Glomerular expression of matrix metalloproteinases in systemic lupus erythematosus in association with activity index and renal function

Purpose: The aim of this study was to examine the expression of matrix metalloproteinases (MMPs) MMP-1, MMP-2, MMP-3, MMP-9, and their specific tissue inhibitor TIMP-1 in kidney biopsies of patients with lupus nephritis (LN) and to investigate the relationship between MMPs, activity index, and renal function at the time of kidney biopsy.

Methods: We performed immunohistochemistry with monoclonal antibodies against MMP-1, MMP-2, MMP-3, MMP-9, and TIMP-1 in 58 kidney-biopsy specimens with LN (according to the 2004 ISN/RPS classification) and eight specimens from normal kidney tissue. We used clinical data of 36 patients at the time of kidney biopsy to evaluate the association between MMPs expression and renal function.

Results: We found increased MMP-1, MMP-2, and MMP-3 expression in LN glomeruli and a significant correlation with the activity features, with higher activity index score and worse renal function (p < .001). In particular, we have noticed a significant correlation of MMP-1 with leukocyte influx (OR:16.5 95%CI 4.3–62.5 p < .001), and MMP-3 with glomerular hypercellularity (OR:18.6 95%CI 4.8–72.8 p < .001). Moreover, we found a strong correlation of MMP-2 expression with fibrinoid necrosis and cellular crescents formation (OR:17.1 95%CI 4.3–67.7 p < .001).

Conclusions: MMP expression in renal biopsy of patients with LN is increased and directly related to a highly active inflammatory response. Moreover, stronger MMP expression is associated with higher activity index and a more profound renal dysfunction.

Oxalate nephropathy in a diabetic patient after gastric by-pass

We report a case of 48-year-old woman with history of diabetes and hypertension, who presented with acute to chronic kidney injury. Sixteen months before presentation, she had undergone Roux-en-Y gastric by-pass (RYGB) for morbid obesity. Kidney biopsy showed lesions consistent with oxalate nephropathy and deposition of calcium oxalate crystals. An extensive workshop excluded other causes of kidney injury. The patient subsequently required dialysis with no improvement of renal function on follow-up. The mechanism by which patients develop hyperoxaluria after RYGB remains obscure; it is suggested that RYGB provokes fat malabsorption, which results in increased load of free fatty acid in the intestine. Thus, calcium binds to free fatty acids provoking reduced synthesis of calcium oxalate. Consequently, increased quantity of oxalate remains free and is absorbed in the intestine causing hyperoxaluria. Similar to our case, oxalate nephropathy after RYGB is seen in patients with diabetes, hypertension and chronic kidney injury. Treatment includes low-fat, low-oxalate diet along with administration of calcium supplements. Unfortunately, prognosis is rather poor with the majority of patients eventually requiring permanent dialysis. Therefore, patients with history of chronic kidney disease undergoing RYGB should be closely monitored, particularly those with long standing history of diabetes and hypertension.

Severe acute renal failure in a 19-year-old woman following laparoscopic cholecystectomy

A case of severe acute renal failure in a young female patient necessitating renal replacement therapy after laparoscopic cholecystectomy is described. The histology of the renal lesion assigned to the effects of laparoscopic surgery is relevant for the pathogenesis of renal complications after such procedures. This explains part of the pathogenesis of the ischemic lesions in kidney structure that increased intra-abdominal pressure can provoke. Emphasis is given on the prevention of such side effects.

Sclerosing encapsulating peritonitis secondary to CAPD: the effect of fibrotic debridement on further dialysis

BACKGROUND

Sclerosing peritonitis (SCP) is a complication of continuous ambulatory peritoneal dialysis (CAPD) and is characterized by progressive fibrosis of the peritoneum. Entrapment of the intestine in a fibrous sac resulting in complete intestinal obstruction is called sclerosing-encapsulating peritonitis (SEP) and represents the most severe form of the disease. Various reports have been pessimistic regarding the surgical outcome when SEP has caused complete intestinal obstruction. Continuation of CAPD after laparotomy is generally considered not feasible. The aim of this article is to present our experience in the surgical management of SEP and, in particular, in the postoperative continuation of CAPD.

MATERIAL AND METHODS

Seventeen consecutive patients with SCP among 175 patients undergoing CAPD during a period of 14 years in a single Unit were retrospectively reviewed. Two groups of patients were recognized. The SCP group included 9 patients with incomplete intestinal obstruction that were treated with single peritoneal catheter removal and switching to haemodialysis. The SEP group included 8 patients with complete obstruction that necessitated laparotomy for surgical debridement of the fibrotic tissue and release of the intestinal loops.

RESULTS

Switching to haemodialysis improved the majority of the group of patients. In 2 of the SEP group of patients (early in the series), where enterectomy was inevitable, performance of an intestinal anastomosis resulted in leakage with subsequent fatal outcome. Two of the SEP group of patients were transferred to haemodialysis after the laparotomy. In the remaining 4 SEP patients (50%), exposure of a significant portion of active peritoneal surface was achieved - called "neoperitonization"-and allowed effective continuation of peritoneal dialysis for an average duration of 16 months (range 1-32).

CONCLUSIONS

In patients with SEP, careful release of the intestinal loops avoiding enterectomies and even inadvertent intestinal wounds is mandatory. Continuation of peritoneal dialysis after meticulous debridement and removal of the fibrotic tissue is possible and may be effective. To the best of our knowledge, there have not been previously reported cases of continuations of CAPD after laparotomy for SEP.

Renal involvement in Adamantiades-Behçet's disease. Case report and review of the literature

A patient with Adamantiades-Behçet's disease with renal involvement is reported. This patient fulfilled the International Study Group criteria for the disease. Kidney biopsy was performed and proliferative glomerulonephritis with deposition of IgA and IgM immunoglobulins were demonstrated. Review of the literature demonstrates that renal involvement in this disease is not so rare as it was believed. Crescent formation and IgA nephropathy are infrequently observed. Treatment of renal involvement may require immunosuppressive drugs.

HLA-TNF haplotype heterogeneity in Greek SLE patients

OBJECTIVE

To examine TNF microsatellite allele frequencies in SLE patients in the Greek population, where disease susceptibility is less associated with HLA-DR3 haplotypes.

METHODS

A cohort of 46 Greek SLE patients were investigated. Allele frequencies for the TNF microsatellite markers a, b, c and d were determined using a fluorescence based DNA fragment sizing technique. HLA class II typing was performed using a molecular based technique.

RESULTS

Associations between SLE and DRB1*1501, *1601 and *0701 were observed and DRB1*0301 was only marginally increased in patients. Linkage disequilibrium was found between DRB1*1501 and TNF a11 and also for DR3 and TNF a2, b3, d2. Stratification of patients suggested that DRB*1501 and TNF a11 frequencies were higher in SLE patients with renal disease and TNF a2 and b 3 frequencies in those without, although these differences did not reach statistical significance.

CONCLUSIONS

SLE in this Greek population appears to be associated with a number of HLA-DRB1 alleles. The development of renal complications in these patients may be related to the TNF polymorphism encoded on these HLA haplotypes.

HLA antigens in microscopic polyarteritis (MP) with renal involvement

Serological HLA-A, B, C, DR and DQ typing was performed in 23 patients with microscopic polyarteritis and renal involvement and in 405 healthy individuals, all of Greek origin. An increased frequency of HLA-A26 (26% vs. 11.3%, x2 = 4.423, p < 0.05) and HLA-A11 (26% vs. 9.6%, x2 = 6.825, P < 0.02), and a decreased frequency of HLA-DR3 (4.3% vs. 24.1%, x2 = 5.935, p < 0.025) were found. Five out of six patients, who did not respond to treatment possessed HLA-DR5. These observations suggest that HLA gene products may influence the clinical expression, as well as the outcome of this disease.