The Success Story of Peritoneal Dialysis in Romania: Analysis of Differences in Mortality by Dialysis Modality and Influence of Risk Factors in a National Cohort

Background

This report describes the status of renal replacement therapy (RRT), particularly continuous ambulatory peritoneal dialysis (CAPD), in Romania (a country with previously limited facilities), outlines the fast development rate of CAPD, and presents national changes in a European context.

Methods

Trends in the development of RRT were analyzed in 2003 on a national basis using annual center questionnaires from 1995 to 2003. Survival data and prognostic risk factors were calculated retrospectively from a representative sample of 2284 patients starting RRT between 1 January 1995 and 31 December 2001 (44% of the total RRT population investigated).

Results

The annual rate of increase in the number of RRT patients (11%) was supported mainly by an exponential development of the CAPD population (+600%); the hemodialysis (HD) growth rate was stable (+33%) and renal transplantation had a marginal contribution. The characteristics of both HD and PD incident patients changed according to current European epidemiology (increasing age and prevalence of diabetes and nephroangiosclerosis). There were significant differences between PD and HD incident populations, PD patients being significantly older and having a higher prevalence of diabetic nephropathy and baseline comorbidities, probably reflecting different inclusion policies. The estimated overall survival of RRT patients in Romania was 90.6% at 1 year [confidence interval (CI) 89.4 – 91.8] and 62.2% at 5 years (CI 59.4 – 65.0). The initial treatment modality did not significantly influence patients’ survival. There was no difference in unadjusted technique survival during the first 2 years; afterwards, there was a clear advantage for HD, with more patients being transferred from PD to HD. Several factors seemed to significantly and negatively influence PD patients’ survival (Cox regression analysis): male gender, lack of predialysis erythropoietin treatment, and initial comorbidities. Stratified analysis to discover the influence of these factors on patients’ survival revealed that HD was associated with an increased risk of death in the younger nondiabetic end-stage renal disease population, regardless of other coexisting comorbid conditions. However, in older patients (>65 years) and in diabetics, regardless of the presence or absence of associated comorbid conditions, there was no significant difference in death rates between HD and PD patients.

Conclusions

We report an impressive quantitative and qualitative development of CAPD in one of the rapidly growing Central and Eastern Europe countries. CAPD should be the method of choice for young nondiabetic end-stage renal disease patients. Improvement in predialysis nephrologic care and in transplantation rates is required to further ensure the ultimate success of the Romanian PD program.

Deregulated profiles of urinary microRNAs may explain podocyte injury and proximal tubule dysfunction in normoalbuminuric patients with type 2 diabetes mellitus

MicroRNAs (miRNAs) are short non-coding RNA species that are important post-transcriptional regulators of gene expression. The aim of the study was to establish a potential explanation of podocyte damage and proximal tubule (PT) dysfunction induced by deregulated miRNAs expression in the course of type 2 diabetes mellitus (DM). A total of 68 patients with type 2 DM and 11 healthy subjects were enrolled in a cross-sectional study and assessed concerning urinary albumin:creatinine ratio (UACR), urinary N-acetyl-β-D-glucosamininidase (NAG), urinary kidney injury molecule-1, urinary nephrin, podocalyxin, synaptopodin, estimated glomerular filtration rate (eGFR), urinary miRNA21, miRNA124, and miRNA192. In univariable regression analysis, miRNA21, miRNA124, and miRNA192 correlated with urinary nephrin, synaptopodin, podocalyxin, NAG, KIM-1, UACR, and eGFR. Multivariable regression analysis yielded models in which miRNA192 correlated with synaptopodin, uNAG, and eGFR (R²=0.902; P<0.0001), miRNA124 correlated with synaptopodin, uNAG, UACR, and eGFR (R²=0.881; P<0.0001), whereas miRNA21 correlated with podocalyxin, uNAG, UACR, and eGFR (R²=0.882; P<0.0001). Urinary miRNA192 expression was downregulated, while urinary miRNA21 and miRNA124 expressions were upregulated. In patients with type 2 DM, there is an association between podocyte injury and PT dysfunction, and miRNA excretion, even in the normoalbuminuria stage. This observation documents a potential role of the urinary profiles of miRNA21, miRNA124, and miRNA192 in early DN. Despite their variability across the segments of the nephron, urinary miRNAs may be considered as a reliable tool for the identification of novel biomarkers in order to characterize the genetic pattern of podocyte damage and PT dysfunction in early DN of type 2 DM.

Therapy with atorvastatin versus rosuvastatin reduces urinary podocytes, podocyte-associated molecules, and proximal tubule dysfunction biomarkers in patients with type 2 diabetes mellitus: a pilot study

BACKGROUND

Diabetic nephropathy is a severe complication of Type 2 diabetes. Tubular lesions may play an important role in its early stages. The aim of our study was to determine if atorvastatin protects the podocytes and the proximal tubule in patients with Type 2 diabetes.

METHODS

A total of 63 patients with Type 2 diabetes completed this 6-months prospective pilot study. They were randomized to continue rosuvastatin therapy (control group) or to be administered an equipotent dose of atorvastatin (intervention group), and were assessed regarding urinary podocytes, podocyte-associated molecules, and biomarkers of proximal tubule dysfunction.

RESULTS

The patients from the intervention group presented a significant reduction in podocyturia (from 7.0 to 4.0 cells/ml, p < .05), urinary nephrin (from 1.7 to 1.3 mg/g, p < .001), urinary vascular endothelial growth factor (from 262.8 to 256.9, p < .01), urinary alpha1-microglobulin (from 10.0 to 8.3 mg/g, p < .01), urinary kidney injury molecule-1 (from 139.5 to 136.3 ng/g, p < .001), and urinary advanced glycation end-products (from 112.6 to 101.3 pg/ml, p < .001). Podocyturia correlated directly with the podocyte damage biomarkers, proximal tubule dysfunction biomarkers, albumin to creatinine ratio, and advanced glycation end-products, and inversely with the glomerular filtration rate.

CONCLUSIONS

In patients with Type 2 diabetes, atorvastatin exerts favorable effects on the kidney. There is a correlation between the evolution of the podocytes and of the proximal tubule biomarkers, supporting the hypothesis that the glomerular changes parallel proximal tubule dysfunction in the early stages of diabetic nephropathy.

Podocyturia parallels proximal tubule dysfunction in type 2 diabetes mellitus patients independently of albuminuria and renal function decline: A cross-sectional study

AIMS

Detection of podocytes in the urine of patients with type 2 diabetes may indicate severe injury to the podocytes. In the course of type 2 diabetes the proximal tubule is involved in urinary albumin processing. We studied the significance of podocyturia in relation with proximal tubule dysfunction in type 2 diabetes.

METHODS

A total of 86 patients with type 2 diabetes (34-normoalbuminuria; 30-microalbuminuria; 22-macroalbuminuria) and 28 healthy subjects were enrolled in the study and assessed concerning urinary podocytes, podocyte-associated molecules, and biomarkers of proximal tubule dysfunction. Urinary podocytes were examined in cell cultures by utilizing monoclonal antibodies against podocalyxin and synaptopodin.

RESULTS

Podocytes were detected in the urine of 10% of the healthy controls, 24% of the normoalbuminuric, 40% of the microalbuminuric, and 82% of the macroalbuminuric patients. In multivariate logistic regression analysis, urinary podocytes correlated with urinary albumin:creatinine ratio (p=0.006), urinary nephrin/creat (p=0.001), urinary vascular endothelial growth factor/creat (p=0.001), urinary kidney injury molecule-1/creat (p=0.003), cystatin C (p=0.001), urinary advanced glycation end-products (p=0.002), eGFR (p=0.001).

CONCLUSIONS

In patients with type 2 diabetes podocyturia parallels proximal tubule dysfunction independently of albuminuria and renal function decline. Advanced glycation end-products may impact the podocytes and the proximal tubule.

Urinary podocyte-associated mRNA levels correlate with proximal tubule dysfunction in early diabetic nephropathy of type 2 diabetes mellitus

AIM

The study assessed mRNA expression of podocyte-associated molecules in urinary sediments of patients with type 2 diabetes mellitus (DM) in relation to urinary podocytes, biomarkers of podocyte injury and of proximal tubule (PT) dysfunction.

METHODS

A total of 76 patients with type 2 DM and 20 healthy subjects were enrolled in a cross-sectional study, and assessed concerning urinary podocytes, urinary mRNA of podocyte-associated genes, urinary biomarkers of podocyte damage and of PT dysfunction.

RESULTS

We found significant differences between urinary mRNA of podocyte-associated molecules in relation with albuminuria stage. In multivariable regression analysis, urinary mRNA of nephrin, podocin, alpha-actinin-4, CD2-associated protein, glomerular epithelial protein 1 (GLEPP1), ADAM 10, and NFκB correlated directly with urinary podocytes, albuminuria, urinary alpha₁-microglobulin, urinary kidney-injury molecule-1, nephrinuria, urinary vascular endothelial growth factor, urinary advanced glycation end-products (AGE), and indirectly with eGFR (p < 0.0001, R² = 0.808; p < 0.0001, R² = 0.825; p < 0.0001, R² = 0.805; p < 0.0001, R² = 0.663; p < 0.0001, R² = 0.726; p < 0.0001, R² = 0.720; p < 0.0001, R² = 0.724).

CONCLUSIONS

In patients with type 2 DM there is an association between urinary mRNA of podocyte-associated molecules, biomarkers of podocyte damage, and of PT dysfunction. GLEPP1, ADAM10, and NFκB may be considered additional candidate molecules indicative of early diabetic nephropathy. AGE could be involved in this association.

Is ciprofloxacin safe in patients with solitary kidney and upper urinary tract infection?

The solitary kidney (SK) undergoes adaptive phenomena of hyperfunction and hyperfiltration. These secondary adaptive phenomena can make it more vulnerable to potentially nephrotoxic therapies. Adverse reactions of the kidneys to ciprofloxacin are rare, but sometimes severe. Therefore, our study sought to assess the reactions to ciprofloxacin of patients with solitary kidney (SK) and urinary tract infection (UTI) by means of urinary biomarkers. We studied 19 patients with SK and urinary tract infection (UTI) who had been administered a 7-day treatment with intravenous ciprofloxacin. Urinary N-acetyl-beta-d-glucosaminidase, alpha 1-microglobulin, and estimated glomerular filtration rate (eGFR) of these patients were measured at the initiation and at the end of treatment. In 47.37% patients NAG diminished under ciprofloxacin treatment. This observation has the significance of favourable evolution of the tubulointerstitial lesions caused by UTI and lack of nephrotoxic effects; 52.63% cases presented an increase of urinary NAG, a fact that suggests a nephrotoxic effect of ciprofloxacin. The evolution of urinary alpha 1-microglobulin was similar to that one of urinary NAG. Only one of three cases with chronic kidney disease (CKD) stage 5 presented acute kidney injury, associated with increase in the tubular markers. In spite of the high variability of the urinary biomarkers, UTI evolved favourably in these cases; eGFR increased in 16 out of 19 patients, a fact which is indicative of a good outcome of renal function, even in patients with elevated levels of the tubular damage biomarkers. This observation supports the hypothesis that eGFR may be dissociated from the biomarkers which assess tubular injury. In SK patients the occurrence of AKI is not frequent, although the urinary biomarkers rise in some patients treated with ciprofloxacin. This is related not only to the nephrotoxic effect of the drug, but probably to the association of other factors (allergy, individual susceptibility). In SK patients, renal tubular biomarkers, especially NAG, allow monitoring of tubular injury and impose caution in prescribing ciprofloxacin treatment, mainly to patients at risk. Ciprofloxacin is relatively safe regarding its nephrotoxicity, while caution is required in vulnerable patients.

Urinary Biomarkers in the Assessment of Early Diabetic Nephropathy

Diabetic nephropathy (DN) is a frequent and severe complication of diabetes mellitus (DM). Its diagnosis in incipient stages may allow prompt interventions and an improved prognosis. Towards this aim, biomarkers for detecting early DN can be used. Microalbuminuria has been proven a remarkably useful biomarker, being used for diagnosis of DN, for assessing its associated condition-mainly cardiovascular ones-and for monitoring its progression. New researches are pointing that some of these biomarkers (i.e., glomerular, tubular, inflammation markers, and biomarkers of oxidative stress) precede albuminuria in some patients. However, their usefulness is widely debated in the literature and has not yet led to the validation of a new "gold standard" biomarker for the early diagnosis of DN. Currently, microalbuminuria is an important biomarker for both glomerular and tubular injury. Other glomerular biomarkers (transferrin and ceruloplasmin) are under evaluation. Tubular biomarkers in DN seem to be of a paramount importance in the early diagnosis of DN since tubular lesions occur early. Additionally, biomarkers of inflammation, oxidative stress, podocyte biomarkers, and vascular biomarkers have been employed for assessing early DN. The purpose of this review is to provide an overview of the current biomarkers used for the diagnosis of early DN.

Glycated peptides are associated with the variability of endothelial dysfunction in the cerebral vessels and the kidney in type 2 diabetes mellitus patients: a cross-sectional study

BACKGROUND

Diabetic atherosclerosis and microangiopathy parallel diabetic nephropathy. The aim of our study was to evaluate the pattern of endothelial dysfunction in two vascular territories, the kidney and the brain, both affected by diabetic vasculopathic complications. The endothelial variability was evaluated in relation to advanced glycation end-products modified peptides.

METHODS

Seventy patients with type 2 diabetes mellitus and 11 healthy subjects were assessed concerning urine albumin: creatinine ratio, plasma and urinary advanced glycation end-products, plasma asymmetric dimethyl-arginine, serum cystatin C, intima-media thickness in the common carotid arteries, the pulsatility index, the resistance index in the internal carotid arteries and the middle cerebral arteries, the cerebrovascular reactivity through the breath-holding test.

RESULTS

The breath-holding index correlated with asymmetric dimethyl-arginine (R²=0.151; p<0.001), plasma advanced glycation end-products (R²=0.173; p<0.001), C-reactive protein (R²=0.587; p<0.001), duration of diabetes mellitus (R²=0.146; p=0.001), cystatin C (R²=0.220; p<0.001), estimated glomerular filtration rate (R²=0.237; p=0.001). Urine albumin: creatinine ratio correlated with urinary advanced glycation end-products (R²=0.257; p<0.001), but not with asymmetric dimethyl-arginine (R²=0.029; p=0.147).

CONCLUSIONS

In type 2 diabetic patients endothelial dysfunction in the cerebral vessels appears to be dissociated from glomerular endothelial dysfunction in early diabetic nephropathy. Advanced glycation end-products could impact both the cerebral vessels and the glomerular endothelium.

Glycated peptides are associated with proximal tubule dysfunction in type 2 diabetes mellitus

BACKGROUND

Advanced glycation end-products have been involved in the pathogenesis of proximal tubule dysfunction which characterizes diabetic tubulopathy.

METHODS

A total of 76 Type 2 diabetes mellitus patients and 28 healthy controls were evaluated concerning a potential association of glycated peptides with proximal tubule dysfunction by assessing urine albumin:creatinine ratio, urinary alpha1-microglobulin, urinary neutrophil gelatinase-associated lipocalin, plasma and urinary advanced glycation end-products, plasma asymmetric dimethyl-arginine, serum cystatin C. Fully automated chip-nanoelectrospray ionization and high-capacity ion trap multistage mass spectrometry characterized the urinary proteomic profile.

RESULTS

The urinary glycated proteins displayed a molecular weight of 15,121.4 Da in normoalbuminuric patients and of 30,180.4 Da in microalbuminuric patients. Urinary alpha1-microglobulin and neutrophil gelatinase-associated lipocalin correlated with urinary advanced glycation end-products (R(2)=0.586; R(2)=0.415), urine albumin: creatinine ratio (R(2)=0.292; R(2)=0.116), estimated glomerular filtration rate (R(2)=0.172; R(2)=0.135), serum cystatin C (R(2)=0.146; R(2)=0.129), but not with asymmetric dimethyl-arginine. In multivariable regression analysis models, the correlations for urinary alpha1-microglobulin and neutrophil gelatinase-associated lipocalin remained significant with urine albumin: creatinine ratio, urinary advanced glycation end-products, estimated glomerular filtration rate (P<0.0001, R(2)=0.674; P<0.0001, R(2)=0.551; P<0.0001, R(2)=0.482).

CONCLUSIONS

In patients with Type 2 diabetes mellitus urinary glycated peptides are associated with proximal tubule dysfunction. The proteomic patterns of urinary glycated peptides could differentiate normo- from microalbuminuric patients and may explain a potential relation between the size and the glycation status of glycated peptides, and the extent of proximal tubule dysfunction. The lack of correlation between parameters of endothelial dysfunction and proximal tubule dysfunction cannot exclude glomerular involvement in early diabetic nephropathy.

Proximal tubule dysfunction is associated with podocyte damage biomarkers nephrin and vascular endothelial growth factor in type 2 diabetes mellitus patients: a cross-sectional study

BACKGROUND

There is an ongoing debate as to whether early diabetic nephropathy in Type 2 diabetes mellitus may be attributed to the glomerulus or to the proximal tubule. Urinary excretion of nephrin and vascular endothelial growth factor may increase even in the normoalbuminuria stage. In the course of diabetic nephropathy, the proximal tubule may be involved in the uptake of urinary nephrin and vascular endothelial growth factor.

MATERIALS AND METHODS

Two groups of consecutive Type 2 diabetes mellitus outpatients (38 normo-, 32 microalbuminuric) and 21 healthy subjects were enrolled in a cross-sectional study and evaluated concerning the relation of proximal tubule dysfunction with the podocyte biomarkers excretion, assessed by ELISA methods. The impact of advanced glycation end-products on this relation was also queried.

RESULTS

Urinary alpha1-microglobulin and kidney injury molecule-1 correlated with urinary albumin:creatinine ratio (R2 = 0.269; p < 0.001; R2 = 0.125; p < 0.001), nephrinuria (R2 = 0.529; p<0.001; R2 = 0.203; p < 0.001), urinary vascular endothelial growth factor (R2 = 0.709; p < 0.001; R2 = 0.360; p < 0.001), urinary advanced glycation end-products (R2 = 0.578; p < 0.001; R2 = 0.405; p < 0.001), serum cystatin C (R2 = 0.130; p < 0.001; R2 = 0.128; p<0.001), and glomerular filtration rate (R2 = 0.167; p < 0.001; R2 = 0.166; p < 0.001); nephrinuria and urinary vascular endothelial growth factor correlated with urinary albumin:creatinine ratio (R2 = 0.498; p < 0.001; R2 = 0.227; p<0.001), urinary advanced glycation end-products (R2 = 0.251; p < 0.001; R2 = 0.308; p < 0.001), serum cystatin C (R2 = 0.157; p < 0.001; R2 = 0.226; p < 0.001), and glomerular filtration rate (R2 = 0.087; p = 0.007; R2 = 0.218; p < 0.001).

CONCLUSIONS

In Type 2 diabetes mellitus there is an association of proximal tubule dysfunction with podocyte damage biomarkers, even in the normoalbuminuria stage. This observation suggests a potential role of the proximal tubule in urinary nephrin and urinary vascular endothelial growth factor processing in early diabetic nephropathy, a fact which could be related to advanced glycation end-products intervention. Podocyte damage and proximal tubule dysfunction biomarkers could be validated as a practical approach to the diagnosis of early diabetic nephropathy by further studies on larger cohorts.

Familial versus environmental factors in Balkan endemic nephropathy in Mehedinti county, Romania, by means of albuminuria and tubular biomarkers: preliminary study

INTRODUCTION AND AIMS

Balkan endemic nephropathy (BEN), a regional tubulointerstitial kidney disease encountered in South-Eastern Europe, with still undefined etiology and inexorable evolution towards end stage renal disease, raises the question of the relative contribution of family and environmental factors in its etiology. In order to evaluate the intervention of these factors, markers of tubular injury have been assessed, this lesion being considered an early renal involvement in BEN.

METHODS

The paper studies relatives of BEN patients currently included in dialysis programmes (for involvement of the family factor) and their neighbors (for involvement of environmental factors) and analyzes them with regard to tubular injury by means of tubular biomarkers (N-acetyl-beta-d-glucosaminidase-NAG and alpha-1-microglobulin), and albuminuria. At the same time, glomerular filtration rate (GFR) (CKD-EPI) was measured. It is considered that, in order to acquire the disease, one should have lived for 20 years in the BEN area. The relatives have been classified according to this criterion.

RESULTS

More evident tubular injury was found in the neighbors of BEN patients living for more than 20 years in the endemic area, which argues in favor of environmental factors. Higher levels of urinary alpha-1-microglobulin and albumin in relatives of BEN patients who had been living for more than 20 years in the area than in relatives with a residence under 20 years, plead for the same hypothesis. GFR was lower in persons who had been living for more than 20 years in the BEN area (neighbors and relatives).

CONCLUSIONS

Environmental factors could be more important in BEN than family factors.

Consensus statement on screening, diagnosis, classification and treatment of endemic (Balkan) nephropathy

Currently used diagnostic criteria in different endemic (Balkan) nephropathy (EN) centers involve different combinations of parameters, various cut-off values and many of them are not in agreement with proposed international guidelines. Leaders of EN centers began to address these problems at scientific meetings, and this paper is the outgrowth of those discussions. The main aim is to provide recommendations for clinical work on current knowledge and expertise. This document is developed for use by general physicians, nephrologists, urologist, public health experts and epidemiologist, and it is hoped that it will be adopted by responsible institutions in countries harboring EN. National medical providers should cover costs of screening and diagnostic procedures and treatment of EN patients with or without upper urothelial cancers.

Urinary biomarkers in assessing the nephrotoxic potential of gentamicin in solitary kidney patients after 7 days of therapy

INTRODUCTION

The solitary kidney (SK) may present increased vulnerability to nephrotoxicity because of adaptive phenomena.

AIMS

Assessing the vulnerability of the SK with urinary tract infections (UTI) to gentamicin by means of urinary biomarkers (N-acetyl-beta-D-glucosaminidase (NAG) and urinary alpha-1-microglobulin), as well as glomerular filtration rate (GFR).

METHODS

We studied 14 patients with SK with UTI (group A) (mean age 58.07 ± 13.61 years, mean duration of SK 13.55 ± 12.33 years) who were administered gentamicin for 7 days. Group B consisted by 17 patients with SK without any other associated renal pathology (average age 51.17 ± 9.39 years, average existence period of a single kidney 33.23 ± 21.73 years). We also included a third group (group C) represented by nine healthy individuals, with two kidneys.

RESULTS

Increased values of urinary NAG were found in group B as compared to group C and alpha-1 microglobulin in group A as compared to group B. During treatment with gentamicin, increased values of both NAG and alpha-1-microglobulin in group A were found on day 7 as compared to values before treatment (day 7 NAG=18.99 ± 14.07 U/g creat versus day 0, NAG=5.15 ± 6.54 U/g creat, p=0.004; day 7 alpha-1-microglobulin=20.88 ± 18.84 mg/g creat versus day 0, urinary alpha-1-microglobulin=4.96 ± 6.57 mg/g creat, p=0.003). No statistically significant alterations of GFR were noticed after 7 days of treatment.

CONCLUSIONS

We found the nephrotoxic effects of gentamicin at tubular level, but not at glomerular level. The nephrotoxic potential of gentamicin in patients with a SK can be monitored by assessing urinary biomarkers during treatment of UTI.

"Surprise" in the evolution of chronic membranoproliferative glomerulonephritis associated with severe strongyloidiasis under corticotherapy: "hygienic paradox"?

A case of strongyloidiasis in a patient with membranoproliferative glomerulonephritis is reported. In our patient, strongyloidiasis evolved latently and became overt after corticotherapy, and it turned to be a very severe outcome and life-threatening complications, hyperinfection syndrome and upper digestive tract hemorrhage. Besides its well-known complications, steroid therapy may provide real surprises. The association of this therapy with strongyloidiasis may turn an undiagnosed inactive, chronic form of the disease into an active form within the framework of a hyperinfection syndrome which might lead to death. In our case, the diagnosis of strongyloidiasis was established only after duodenal biopsy was performed for upper digestive tract hemorrhage, which revealed the parasite. It should be underlined that under corticotherapy, the patient evolved favorably with regard to glomerular disease, while strongyloidiasis worsened. The outcome was positive after the patient was treated with albendazole and ivermectin. The diagnosis of strongyloidiasis is sometimes difficult to establish due to the fact that eosinophilia may be absent, while commonly utilized stool examinations may be negative. By analyzing our case, it may be assumed that the immune mechanisms involved in strongyloidiasis do not activate the glomerular nephropathy. On the contrary, these mechanisms seem to have an immunosuppressive effect. The "hygienic hypothesis" also needs to be considered. While on corticotherapy, patients with glomerulonephritis need immunologic and parasitologic monitoring. This is important for other immunodepressing diseases and for immunosuppressive drugs. If the patient has originated in a mining area, as is the case with our patient, or in endemic areas, this monitoring becomes mandatory. The case reflects the complexity of the interrelation between the immune mechanisms in glomerulonephritis and those in parasitic diseases, strongyloidiasis in our case.

Evidence of exposure to aristolochic acid in patients with urothelial cancer from a Balkan endemic nephropathy region of Romania

Recently, chronic Aristolochia poisoning was found responsible for the aetiology of Balkan endemic nephropathy (BEN) in Croatia, Serbia, and Bosnia, and diet was the likely route of exposure to aristolochic acid (AA). BEN, often associated with an increased incidence of upper urinary tract carcinoma (UUC), also affects residents of certain rural villages in Romania. AA is a nephrotoxin and human carcinogen that forms DNA adducts after metabolic activation, which induce characteristic TP53 mutations in urothelial tumours. Here we present the first evidence linking AA exposure to UUC in residents of an endemic region in the Romanian Mehedinti County. DNA was extracted from kidney and tumour tissue of seven patients who underwent nephroureterectomy for UUC and resided in BEN villages (endemic group). Five patients with UUC from nonendemic villages served as controls. AA-DNA adducts (7-(deoxyadenosin-N(6) -yl)-aristolactam I), established biomarkers of AA exposure, were identified by (32)P-postlabelling in renal DNA of six patients from the endemic group and in one of the nonendemic group (adduct levels ranged from 0.3 to 6.5 adducts per 10(8) nucleotides). Additionally, an A to T transversion in TP53, a base substitution characteristic of AA mutagenic activity was found in urothelial tumour DNA of one patient from the endemic group. Our results provide a molecular link to the cause of urothelial tumours in BEN regions of Romania indicating that AA is the common aetiological agent for BEN across its numerous geographical foci.

The dynamics of urinary N-acetyl-β-D-glucosaminidase (NAG), a marker of renal tubular dysfunction, in patients with lupus nephritis undergoing oral prednisone therapy

INTRODUCTION AND AIMS

N-Acetyl-β-D-glucosaminidase (NAG), a marker of renal tubular dysfunction, is increased in patients with lupus nephritis. In addition to the toxic effects of proteinuria, patients with lupus nephritis may exhibit other factors that contribute to tubular dysfunction, such as pathogenic antitubular basement membrane antibodies. The aim of our study was to assess urinary NAG, proteinuria, and glomerular filtration rate (GFR) before treatment and after 7 and 30 days of oral prednisone therapy in patients with lupus nephritis.

METHODS

Ten patients with lupus nephritis, all females, mean age: 29.4 ± 10.17 years, were enrolled into the study. All the patients received oral prednisone 1 mg/kg. Twenty healthy subjects served as controls. We measured urinary NAG before treatment and after 7 and 30 days of oral prednisone therapy. Proteinuria, GFR, blood pressure, and side effects of therapy were also followed up. Urinary NAG was measured using the colorimetrical method and expressed as units per gram of creatinine (U/gCr). Statistical analysis (Wilcoxon signed ranks test and Wilcoxon rank sum test) was performed using SPSS 17.

RESULTS

In the 10 patients with lupus nephritis, urinary NAG before treatment was 16.9 ± 13.39 U/gCr (P = 0.005 compared with controls). NAG in controls was 1.73 ± 0.51 U/gCr. Proteinuria before treatment was 3.84 ± 1.93 g/24 h. The GFR before treatment was 50.48 ± 11.98 mL/min/1.73 m². After 7 days of prednisone, urinary NAG was 23.55 ± 25.25 U/gCr (P = 0.878 compared with baseline, and P = 0.02 compared with controls). Proteinuria was 2.94 ± 1.3 g/24 h (P = 0.005 compared with baseline), and the GFR was 58.11 ± 13.64 mL/min/1.73 m² (P = 0.005 compared with baseline). After 30 days of prednisone, urinary NAG was 11.77 ± 12.18 U/gCr (P = 0.203 compared with baseline, P = 0.022 compared with the value after 7 days of prednisone, and P = 0.01 compared with controls). Proteinuria was 1.73 ± 0.68 g/24 h (P = 0.005 compared with baseline, and P = 0.005 compared with the value after 7 days of prednisone), and the GFR was 67.49 ± 16.42 mL/min/1.73 m² (P = 0.005 compared with baseline and P = 0.009 compared with the value after 7 days of prednisone). Blood pressure measurements did not show any significant changes. No major side effects of steroid therapy were noticed.

CONCLUSIONS

Urinary NAG showed a significant reduction between 7 and 30 days of therapy. The reduction in urinary NAG set in later than the decline in proteinuria and the improvement in GFR. Further studies incorporating a longer follow-up are needed to observe whether the reduction in NAG persists upon continuation of prednisone therapy.

Does the antiviral therapy of patients with chronic hepatitis exert nephrotoxic effects?

INTRODUCTION

HBV and HCV chronic hepatitis can be accompanied by secondary renal disease. In addition, these patients receive antiviral drugs with potential nephrotoxicity. It is known that interferon (IFN) therapy in HCV-infected kidney transplant recipients is followed by rejection of the transplant in 50% of the cases. Ribavirin is contraindicated in hemodialyzed patients and in patients with a GFR <50 ml/min/1.73 m(2). IFN therapy requires dosage reduction and close monitoring in patients with a GFR <50 ml/min/1.73 m(2) and in patients with end stage renal disease. The aim of our study was to assess the nephrotoxicity of antiviral drugs in patients with chronic hepatitis by measuring three renal biomarkers: urinary albumin, N-acetyl-β-D-glucosaminidase (NAG) and α 1-microglobulin, as well as glomerular filtration rate (GFR-MDRD4) before and at 6 months of therapy.

METHODS

Fifty-five patients (28 male and 27 female, with a mean age of 47.85 ± 12.03 years) with chronic hepatitis (40 patients with HCV, 13 patients with HBV, 1 patient with HBV+HCV, and 1 patient with HBV+HDV) were enrolled into the study. Different antiviral drug associations were used on a case-by-case basis. The 40 patients with HCV chronic hepatitis received either Peg-IFN-α 2a+Ribavirin (37 patients) or Peg-IFN-α 2b+Ribavirin (3 patients). The 13 patients with HBV chronic hepatitis received Peg-IFN-α 2a (9 patients), Lamivudine (2 patients), Entecavir (1 patient), or Adefovir (1 patient). The patient with HBV+HCV chronic hepatitis received Peg-IFN-α 2a+Ribavirin. The patient with HBV+HDV chronic hepatitis received IFN-α 2a. Urinary albumin (ELISA), NAG (colorimetrical method), α 1-microglobulin (ELISA), and serum creatinine were measured before and at 6 months of antiviral therapy. Urinary markers were expressed as either mg/gCr (for albumin and α 1-microglobulin) or U/gCr (for NAG). Statistical analysis (Pearson's correlation coefficient, paired t-test and χ(2)-test) was performed.

RESULTS

At 6 months of therapy urinary albumin/gCr did not increase significantly: 16.58 ± 23.39 vs. 15.85 ± 24.96 mg/gCr before therapy, p = 0.87. Urinary NAG/gCr did not increase significantly: 4.21 ± 3.37 vs. 3.83 ± 3.2 U/gCr before therapy, p = 0.53. Urinary α 1-microglobulin/gCr was almost unchanged: 4.38 ± 4.47 vs. 4.38 ± 3.57 mg/gCr before therapy, p = 0.99. The GFR did not decline significantly: 92.41 ± 22.21 vs. 94.59 ± 36.1 ml/min/1.73 m(2) before therapy, p = 0.7. Ten patients (18.18%) were albuminuric before therapy, and 14 patients (25.45%) were albuminuric at 6 months of therapy, a non-significant increase (p = 0.35). We found a correlation between urinary albumin/gCr and NAG/gCr and between urinary albumin/gCr and α 1-microglobulin/gCr both at baseline and at 6 months of therapy: r = 0.54, p = 0.0005; r = 0.29, p = 0.03; r = 0.51, p = 0.0005; and r = 0.4, p = 0.002, respectively. In the patient receiving Adefovir, a known nephrotoxic drug, two of the three biomarkers (urinary albumin/gCr and NAG/gCr) increased, most notably NAG/gCr. Both HCV and HBV chronic hepatitis therapy were associated with non-significant changes in renal biomarker excretion and GFR.

CONCLUSIONS

With the exception of Adefovir, all of the drug associations used in this study were safe.

Diabetic nephropathy and multiorgan protection. Part II

Diabetic nephropathy (DN) presents a complex pathogenesis in which both the vascular system and the metabolism, in its complexity and mainly glucidic metabolism, are involved. Together with the glucid metabolism, lipid metabolism, anemia, oxidative stress, generalised inflammation, vitamin D disorders and smoking participate in DN pathogenesis. All these factors that disturb the homeostasis of the patient with DN require protective factors which will be presented in the second part of the paper. Like hypotensive medication, and especially the inhibitors of the renin angiotensin aldosterone (RAAS) system, antiproteinuric medication, and especially intensive control of glycaemia that have an important protective role, the pathogenic factors mentioned above also require protective measures. As they interest the whole organism in DN and in DM, respectively, we speak about multiple organ protection or multiorgan protection. The concept of multiorgan protection is especially important in DM. Although sometimes, some measures with multiorgan protective character are applied in current practice, it is necessary that they should be gathered and applied within a well established framework, a fact that is achieved by the concept of multiorganprotection. Diabetes mellitus, requires multiple measures of protection because of its vascular and metabolic complications. Diabetic nephropathy represents an important complication of diabetes mellitus, frequently associated with its other complications. The first part of the paper presented the concept of multiorgan protection, as well as some of the main protective measures: control of blood pressure mainly by means of inhibitors of the renine angiotensine aldosterone system, glycaemia monitoring and antiproteinuric treatment. The second part of the paper refers to protective measures used in diabetes mellitus, and diabetic nephropathy, respectively, regarding control of the anaemia, of endothelial disturbances, of the metabolism of lipids, of oxidative stress, of inflammation, smoking, of the metabolism of vitamin D, respectively. Diabetic nephropathy, by the complexity of its lesions, as well as by the complications of diabetes mellitus, cannot be regarded as separate from the organism seen as a unitary whole, a reason because of which the measures of protection are not limited only to the kidney, they must address all organs and metabolism in general, requiring measures of multiorgan protection.

Fifty years of Balkan endemic nephropathy in Romania: some aspects of the endemic focus in the Mehedinti county

Balkan endemic nephropathy (BEN) is a chronic tubulointerstitial nephritis seen primarily in countries in the Balkan Peninsula. The disease, which was first described in Romania 50 years ago, often manifests as a form of chronic nephritis that is also associated with upper urothelial cancers (UUC). This review summarizes the observations and studies performed in Romania regarding this disease during the last 50 years with particular emphasis on Mehedinti county. The paper analyzes current data on the epidemiology of the disease in this area, specifically in relation to the observations made in dialysis centers in the same area. It also discusses the diagnostic criteria of patients with BEN stemming from collaborations between specialists working in other countries affected by the disease. Moreover, the paper analyzes the main etiological factors suspected to play a role in BEN: aristolochic acid (the disease has many similarities to aristolochic nephropathy caused by Chinese herbs), mycotoxins, toxic substances from pliocene lignite, genetic factors, and viruses. Studies performed by Romanian authors are presented briefly in comparison to studies performed by other authors. Finally, given that BEN is an important health problem in the region, the relationship between BEN and UUC is further analyzed.

Estimated glomerular filtration rate in patients with surgically acquired single kidney compared with patients with congenital single kidney: implications for kidney transplant from live donors

OBJECTIVES

The pathophysiology of the single kidney is involved in the evolution toward endstage renal disease. Furthermore, most data suggest that the renal function of the donor is maintained after nephrectomy. This study sought to analyze the difference between surgically acquired single kidney and the congenital single kidney, regarding kidney function at a similar moment in time of the existence of a single kidney.

MATERIALS AND METHODS

Two groups were enrolled in this study. Group A consisted of 28 patients with surgically acquired single kidney, time from nephrectomy was 30.23 +/- 10.82 years; mean age, 54.42 +/- 14.99 years. Group B consisted of 20 patients with a congenital single kidney (mean age, 30.3 +/- 10.43 years). We assessed glomerular filtration rate (Modification of Diet in Renal Disease 4 Study Equation) and the presence of classic and nonclassic risk factors for chronic kidney disease.

RESULTS

The estimated glomerular filtration rate showed no statistically significant difference between the 2 groups.

CONCLUSIONS

Our study did not show any influence of surgical nephrectomy on the evolution of kidney function. Kidney function in the surgically acquired single kidney was similar to the kidney function in the congenital single kidney at a comparable time interval. Our results have potential favorable implications for kidney transplant from living donors.

Therapeutic remedies based on Aristolochia clematitis in the main foci of Balkan endemic nephropathy in Romania

Balkan endemic nephropathy (BEN) is a disease found in Romania and neighboring countries in the Balkan area. In Romania, BEN is most prevalent in Mehedinti County, located in the South of Romania near the Danube River. The etiology of the disease is as yet unknown. One of the current hypotheses concerning BEN etiology is an involvement of aristolochic acid (AA). BEN bears many similarities to aristolochic nephropathy, which is developed due to the use of Chinese herbs as therapeutic remedies in slimming diets. This paper analyzes the involvement of therapeutic remedies based on AA in the BEN found in Mehedinti County, where these herbs have been traditionally used. The presence of AA in the plasma of BEN patients as well as of other subjects, including healthy relatives of these patients and other persons from the BEN-affected area, has been analyzed. No AA was detected in the plasma of the studied subjects. This proves the absence, at the current time, of an AA contribution in the analyzed subjects. Therapeutic remedies based on AA have been used in the BEN-affected area. We were not able to reveal direct relationships between these remedies and either the development of BEN in dialyzed patients or the development of urinary-tract tumors in dialyzed patients with urothelial tumors. Therapeutic remedies based on Aristolochiaclematitis may play a stimulating role in BEN with regard to its development and the development of urinary-tract tumors. There may be a relationship between BEN and cumulative previous exposure to low doses of AA due to the consumption of contaminated foodstuffs, which could add to any contributions by therapeutic remedies.

Treatment of systemic lupus erythematosus in two patients with extreme B-cell lymphopenia: importance of immunomonitoring and avoidance of B-cell targeted therapy

INTRODUCTION

Because dysfunction of the B-cell compartment is thought to be important in the pathogenesis of systemic lupus erythematosus (SLE), there has been a recent focus on therapies that target humoral immunity via multiple mechanisms. The aim of this paper was to demonstrate the importance of immunomonitoring in two cases with class II lupus nephritis on steroids who presented with a flare-up of disease. After a thorough work-up for infectious triggers of disease activity, conversion to another histopathological class of lupus nephritis was suspected. Deterioration of the patients' clinical condition made kidney biopsy impossible, and as B-cell targeted therapy was considered, we decided to perform an immunophenotypic analysis and to tailor therapy to the results of the lymphocyte profile. As we incidentally found extremely low B-cell counts, any B-cell-targeted therapy was prohibited, and cyclophosphamide (Cy) was considered a viable therapeutic option.

METHODS

We performed flow-cytometric lymphocyte (Ly) phenotyping (CD19, CD3, CD3CD4, CD3CD8, CD56/16) on two patients with class II lupus nephritis before and after two intravenous (i.v.) Cy pulse administrations. During all this time, patients were on steroids.

RESULTS

 Both patients showed extreme B-cell lymphopenia, a marker of active SLE, which was not greatly impacted by the treatment over the follow-up period.

CONCLUSIONS

As current therapies are aimed at targeting the B cell, an important component of adaptive immunity, caution must be exercised before their use. In addition, monitoring of Ly subsets is essential due to the occurrence of extreme B-cell lymphopenia.

What is the significance of CD34 immunostaining in the extraglomerular and intraglomerular mesangium?

CD34, traditionally a marker of hematopoietic stem cells (HSCs), was found on endothelial cells and fibroblasts as well. At the level of the extraglomerular or intraglomerular mesangium, CD34 may signal either the presence of HSCs or, conversely, may be a marker of transdifferentiation. CD34-positive cells of the extraglomerular mesangium could migrate into the intraglomerular mesangium and participate in reparative processes at this level. The aim of our study was to analyze the presence of CD34 at the level of the extraglomerular and intraglomerular mesangium and its relationship with histological markers of activity and chronicity, as well as with other immunohistochemical markers in glomerulonephritis (GN). A cross-sectional study of 36 patients with GN was conducted. Conventional stains: hematoxylin-eosin, periodic acid Schiff, and Trichrome Gömöri, as well as immunohistochemistry: CD34, alpha smooth muscle actin (alpha SMA), vimentin, and proliferating cell nuclear antigen (PCNA) were employed. Activity and chronicity of GN were evaluated according to a scoring system initially used for lupus nephritis and antineutrophil-cytoplasmic-antibody-associated vasculitis. Immunohistochemistry was assessed using a semiquantitative score. The mean age was 46.44 +/- 12.97 years; 22 were male and 14 were female. The extraglomerular mesangium was visible on specimens in 30 patients. CD34 was present in the extraglomerular mesangium in 15 patients: 11 of these patients showed concomitant intraglomerular and extraglomerular mesangial CD34 immunostaining, while four showed only extraglomerular mesangial immunostaining. In three patients, CD34 immunostaining was present only in the intraglomerular mesangium. Twelve patients showed negative immunostaining in both the extraglomerular and the intraglomerular mesangium. Overall, there was a fair degree of relationship, which did not reach statistical significance between CD34 in the extraglomerular mesangium and CD34 in the intraglomerular mesangium across the 36 patients. In the intraglomerular mesangium, CD34 did not significantly correlate with mesangial alpha SMA, vimentin, PCNA, and activity or chronicity index. In the extraglomerular mesangium, CD34 did not show a significant correlation with alpha SMA, vimentin, or PCNA. The activity index and the chronicity index showed a good correlation with serum creatinine. Mesangial cell proliferation correlated well with the mesangial matrix increase, while interstitial vimentin showed a good correlation with interstitial alpha SMA. We demonstrated the presence of CD34 in the extraglomerular mesangium, which could be related to transdifferentiated mesangial cells or to HSCs in the absence of blood vessels at this level. Our study shows the value of histological indices for evaluating GN but cannot assign significance to CD34 immunolabeling for the assessment of GN.

Multiorgan-protective actions of blockers of the renin-angiotensin system, statins and erythropoietin: common pleiotropic effects in reno-, cardio- and neuroprotection

Renal diseases induce nephroprotective measures that may affect the heart, brain and other organs. In addition, many cardiovascular and neurological diseases are accompanied by renal lesions. For these reasons, multiorgan-protective measures, including cardio-, reno- and neuro-protective measures, are necessary to treat these diseases. The drugs used in nephrology are often pleiotropic. Although they usually address a single organ or tissue, many of them have complex actions that may provide multiorgan-protection. The present paper aims to review 3 classes of drugs that are commonly prescribed in nephrological practice: statins, RAS blockers (such as ACEIs and ARBs) and erythropoietin (EPO). This paper highlights the renoprotective actions, as well as those that are protective of the heart, brain and other organs, of these drugs at the cellular and molecular level. Their protective actions are attributable to their main effects and pleiotropic effects. The protective pleiotropic actions of these drugs may be exerted on multiple organs, making them multiorgan-protective. Another objective is to analyse the shared multiorgan-protective pleiotropic effects of RAS blockers (ACEIs and ARBs), statins and erythropoietin. This will allow for the practical association of the main renoprotective drugs with multiorgan protection.

Histological, immunohistochemical and biological data in assessing interstitial fibrosis in patients with chronic glomerulonephritis

The aim of this study was to determine the relationship between histological, immunohistochemical (IHC) and biological data in the assessment of interstitial fibrosis in patients with glomerular diseases. A group of 41 patients with primary and secondary glomerulonephritis was studied. In order to quantify the histological changes and to assess the extent of active-inflammatory and chronic-sclerotic/fibrotic interstitial lesions, we adapted a scoring system, initially used for lupus nephritis, and ANCA-associated vasculitis. IHC labeling procedures with monoclonal antibodies anti-smooth muscle actin (SMA), anti-vimentin and anti-transforming growth factor beta (TGFbeta) were assessed using a semi-quantitative score, correlated with the histological and biological data. Our results showed that interstitial labeling of SMA correlated with scores for sclerotic/fibrotic lesions (chronicity index) and with active-inflammatory lesions (interstitial infiltrate, activity index). Interstitial vimentin correlated with the score for interstitial infiltrate. Both interstitial vimentin and TGFbeta immunopositivity correlated with sclerotic/fibrotic lesions (interstitial fibrosis, tubular atrophies, vascular hyalinosis/fibrosis, chronicity index), and negatively with glomerular filtration rate. An important correlation was found between the interstitial labeling of the two IHC markers of myofibroblasts (SMA and vimentin). We conclude that IHC studies related to clinico-biological and histological data can have an important role in the evaluation of the glomerular diseases, but the classical histological investigation assessed through quantification has still not lost its importance.

Cerebrovascular reactivity is impaired in patients with non-insulin-dependent diabetes mellitus and microangiopathy

BACKGROUND

Cerebrovascular reactivity (CVR) is a hemodynamic parameter representing the increase in normal cerebral artery blood flow in response to a vasodilatory stimulus such as hypercapnia.

MAIN PURPOSE

The aim of the study was to assess CVR using transcranial Doppler ultrasound and the breath-holding test (BHT) in normotensive patients with non-insulin-dependent diabetes mellitus (NIDDM). The cerebrovascular response to hypercapnia was evaluated in relation to risk factors for cerebral microangiopathy.

METHODS

The study was carried out in a group of 34 normotensive NIDDM patients and a group of 31 sex- and age-matched normal controls. The NIDDM group was subdivided into 21 patients with microangiopathic complications (Group A, 12 men, 9 women; mean age 58.77 +/- 8.91 years) and 13 patients with no such complications (Group B, 8 men, 5 women; mean age 56.34 +/- 9.83 years). The control group comprised 17 men and 14 women (Group C, mean age 58.43 +/- 6.31 years). Exclusion criteria were hypertension and past or present symptomatic cerebrovascular disease. The BHT consisted of spontaneous hypercapnia induced by holding the breath for 20 seconds. CVR was estimated in relation to the increase in the mean flow velocity (MFV) compared with the basal velocity in both middle cerebral arteries during hypercapnia.

RESULTS

In Group A, the CVR was significantly decreased in 71.42% of patients, whereas in Group B only 30.76% of patients presented with mildly to moderately impaired CVR. Predictors for impaired % increase in the MFV during the BHT demonstrated by univariate regression analysis were: duration of diabetes (r = 0.802; P < 0.0001), fibrinogen (r = 0.574; P < 0.0001), C-reactive protein (r = 0.525; P < 0.001), proteinuria (r = 0.924; P < 0.0001) and serum creatinine (r = 0.969; P < 0.0001). Multivariate regression analysis showed as predictors: duration of diabetes (P < 0.0001), proteinuria (P < 0.0001) and serum creatinine (P < 0.0001).

CONCLUSION

CVR is impaired in normotensive NIDDM patients. These cerebral hemodynamic changes correlate significantly with the duration of DM, parameters of inflammation, proteinuria and serum creatinine.

The effect of steroids on lymphocyte profile in primary chronic glomerulonephritis. Empirical or tailored therapy?

Steroids are still the mainstay of therapy in primary chronic glomerulonephritis (PCGN), regardless of underlying disturbance or pathology. Moreover, relationship between known abnormalities and disease manifestation is stochastic, therefore treatment continues to be empirical. It is not known whether responsiveness is related to immune phenotype. We performed flowcytometric lymphocyte (Ly) phenotyping (CD19, CD3, CD3CD4, CD3CD8, CD56/16) on 16 patients (pts) (12M, 4F), mean age 37.6+/-13 years with primary chronic glomerulonephritis (PCGN): minimal change disease (MCD)--6 pts, focal and segmental glomerulosclerosis (FSGS)--4 pts, mesangial proliferative glomerulonephritis--5 pts, mesangiocapillary glomerulonephritis--1 pt, before and at 7 days of oral Prednisone 1 mg/kg/day (in 2 divided doses). Before steroids: 4/16 pts(25%) had elevated BP; 9/16(56.2) showed nephrotic proteinuria. Serum creatinine was >1.2 mg% in 6/16(37.5%). At 7 days WBC count increased (13,079.37+/-4966.4/microl vs. 8021.25+/-2077.4/microl; p=0.0007), Ly percentage (%) decreased (20.30+/-9% vs. 29.9+/-10.4%; p=0.0095), while absolute (abs.) Ly count remained unchanged. Both CD19 Ly% and CD19 Ly abs. count increased (16.13+/-6.5% vs. 9.52+/-3.7%; p=0.0015, and 410.012+/-29.7/microl vs. 223.56+/-123.8/microl; p=0.0077, respectively). NK (natural killer)% decreased (9.15+/-5.2% vs. 14.19+/-7.1%; p=0.0296). CD3, CD3CD4, CD3CD8 Ly subsets and CD4/CD8 ratio showed no change. Variation in proteinuria (2.88+/-2.1 g/24 h vs. 3.45+/-1.7 g/24 h; p=0.4) did not reach statistical significance (Wilcoxon-Mann-Whitney). In 11 pts we performed an additional analysis at 1 month. Compared to levels before steroids, there was an increase in WBC, CD19 Ly% and CD19 Ly abs. count and a decrease in NK% and NK abs. count. Other Ly subsets and CD4/CD8 ratio remained unchanged. Variation in clinical parameters (proteinuria, serum Creatinine, BP) did not reach statistical significance. Changes in Ly profile precede changes in clinical parameters and thus are divergent. While our patients proved to be early non-responders, further studies to elucidate whether profile changes provide for response specification are warranted.

Cerebral Microangiopathy in Patients with Non-insulin-dependent Diabetes Mellitus

Introduction: The aim of the study was to evaluate cerebral microangiopathy in type 2 non-insulin-dependent diabetes mellitus (NIDDM) patients and to establish potentially conducive factors. Materials and Methods: A group of 34 patients with NIDDM and 31 gender- and age-matched normal controls (NC) were assessed by extracranial Doppler ultrasound, in order to evaluate the pulsatility index (PI) and the resistance index (RI) in the internal carotid arteries (ICAs); transcranial Doppler was utilised to assess the same parameters in the middle cerebral arteries (MCAs). All patients underwent screening for favouring factors for cerebral vascular remodelling. Results: Of the 34 NIDDM patients, 21 patients (61.76%) (subgroup A) presented with microangiopathic complications [of these, 19 patients (90.46%) had diabetic nephropathy (DN)] versus 13 NIDDM patients (38.24%) (subgroup B) without complications. In subgroup A, 16 patients (76.19%) had PI >1 and RI >0.7 in the ICAs and MCAs (changes consistent with cerebral microangiopathy) versus 5 patients (35.46%) in subgroup B, and no modifications in NC. Of the 19 patients with DN, 14 patients (73.68 %) had impaired haemodynamic indices. Univariate regression analysis showed the following risk factors for the cerebral haemodynamics changes: fibrinogen (F) (OR = 3.11), C-reactive protein (CRP) (OR = 2.40), duration of DM (OR=2.40), proteinuria (OR = 1.80), serum creatinine (OR = 1.66). Multivariate regression analysis showed as predictors for impaired haemodynamic indices: duration of DM (HR =1.70), proteinuria (HR = 1.70). The haemodynamic indices in the ICAs correlated with duration of DM (r = 0.87, P <0.0001), F (r = 0.86; P <0.0001), CRP (r = 0.80; P <0.0001); in the MCAs with the duration of DM (r = 0.66, P <0.0001), F (r = 0.38; P <0.0001), CRP (r = 0.88; P <0.0001). Conclusion: Cerebral microangiopathy has a high prevalence in NIDDM patients. These cerebral vascular changes correlate with the duration of DM, parameters of inflammation, and proteinuria. Key words: Cerebral microangiopathy, Diabetic nephropathy, Doppler ultrasound, Non-insu-lin-dependent diabetes mellitus, Risk factors

Cerebral microangiopathy in patients with non-insulin-dependent diabetes mellitus

INTRODUCTION

The aim of the study was to evaluate cerebral microangiopathy in type 2 noninsulin- dependent diabetes mellitus (NIDDM) patients and to establish potentially conducive factors.

MATERIALS AND METHODS

A group of 34 patients with NIDDM and 31 gender- and agematched normal controls (NC) were assessed by extracranial Doppler ultrasound, in order to evaluate the pulsatility index (PI) and the resistance index (RI) in the internal carotid arteries (ICAs); transcranial Doppler was utilised to assess the same parameters in the middle cerebral arteries (MCAs). All patients underwent screening for favouring factors for cerebral vascular remodelling.

RESULTS

Of the 34 NIDDM patients, 21 patients (61.76%) (subgroup A) presented with microangiopathic complications [of these, 19 patients (90.46%) had diabetic nephropathy (DN)] versus 13 NIDDM patients (38.24%) (subgroup B) without complications. In subgroup A, 16 patients (76.19%) had PI >1 and RI >0.7 in the ICAs and MCAs (changes consistent with cerebral microangiopathy) versus 5 patients (35.46%) in subgroup B, and no modifications in NC. Of the 19 patients with DN, 14 patients (73.68 %) had impaired haemodynamic indices. Univariate regression analysis showed the following risk factors for the cerebral haemodynamics changes: fibrinogen (F) (OR = 3.11), C-reactive protein (CRP) (OR = 2.40), duration of DM (OR = 2.40), proteinuria (OR = 1.80), serum creatinine (OR = 1.66). Multivariate regression analysis showed as predictors for impaired haemodynamic indices: duration of DM (HR =1.70), proteinuria (HR = 1.70). The haemodynamic indices in the ICAs correlated with duration of DM (r = 0.87, P <0.0001), F (r = 0.86; P <0.0001), CRP (r = 0.80; P <0.0001); in the MCAs with the duration of DM (r = 0.66, P <0.0001), F (r = 0.38; P <0.0001), CRP (r = 0.88; P <0.0001).

CONCLUSION

Cerebral microangiopathy has a high prevalence in NIDDM patients. These cerebral vascular changes correlate with the duration of DM, parameters of inflammation, and proteinuria.

The success story of peritoneal dialysis in Romania: analysis of differences in mortality by dialysis modality and influence of risk factors in a national cohort

BACKGROUND

This report describes the status of renal replacement therapy (RRT), particularly continuous ambulatory peritoneal dialysis (CAPD), in Romania (a country with previously limited facilities), outlines the fast development rate of CAPD, and presents national changes in a European context.

METHODS

Trends in the development of RRT were analyzed in 2003 on a national basis using annual center questionnaires from 1995 to 2003. Survival data and prognostic risk factors were calculated retrospectively from a representative sample of 2284 patients starting RRT between 1 January 1995 and 31 December 2001 (44% of the total RRT population investigated).

RESULTS

The annual rate of increase in the number of RRT patients (11%) was supported mainly by an exponential development of the CAPD population (+600%); the hemodialysis (HD) growth rate was stable (+33%) and renal transplantation had a marginal contribution. The characteristics of both HD and PD incident patients changed according to current European epidemiology (increasing age and prevalence of diabetes and nephroangiosclerosis). There were significant differences between PD and HD incident populations, PD patients being significantly older and having a higher prevalence of diabetic nephropathy and baseline comorbidities, probably reflecting different inclusion policies. The estimated overall survival of RRT patients in Romania was 90.6% at 1 year [confidence interval (CI) 89.4 - 91.8] and 62.2% at 5 years (CI 59.4 - 65.0). The initial treatment modality did not significantly influence patients' survival. There was no difference in unadjusted technique survival during the first 2 years; afterwards, there was a clear advantage for HD, with more patients being transferred from PD to HD. Several factors seemed to significantly and negatively influence PD patients' survival (Cox regression analysis): male gender, lack of predialysis erythropoietin treatment, and initial comorbidities. Stratified analysis to discover the influence of these factors on patients' survival revealed that HD was associated with an increased risk of death in the younger nondiabetic end-stage renal disease population, regardless of other coexisting comorbid conditions. However, in older patients (>65 years) and in diabetics, regardless of the presence or absence of associated comorbid conditions, there was no significant difference in death rates between HD and PD patients.

CONCLUSIONS

We report an impressive quantitative and qualitative development of CAPD in one of the rapidly growing Central and Eastern Europe countries. CAPD should be the method of choice for young nondiabetic end-stage renal disease patients. Improvement in predialysis nephrologic care and in transplantation rates is required to further ensure the ultimate success of the Romanian PD program.