrologist to use ultrasound for getting a diagnostic help is hospital emergency room. Here, while having to face frequently with not optimal conditions for outdated ultrasound machines and patients without adequate preparation or compliance, the collection of few critical information with point-of-care ultrasound can make the difference in the diagnostic and therapeutic process.

Method

unprovided of an hospital ward our Unit activity is focused on dialysis, and nephrological examinations for patients hospitalized or not. We evaluated all the advices required to our Unit from the emergency room of our hospital between August 1st, 2016 and July 31th 2019. Then we selected those when Nephrologist decided to evaluate the patient also by point-of-care ultrasound. We collected data about age, sex, diagnostic questions, ultrasound findings, diagnosis and subsequent therapeutic processes.

Results

as shown in figure, among 393 advices, Nephrologists decided to use point-of-care ultrasound in 70 of them (18%, 47 males, 23 females, medium age 75,4±14 years).

More frequent diagnostic questions were related to alterations of biochemical renal function markers (77%) divided between AKI with (30%) or without (47%) a known history of CKD. Less frequent diagnostic questions were focused on clinical anomalies such as oligo-anuria (16%) and lower extremity edema and dyspnea (7%).

During point-of care ultrasound, more common findings were signs of CKD (41%) and urinary retention (48% divided in bladder retention -22%-, monolateral -4%- or bilateral hydronephrosis -22%-). Less frequent findings were normal kidneys (9%), unknown adult polycystic kidney disease (ADPKD) (1%) and suspect kidney myeloma (1%).

Guided by ultrasound, Nephrologist’s more frequent diagnosis were: AKI secondary to obstruction by various causes (46%: prostatic hypertrophy, kidney stones, dislodgment of bladder catheter or nephrostomy, solitary kidneys, intrinsic o extrinsic obstruction for subsequently diagnosed gynecological or urological cancers) and dehydration (36%). Less common diagnosis were congestive heart failure (11%) and uremia (7%).

Among all patients, only 17% were discharged: 8.3% entrusted to their general practitioner after intravenous hydration, 50% addressed to a nephrological follow-up, frequently after intravenous hydration, and 41.6% addressed to urological follow-up frequently after urinary catheter placement. The main part of patients (73%) were conservative treated by Nephrologist and hospitalized in various units: Internal Medicine (72,5%), Urology (21,5%, frequently after urinary catheter placement), Cardiology (4% with or without start of intravenous diuretic therapy) and Gynecology (2%). Finally, a significant part of patients (10%) required urgent hemodialysis treatment before being hospitalized.

Conclusion

in evaluated population, more frequent diagnosis formulated during nephrological advices in emergency room by our Unit were CKD and AKI due to obstructive causes. Besides these, point-of-care ultrasound allowed to promptly detect less frequent but not less important conditions such as unknown ADPKD, solitary kidneys or kidney myeloma. These data clarify how point-of-care ultrasound provides an important support for Nephrologist in clinical evaluation of emergency room patients, allowing to direct the subsequent investigations reducing useless examination and focusing the therapeutic process.

Late onset of hepatitis B virus reactivation following hematopoietic stem cell transplantation: successful treatment with combined entecavir plus tenofovir therapy

Prophylaxis with lamivudine (LAM) is recommended for hepatitis B core antibody-positive allogenic hematopoietic stem cell transplant (HSCT) recipients, but the optimal timing for the institution and duration of the prophylaxis is still unknown. Furthermore, considering the high rate of mortality associated with hepatitis B virus reactivation (HBV-R), the most potent and long-term effective antiviral regimen should be considered. We report here a case of late onset of HBV-R after a long-term prophylaxis with LAM in a patient who underwent HSCT for non-Hodgkin lymphoma and who was successfully treated with a combination antiviral regimen including entecavir and tenofovir disoproxil fumarate.

Echo-color-Doppler balance in dialysis patient

Ultrasonography is a non-invasive,well-controlled, quickly and easily available diagnostic procedure for the patient, is repeatable and not using ionizing radiation. For all these features plays an important role in the clinical management of patients undergoing dialysis. A census of the National Renal Ultrasound Study Group from Italian Society of Nephrology revealed that the 73.04% of Italian Departments of Nephrology and Dialysis are equipped with the ultrasound scanning and this one is commonly used in normal working routine. The main fields of application of this methodology in dialysis patient are: vascular pathology (damages due to systemic atherosclerosis, study and monitoring of arteriovenous fistula), muscle-tendon pathology (caused by hyperparathyroidism and amyloidosis), hyperparathyroidism (parathyroid assessment) and neoplastic disease.

Post-kala-azar dermal leishmaniasis as an immune reconstitution inflammatory syndrome in a patient with acquired immune deficiency syndrome

Post-kala-azar dermal leishmaniasis (PKDL) is a complication of visceral leishmaniasis (VL) observed mainly in Sudan and India where it follows treated VL in 50% and 10% of cases, respectively. We report a 46-year-old patient with acquired immune deficiency syndrome who, 7 months after diagnosis of VL, developed PKDL and uveal leishmaniasis following HAART-induced immune recovery. In southern Europe PKDL seems to be an emerging clinical presentation among human immunodeficiency virus (HIV)-infected patients experiencing HAART-induced immune recovery after a previous diagnosis of VL. The best treatment among HIV-infected patients remains to be determined.

Hepatocyte growth factor (HGF) modulates matrix turnover in human glomeruli

BACKGROUND

The imbalance between synthesis and degradation of mesangial matrix causes glomerulosclerosis and leads to renal failure. Hepatocyte growth factor (HGF) has been shown to reduce the progression in murine models of chronic renal failure. The present study evaluated the effect of HGF on the extracellular matrix turnover and on c-met receptor in human glomeruli.

METHODS

Human glomeruli microdissected from donor kidney biopsies before transplantation were incubated with culture media containing HGF (50 ng/mL). After 24 and 48 hours, the expression of c-met, (alpha2) IV collagen, transforming growth factor-beta (TGF-beta), metalloprotease (MMP) 2 and 9 and of the inhibitor of MMP-2, tissue inhibitors of metalloprotease-1 (TIMP-1), was evaluated by polymerase chain reaction (PCR). beta-actin was used as housekeeping gene. The production of collagen type IV and TGF-beta was evaluated by enzyme-linked immunosorbent assay (ELISA) and Western blotting and the activity of MMP by zymography.

RESULTS

(alpha2) IV collagen, TGF-beta, and TIMP-1 mRNA levels were markedly decreased in glomeruli treated with HGF at 24 and 48 hours. The expression of c-met was up-regulated by HGF treatment. HGF reduced the production of collagen type IV and TGF-beta. MMP-2 but not MMP-9 mRNA level was increased in HGF-treated glomeruli, although the gelatinolytic activity of the supernatant was not changed. By light microscopic examination kidney biopsies neither showed glomerular hypercellularity nor mesangial expansion.

CONCLUSION

HGF reduced expression and synthesis of TGF-beta and collagen type IV and increased MMP-2 mRNA level in normal human glomeruli. These results suggest an antifibrotic effect of HGF on glomerular cells and may explain its beneficial role in glomerulosclerosis.

Hyperkalemia-induced ECG abnormalities in patients with reduced renal function

Hyperkalemia is a potentially lethal condition to be aware of in the presence of ECG abnormalities especially in patients with reduced renal function. However, ECG abnormalities are not always dependent on the degree ofhyperkalemia but may be aggravated by the rapidity of the development of hyperkalemia and by associated electrolyte disorders. We describe 3 patients with renal failure and different ECG changes induced by hyperkalemia. More severe changes were observed when hyperkalemia developed rapidly, but not in presence of electrolyte disorders. Even minor ECG abnormalities must alarm physicians in patients with renal failure since severe hyperkalemia is not always associated with critical ECG changes.

Effect of calcineurin inhibitors on extracellular matrix turnover in isolated human glomeruli

INTRODUCTION

Although chronic cyclosporine toxicity is mainly characterized by tubular atrophy and interstitial fibrosis, glomerular injury with expansion of mesangial matrix and sclerosis is not uncommon. Tacrolimus is a newer calcineurin inhibitor that has been used in renal transplant recipients as primary or rescue therapy. Clinical trials suggest an improved long-term graft survival among patients treated with tacrolimus. Recently we have shown that tacrolimus and cyclosporine have similar effects on extracellular matrix turnover in cultured cells. The present study was performed to investigate the effects of the calcineurin inhibitors on whole glomeruli extracellular matrix turnover.

METHODS

Human glomeruli isolated from kidney biopsies just before transplantation were incubated with culture media containing either cyclosporine (200 ng/mL) or tacrolimus (10 ng/mL) for 24 hours. Glomeruli incubated only with culture medium were used as control.

RESULTS

The expressions of (alpha2)IV collagen, metalloprotease 9 (MMP9), tissue inhibitors of metalloproteases 2 (TIMP-2), and TGFbeta were evaluated by in situ reverse transcription and polymerase chain reactions (RT-PCR). beta-actin was used as a control gene. Cyclosporine (but not tacrolimus) increased the expression of (alpha2)IV collagen and TIMP2 in isolated glomeruli. TGF-beta was markedly increased by cyclosporine. MMP9 expression was not affected by the calcineurin inhibitors. By light microscopy kidney biopsies did not show pathologic changes.

CONCLUSION

Cyclosporine treatment modulates extracellular matrix turnover in isolated human glomeruli, inducing an imbalance between synthesis and degradation. This effect, not observed in tacrolimus-treated human glomeruli, may induce the extracellular matrix deposition and sclerosis characteristic of chronic cyclosporine toxicity.

[Hepatocyte growth factor (HGF) reduces the expression of profibrotic factors in human isolated glomeruli]

BACKGROUND

The imbalance between the synthesis and degradation of the mesangial matrix causes glomerulosclerosis and ultimately leads to chronic renal failure. HGF is a pleiotropic cytokine involved in angiogenesis, morphogenesis, organogenesis, and bone remodeling. Recently, we and other investigators have shown that HGF has a central role in the recovery of acute renal failure. Furthermore, HGF treatment halts the progression of kidney disease in a murine model of chronic renal failure. The aim of the present study was to evaluate the effect of HGF on the mRNA levels of molecules involved in the extracellular matrix turnover and of the c-met receptor in isolated human glomeruli.

METHODS

Human glomeruli were isolated by microdissection from donor kidney biopsies just before transplantation. Glomeruli were extensively washed and incubated with culture media containing HGF (50 ng/mL) for 24 h at 37 C. Glomeruli incubated without HGF were used as controls. After 24 h, glomeruli were washed and freezed and thawed three times. The expression of c-met, (alpha2) IV collagen, TGF-beta, metalloproteases 9 (MMP9), and of the inhibitor of metalloproteases-1, TIMP-1 was evaluated by in situ reverse transcription (RT) and polymerase chain reaction (PCR). beta-actin was used as a housekeeping gene.

RESULTS

The (alpha2)IV collagen mRNA level was decreased by HGF in human glomeruli. TGF-beta and TIMP-1 gene expression was markedly reduced by HGF treatment, whereas the expression of MMP-9 and c-met did not change. Under light-microscopic examination, kidney biopsies showed neither glomerular hypercellularity nor mesangial expansion.

CONCLUSIONS

HGF treatment reduces the expression of extracellular matrix components and of profibrotic factors in human glomeruli. Our results confirm a protective role of HGF in glomerulosclerosis.

Long-term exposure to high glucose up-regulates VCAM-induced endothelial cell adhesiveness to PBMC

BACKGROUND

The changes induced on endothelial cells by a long-term exposure to high glucose, a situation that mimics the hyperglycemia of diabetics, have not yet been determined. We compared short- and long-term effects of elevated glucose on macrovascular and microvascular endothelial cells.

METHODS

Endothelial cells were grown in high-glucose media for 24 hours and for 8 weeks. Cell proliferation was evaluated by cell counting, apoptosis and expression of adhesion molecules by flow cytometry; nitric oxide (NO) by measuring the concentration of nitrite/nitrate in the cell supernatant; alpha 2(IV) collagen mRNA and protein by reverse transcriptase-polymerase chain reaction and enzyme-linked immunosorbent assay, respectively. The adhesion of peripheral blood mononuclear cells (PBMCs) to endothelial cells was evaluated by adhesion assay. In some experiments, endothelial cells were preincubated with anti-vascular cell adhesion molecule-1 (VCAM-1) and anti-receptor for advanced glycation end product (RAGE) blocking antibodies.

RESULTS

At 24 hours, but not at 8 weeks, high glucose increased endothelial cell proliferation and apoptosis. High glucose did not modify NO synthesis at 24 hours and 8 weeks. Collagen production and expression were increased only after eight weeks. VCAM-1 but not intercellular adhesion molecule-1 was up-regulated after 8 weeks, a change not observed after 24 hours. The adhesion of PBMCs was significantly increased at eight weeks and was completely abrogated by anti--VCAM-1 and by anti-RAGE antibodies. After 24 hours, there was a modest increase of PBMC adhesion that was not blunted by anti-RAGE antibodies.

CONCLUSIONS

Increased adhesion of PBMCs, caused by up-regulation of VCAM-1 with a mechanism involving advanced glycation end product (AGE) adducts, and augmented collagen deposition are critical effects of long-term high glucose on endothelial cells, and may eventually promote the atherosclerotic process.

Hepatocyte growth factor, but not insulin-like growth factor I, protects podocytes against cyclosporin A-induced apoptosis

Cyclosporin A (CsA) nephropathy is associated with altered expression of apoptosis regulatory genes such as Fas-ligand and Bcl-2 family members in the glomerular, tubulointerstitial, and vascular compartments. Both hepatocyte growth factor (HGF) and insulin-like growth factor (IGF-I) protect against apoptosis, and HGF specifically up-regulates Bcl-xL, a protein that regulates apoptosis. We investigated whether Bcl-xL and Fas/Fas-ligand were regulated by CsA in cultured podocytes and whether CsA-induced apoptosis was prevented by HGF or IGF-I. A murine podocyte cell line was treated with CsA in the presence or absence of HGF or IGF-I. Apoptosis was quantitated by ELISA and by flow cytometry; Bcl-xL, Fas, and Fas-ligand were measured by Western blotting. Inhibitors of MAP kinase/ERK kinase (MEK)-1 and of phosphatidylinositol 3'-kinase (PI3'-K) were used to determine the signaling pathways involved in Bcl-xL regulation. Apoptosis was induced by CsA in a dose- and time-dependent fashion. CsA also decreased Bcl-xL levels. HGF, but not IGF-I, prevented apoptosis and restored Bcl-xL levels. The regulation of Bcl-xL by HGF was mediated by the PI3'-K but not by the MEK-1 pathway. In summary, we showed that CsA induces apoptosis in podocytes. Apoptosis was prevented by pretreatment with HGF but not IGF-I. Decreased apoptosis appeared to be mediated by regulation of Bcl-xL via the PI3'-K pathway. Our data suggest that the effect of CsA on podocytes may contribute to the glomerular damage and that HGF could provide protection.

Cyclosporine induces different responses in human epithelial, endothelial and fibroblast cell cultures

BACKGROUND

Nephrotoxicity, accelerated atherosclerosis, and graft vascular disease are common complications of cyclosporine long-term treatment characterized by a wide disruption of organ architecture with increased interstitial areas and accumulation of extracellular matrix (ECM). How cyclosporine induces these changes is not clear, but it is conceivable that they are the sum of changes induced at the cell level.

METHODS

We studied the effects of cyclosporine on human endothelial (HEC), epithelial (HK-2), and fibroblast (MRC5) cells. Cell proliferation was evaluated by cell counting, apoptosis and collagen production by enzyme-linked immunosorbent assay, and nitric oxide by measuring the concentration of nitrite/nitrate in the cell supernatant. (alpha1)I and (alpha2)IV collagen, matrix metalloprotease-9 (MMP9), and tissue inhibitors of metalloprotease-1 (TIMP-1) mRNA levels were measured by reverse transcription-polymerase chain reaction. Proteolytic activity was evaluated by zymography.

RESULTS

Cyclosporine showed a marked antiproliferative and proapoptotic effect on endothelial and epithelial cells. Fibroblast growth was not affected by cyclosporine. Nitric oxide was up-regulated by cyclosporine in epithelial cells and fibroblasts but not in endothelial cells. (alpha1)I and (alpha2)IV collagen synthesis was increased in cyclosporine-treated endothelial and epithelial cells, respectively. Proteolytic activity was increased in endothelial and epithelial cells. TIMP-1 mRNA was up-regulated by cyclosporine in fibroblasts.

CONCLUSIONS

Our results demonstrate that cyclosporine exhibits an antiproliferative effect on endothelial and epithelial cells. This effect is associated with induction of apoptosis probably via nitric oxide up-regulation in epithelial cell cultures. Cyclosporine treatment induces ECM accumulation by increasing collagen synthesis in endothelial and epithelial cells and reducing its degradation by up-regulating TIMP-1 expression in fibroblasts. We conclude that cyclosporine affects cell types differently and that the disruption of organ architecture is the result of multiple effects at the cell level.

Henoch-Schönlein purpura in a chronic hemodialysis patient

We describe a patient on maintenance hemodialysis who developed purpura, abdominal pain with bloody stool, and gross hematuria. A skin biopsy revealed leukocytoclastic vasculitis with IgA deposits. This is the first report of Henoch-Schönlein purpura in a hemodialysis patient.

Accelerated coronary reperfusion through the use of rapid bedside cardiac markers--case reports

Each year, acute myocardial infarctions (AMI) account for more than half a million deaths in the United States. Complicating treatment of AMI is the difficulty in accurately diagnosing the event, for patients have nondiagnostic electrocardiograms (ECG) more than 50% of the time. In this population, cardiac markers are essential to confirm the diagnosis. The new bedside cardiac markers, which use eight drops of whole blood and require 15 minutes to be read negative, make it possible to shorten time needed to diagnose AMI. One hundred twenty-seven consecutive patients presented to the emergency department complaining of atypical chest pain. All had ECGs that were nondiagnostic for myocardial infarction. Serial cardiac markers were performed: myoglobin, troponin I, rapid myoglobin, and rapid troponin I. One hundred eighteen patients with negative serial cardiac markers had exercise treadmill tests in the emergency department. Nine patients with positive serial cardiac markers received emergent primary angioplasty. Six of the nine patients were treated based on the positive results of the rapid bedside cardiac markers. A 100% correlation existed between the quantitative serum results and the rapid bedside markers. With the availability of rapid bedside assays, dependency on the laboratory can be minimized, since quantitative cardiac markers require at least 1 hour of turnaround time. Rapidly and correctly diagnosing AMIs in patients with ECGs nondiagnostic for AMI has always been a dilemma. Rapid bedside assays enable the physician to accurately diagnose myocardial infarction and safely decrease the time in evaluating chest pain, thus maximizing the benefits of early reperfusion.

Massive bilateral pulmonary embolism in a patient with subsequent occurrence of severe mitral regurgitation due to ruptured chordae tendineae--a case report

This report concerns an apparently healthy woman who presented simultaneously with acute massive bilateral pulmonary embolism and mitral regurgitation, subsequently, a month later, resulting in pulmonary edema secondary to chordae rupture of the mitral valve. The authors believe that massive pulmonary embolism predisposed to chordal rupture in this case. It is suggested that increased awareness of ruptured chordae tendineae as a cause of mitral regurgitation and the prompt use of transesophageal echocardiography will facilitate the early recognition of this potentially fatal, but treatable, cause of mitral regurgitation in patients with pulmonary embolism.

Referral pattern and outcome in men and women undergoing coronary artery bypass surgery--a critical review

Women with coronary artery disease are less likely to undergo coronary artery bypass surgery, and this may represent a potential referral bias in favor of men. A higher in-hospital mortality rate in women compared with men has been reported earlier. Accumulating evidence currently suggests, however, that variables other than gender, such as advanced age, late referral, angina classification, diabetes mellitus, concurrent medical conditions, the number of diseased vessels, the caliber of coronary arteries, and the decreased body surface area in women may have accounted for this difference. In fact, when these variables are taken into account, female gender is no longer a statistically significant predictor of operative mortality. Women appear to have comparable immediate and late survival rates. Recurrent angina, perioperative myocardial infarction, congestive heart failure, incomplete revascularization, and early and late graft reocclusion following surgery are, however, more prevalent in women. Men and women show differences in recovery experiences after discharge following bypass surgery. When coronary bypass surgery is offered to women, the decision should be individualized, based on the patients' perioperative baseline clinical risk factors and coronary anatomy. Coronary artery bypass surgery should not be withheld in women who are considered to be appropriate candidates for fear of a reduced success rate.

Prospective, randomized, multicenter comparison of laser-facilitated balloon angioplasty versus stand-alone balloon angioplasty in patients with obstructive coronary artery disease. The Laser Angioplasty Versus Angioplasty (LAVA) Trial Investigators

OBJECTIVES

The goal of this study was to examine the relative safety and efficacy of laser-facilitated percutaneous transluminal coronary angioplasty (PTCA) versus "stand-alone" PTCA.

BACKGROUND

Plaque debulking with lasing before PTCA may result in improved lumen dimensions and decreased rates of periprocedural ischemic complications, thus improving short- and long-term outcomes after percutaneous intervention. The mid-infrared holmium:yttrium-aluminum-garnet (YAG) laser has been shown to be effective in a variety of plaque subtypes and may be particularly useful in high risk acute ischemic syndromes.

METHODS

A total of 215 patients (mean [+/-SD] age 61 +/- 12 years) with 244 lesions were prospectively randomized at 14 clinical centers to laser versus stand-alone PTCA. After laser treatment, all patients underwent PTCA; 148 patients (69%) had unstable angina.

RESULTS

The procedural success rate without major catheterization laboratory complications was similar in patients assigned to laser treatment or PTCA alone (96.6% vs. 96.9%, p = 0.88), as was the in-hospital clinical success rate (89.7% vs. 93.9%, p = 0.27). There was no difference in postprocedural diameter stenosis after laser treatment compared with PTCA (18.3% +/- 13.6% vs. 19.5% +/- 15.1%, p = 0.50). However, use of the laser, versus PTCA alone, did result in significantly more major and minor procedural complications (18.0% vs. 3.1%, p = 0.0004), myocardial infarctions (4.3% vs. 0%, p = 0.04) and total in-hospital major adverse events (103% vs. 4.1%, p = 0.08). At a mean follow-up time of 11.2 +/- 7.7 months, there were no differences in late or event-free survival in patients assigned to laser treatment versus PTCA alone.

CONCLUSIONS

Compared with stand-alone PTCA, laser-facilitated PTCA results in a more complicated hospital course, without immediate or long-term benefits.

Trends in success rate after percutaneous transluminal coronary angioplasty in men and women with coronary artery disease

Women with coronary artery disease are less likely to undergo percutaneous transluminal coronary angioplasty (PTCA) because of the potential referral bias in favor of men with coronary artery disease in the use of invasive diagnostic procedures and interventions. This difference may represent a sex bias in the delivery of medical care. The apparent sex difference in short-term success of PTCA seen in the early 1980s has not persisted in subsequent studies. The higher in-hospital mortality rate, if any, in women compared with men after PTCA is related more to the severity of their underlying disease rather than sex alone. In addition, women have a better long-term PTCA success rate. PTCA should not be withheld in women who are considered appropriate anatomic candidates for fear of reduced success or increased major complications.

Percutaneous transluminal angioplasty of a stenosis at the origin of the left internal mammary artery graft: a case report

A case of percutaneous transluminal angioplasty of a high-grade stenosis at the origin of the left internal mammary graft is presented. An investigational angled-balloon dilating catheter was used.

Tissue T-lymphocytes in untreated Hodgkin's disease: morphologic and functional correlations in spleens and lymph nodes

In the present study the number of E-RFC and the in vitro response to PHA and ConA were determined for lymphocytes obtained from spleens and lymph nodes of untreated HD patients. The results were correlated with tissue involvement and with the histological pattern of the disease. Our investigation has revealed: (1) involved spleens and lymph nodes contained a higher percentage of T-lymphocytes than uninvolved tissues. The differences was statistically significant for lymph nodes. (2) A statistically significant correlation was not found between T-lymphocyte numbers and histology. (3) Lymphocytes from uninvolved spleens were significantly more reactive to both mitogens than cells from involved spleens and control non-neoplastic spleens as well. (4) Similar results were obtained with lymph node lymphocytes; however, a significant difference was observed only when cells were stimulated with ConA. (5) The difference in proliferative response between uninvolved and involved tissues was maximally expressed in MC and progressively decreased in NS and LP. (6) T-cell enrichment does not alter the difference between uninvolved and involved spleens. (7) Cells from uninvolved and involved spleens, cultured for 24 hours, maintained unchanged their proliferative capacity. In this study evidence is provided that in HD T-lymphocytes from uninvolved tissues are characterized by an increased reactivity in mitogens, whereas cells from involved tissues are normally responsive.