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.

Monitoring of patients with type 2 diabetes and nephropathy in a specialized diabetic nephropathy clinic seems to be beneficial

BACKGROUND

The purpose of this study was to evaluate the outcome of DM2 patients with nephropathy when they are under surveillance of a joined clinic run by endocrinologists & nephrologists.

PATIENTS AND METHODS

A cohort of 106 patients with DM2, 42-83 years of age, and eGFR < 60 ml/min/m² were included. Age, sex, duration of diabetes, duration of attending our clinic, smoking habits, BMI, data regarding ischemic heart disease and induction of hemodialysis, urine albumin excretion (UAE) levels, eGFR (MDRD equation) and values of various biochemical parameters were recorded too. Follow-up period ranged from one to 25 years. Paired samples t-test and non-parametrical Kruskal-Wallis test were used for the analyses of the data.

RESULTS

Fifty percent of patients had no further progression, 25.9% improvement, while 24.1% had worsening of the UAE levels. During the follow-up in the joined clinic, there was a smaller than the expected from the medical literature decrease in median eGFR, i.e. 2,3 ml/min/m² and a statistically significant improvement in glycosylated hemoglobin levels from 8.0% to 7.4% (p = 0.016). Time in years of follow-up in the joined clinic of our hospital appeared to be the most significant factor in the improvement or stabilization against deterioration of the UAE levels (p = 0.018).

CONCLUSIONS

Close follow-up of DM2 patients with eGFR < 60 ml/min/m² has resulted in a minor annual eGFR decrease. Monitoring of these patients in a specialized diabetic nephropathy clinic is beneficial for this group of patients for delaying the occurrence of end-stage renal disease.

IgA nephropathy in Greece: data from the registry of the Hellenic Society of Nephrology

Background

Natural history, predisposing factors to an unfavourable outcome and the effect of various therapeutic regimens were evaluated in a cohort of 457 patients with immunoglobulin A nephropathy (IgAN) and follow-up of at least 12 months.

Methods

Patients with normal renal function and proteinuria <1 g/24 h as well as those with serum creatinine (SCr) >2.5 mg/dL and/or severe glomerulosclerosis received no treatment. Patients with normal or impaired renal function and proteinuria >1 g/24 h for >6 months received daily oral prednisolone or a 3-day course of intravenous (IV) methylprednisolone followed by oral prednisolone per os every other day or a combination of prednisolone and azathioprine. The clinical outcome was estimated using the primary endpoints of end-stage renal disease and/or doubling of baseline SCr.

Results

The overall 10-year renal survival was 90.8%, while end-stage renal disease and doubling of baseline SCr developed in 9.2% and 14.7% of patients, respectively. Risk factors related to the primary endpoints were elevated baseline SCr, arterial hypertension, persistent proteinuria >0.5 g/24 h and severity of tubulointerstial fibrosis. There was no difference in the clinical outcome of patients treated by the two regimens of corticosteroids; nevertheless, remission of proteinuria was more frequent in patients who received IV methylprednisolone (P = 0.000). The combination of prednisolone with azathioprine was not superior to IV methylprednisolone followed by oral prednisolone. Side effects related to immunossuppressive drugs were observed in 12.8% of patients.

Conclusion

The clinical outcome of patients with IgAN was related to the severity of clinical and histological involvement. The addition of azathioprine to a corticosteroid-based regimen for IgAN does not improve renal outcome.

Immunologic prognostic factors of renal allograft survival

INTRODUCTION

Successful outcome of renal transplantation depends on various factors, of which immunologic is one of the most important. Accumulated experience of a single center, with the same surgical and immunological team contributes significantly to safe conclusions. Purpose of this study was the evaluation of potential factors, in particular immunologic, that influence renal allograft survival.

PATIENTS AND METHODS

During the period 1991-2013, 20,784 surgical operations have been performed in our Department of Surgery - Transplant Unit, of which 575 were renal transplantations. We examined donor and recipient demographic factors, immunologic characteristics along with patient and graft survival.

RESULTS

Renal allograft was retrieved from living-related donor in 103 cases and in 472 from cadaveric donor. Donor age was 46.7 ± 18.5 years old and 49.9% (287) were male. Recipient age was 48 ± 12.3 years old and 402 were male. HLA histocompatibility was carefully matched resulting in 85.5% renal transplants with 2-4 HLA mismatches and 93.8% renal transplants with at least one HLA-DR. Renal graft survival the first, fifth and tenth year was 89%, 76%, and 67% and patient survival was respectively 95%, 89% and 83%. Statistical analysis revealed that only donor age influenced renal graft survival (P < .05). HLA mismatches were not correlated with graft survival (log rank P = .495), but identification of panel reactive antibodies (PRA) class I and class II post transplantation had a statistically significant impact on long term renal graft survival (log rank P < .001 and P = .021, accordingly).

CONCLUSIONS

Analysis of potential prognostic factor showed that only donor age was correlated with allograft survival. Development of PRA following renal transplantation influenced long term graft survival. Good HLA matching with at least one HLA DR resulted in excellent graft and patient survival.

Progression of coronary artery calcification after kidney transplantation

Calcification of coronary vessels progresses rapidly in hemodialysis (HD) patients and comprises a strong predictor of cardiovascular events. The aim of this prospective study was to evaluate the coronary artery calcification (CAC) in patients with end stage renal disease undergoing regular HD and to determine the effect of renal transplantation (RT) in the progression of CAC, using the Agatston technique for calcium scoring. The study included 20 patients with end-stage renal disease undergoing a regular HD treatment (16 males, 4 females) 54.1 ± 9.5 years old who had just received a renal transplant and 16 more HD patients (11 males, 5 females) 54.4 ± 13.8 years old as control group. The baseline evaluation showed a very high prevalence of CAC in both groups, which was positively correlated with age (p < 0.001) and CRP (p = 0.03). The second (follow-up) evaluation showed a significant slower progression of calcification after RT. In both groups, high calcium score values in the follow-up evaluation had a strong positive correlation with baseline calcium score (p < 0.001).

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.

Prospective monitoring of BK virus replication in renal transplant recipients

BACKGROUND

BK virus-associated nephropathy (BKVAN) can be diagnosed only with renal graft biopsy. Definitive diagnosis of BKVAN requires demonstration of BK virus (BKV) replication in renal allograft tissues. Non-invasive analysis of urine and blood is considered essential in screening renal transplant recipients.

PATIENTS AND METHODS

This study evaluated prospectively the replication of BKV in plasma and urine with qualitative and quantitative real-time polymerase chain reaction in 32 de novo (group A) and 34 chronic (group B) renal transplant recipients and the long-term impact on graft function.

RESULTS

In group A, 456 samples (228 plasma, 228 urine) were examined and BKV was detected in 31 (31/228, 14%) samples of plasma and 57 (57/228, 25%) samples of urine in 20 (20/32, 62.5%) and 23 (23/32, 72%) recipients, respectively. Incidence of viremia and viruria increased during the first 6 months presenting a peak the third postoperative month (viremia: 28% and viruria: 31%). Immune suppressive treatment with tacrolimus showed significant relation with viremia. Renal graft function in de novo renal transplant recipients remained stable throughout the follow-up period without influence of BKV replication. In group B, incidence of viremia and viruria were 3% (1/34) and 9% (3/34) correspondingly, indicating that after the first post-transplant year the risk of BKV re-activation is diminished.

CONCLUSION

The highest incidence of BK viremia and viruria is observed the third post-transplantation month, confirming previously published studies in Europe and the United States, and long-term follow up shows that BKV replication decreases significantly after the third post-transplant month and even transient viremia or viruria does not have an impact on renal function.

Heparin-induced thrombocytopenia type II: a serious hazard in preemptive renal transplantation: a case report

Heparin-induced thrombocytopenia (HIT) type II (HIT II), is an immune-mediated complication of heparin therapy, associated with arterial and venous thrombosis. Herein we have reported a case of a 23-year-old woman who developed HIT following a living related donor, preemptive, renal transplantation. The patient was preoperatively exposed to both unfractionated and low-molecular-weight heparin as she underwent five hemodialysis sessions. HIT caused right common and external iliac vein and renal graft artery thrombosis, resulting in graft loss. Heparin-free hemodialysis was continued, and the patient was successfully treated with anticoagulation by the direct thrombin inhibitor lepirudin for both the thromboses and for hemodialysis. Finally, she was accepted for the continuous ambulatory peritoneal dialysis program. This report highlighted the importance of clinical awareness as far as previous heparin exposure is concerned for establishing an early diagnosis and delivering treatment of this life-threatening prothrombotic complication of heparin administration.

Hypercalcemia Due to Resistant Hyperparathyroidism in Renal Transplant Patients Treated With the Calcimimetic Agent Cinacalcet

INTRODUCTION AND AIMS

Calcimimetic agents increase the sensitivity of calcium-sensing receptors of parathyroid glands and suppress both serum calcium levels and parathyroid hormone (PTH). The use of these drugs in patients with a functioning graft suffering from resistant hyperparathyroidism and hypercalcemia is still under investigation. We report seven patients who were treated with the calcimimetic agent cinacalcet.

METHODS

The four male and three female patients of 38 to 72 years of age received a renal transplant from 4 to 35 months before cinacalcet treatment. Serum creatinine was 1.2 to 1.8 mg/dL (estimated glomerular filtration rate between 40 and 75 mL/min). Immunosuppressive treatment consisted of interleukin-2 antibody induction therapy, calcineurin inhibitors (cyclosporine or tacrolimus), prednisolone, and mycophenolate mofetil. Mild to severe hyperparathyroidism resistant to vitamin D analog treatment (intact parathyroid hormone molecule [iPTH] 174 to 519 pg/mL) was accompanied by severe hypercalcemia (Ca >11 mg%). To date the patients have completed 3 to 18 months of therapy. Cinacalcet 30 mg/d was initially administered.

RESULTS

This treatment resulted in a rapid decrease in total serum calcium (8.6 to 9.2 mg/dL) while PTH showed a milder, progressive decrease. Having controlled calcium levels, 1alpha OH vitamin D (0.25 microg/d per os) was added to the treatment, which resulted in a further decline of iPTH without producing an increase in serum calcium concentrations (median initial iPTH value 401 pg/mL, median value after treatment 176 pg/mL). Therapy was well tolerated without hypocalcemic events.

CONCLUSION

Cinacalcet offered a better holistic treatment approach to such patients.

Treatment of severe hypercalcemia due to refractory hyperparathyroidism in renal transplant patients with the calcimimetic agent cinacalcet

Calcimimetic agents increase the sensitivity of calcium sensing receptors of parathyroid glands and suppress both serum calcium levels and parathyroid hormone. There are still limited data on the treatment of renal transplant patients with severe hypercalcemia and hyperparathyroidism with calcimimetics (cinacalcet). We describe two such renal transplant patients with chronic kidney disease Stage 3 who presented with persistent hypercalcemia (serum calcium 11.5-12 mg/dl) and refractory hyperparathyroidism (iPTH 194-547 pg/ml). Control of hypercalcemia with cinacalcet (serum calcium <10 mg/dl) resulted also in an improvement of hyperparathyroidism, but with a slower rate than that of the lowering of serum calcium. Addition of a vitamin D analog together with the calcimimetic agent resulted in faster control of the resistant hyperparathyroidism in both patients (iPTH <145 pg/ml) with clinical improvement and without any side effect. It seems that this new agent will improve our clinical approach of renal bone disease permitting a more integrated and successful treatment of hyperparathyroidism and its consequences on patients with chronic kidney disease.

Transplantation of pediatric kidneys to adult recipients: An analysis of 13 cases

INTRODUCTION

The shortage of cadaveric donors for kidney transplantation has prompted many centers to expand the criteria used for donor selection to increase the organ supply. The use of cadaveric pediatric kidneys has been suggested as a means to overcome the shortage. However, some studies indicate that kidneys from pediatric donors show inferior results to those from adult donors. In this retrospective study we examined the outcome of kidney transplantation using cadaveric pediatric donors.

MATERIALS AND METHODS

From October 1990 to May 2002, 13 adult patients received pediatric renal transplants including two that were transplanted en bloc. The patients were divided into two groups based upon donor age: group I donors were 18 months to 6 years old; the seven recipients were of mean age 47.3 years. Group II donors were 7 to 15 years old; the six recipients were of mean age 43.6 years old. Cyclosporine-based immunosuppressive regimens were used in both groups.

RESULTS

The patient survival rate was 85.7% in group I and 100% in group II. The graft survival rates at the first and third posttransplant year in group I were 71.4% (5/7) and 57.1% (4/7) and in group II, 66.7% and 50%, respectively. The frequency of urinary complications in group I was 28.5% (2/7) and in group II 33.3% (2/6). There was one case of venous thrombosis in group II.

CONCLUSION

Pediatric renal grafts may be used with reasonable safety. However, surgical complications remain a significant problem especially with younger pediatric grafts.

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.

Morphometric characteristics of the thoracic and lumbar pedicles in the Greek population

OBJECTIVES

To measure the dimensions of the pedicles of T1 to L5 in the Greek population.

METHODS

A total of 12 whole human cadaver spines were evaluated regarding pedicle dimensions (5 women and 7 men). The mean age at the time of death was 69,6 (range 62 to 84 years). The transverse and sagittal out side pedicle isthmus widths, the internal transverse diameter and cortex width were measured with electronic calipers both on the right and left pedicles. The data collected were statistically analyzed with the t-test.

RESULTS

The widest transverse diameter was at the L5 level with a mean of 11,3mm (range 7,55-15,46mm). The narrowest transverse diameter was at the T5 level with a mean of 5,37mm (range 4,10-6,88mm). The widest sagittal diameter was at the T11 level with a mean of 17,23mm (range 14,84-19,57mm), while the narrowest one was at T1 level with a mean of 9,1mm (range 7,18-11,37mm). The maximum internal transverse diameter was at the L4 level with a mean of 8,26 mm (range 7,10-9,23mm) while the minimum was at the T5 level with a mean of 3,9mm (range 3,14-4,78mm). The maximum cortex width was at the L5 level with a mean of 2,55mm (range 2,15-3,02mm) and the minimum at the T5 level with a mean of 1,30mm (range 0,40-2,10mm).

CONCLUSIONS

From the statistic analysis of the above data it was found that regarding the internal diameter there was statistically significant difference between males and females especially at T3, T7, T8 and L3 levels (P<0,05), and almost in all levels regarding the cortex width. There was also statistically significant difference between right and left pedicles regarding the transverse and the sagittal widths (P<0,05). The narrowest pedicle was at the T5 level and the widest was at the L5.

Comparative haemodynamic responses to the first dose of short- and long-acting ACE inhibitors in patients with congestive heart failure

BACKGROUND

Angiotensin Converting Enzyme inhibitors (ACEi's) confer significant mortality and morbidity benefits in all functional grades of chronic heart failure (CHF). However, physicians' concerns regarding the possible occurrence of first-dose hypotension appear to be a contributing factor to their under-utilisation in both hospital and primary care settings. We investigated whether long-acting and short-acting ACEi's differ in their haemodynamic responses to the first-dose in patients with CHF.

METHOD

This was a multicentre, randomised, open, two-parallel-group study of captopril 6.25 mg and perindopril 2 mg. 240 patients with CHF, age 68.9 +/- 8.9 years, of whom 66% were male, NYHA II-IV, with average blood pressure baseline values of 132.2 +/- 16.2/78.5 +/- 10.5 mmHg for systolic and diastolic blood pressure, and left ventricular ejection fraction (LVEF) of 31.3 +/- 7.4% received either captopril (n = 124) or perindopril (n = 116). Blood pressure was continuously monitored during the 8 h following drug intake. Minimum levels and maximum decreases in systolic, diastolic and mean arterial pressures were measured, along with the incidence of hypotensive episodes defined as mean blood pressure (MBP) fall > 20 mmHg, whether symptomatic or not. Subgroups of patients distributed according to age, baseline blood pressure (BP) and LVEF were subsequently analysed.

RESULTS

Overall, a statistically significant treatment effect in favour of perindopril was observed. First-dose hypotension was observed more frequently following captopril than perindopril administration, with lower MAP minimal levels (78.0 +/- 8.9 vs. 84.5 +/- 10.1 mmHg, p < 0.0001), greater maximum falls (17.6 +/- 8.3 vs. 12.8 +/- 7.3 mmHg, p < 0.0001) and more frequent hypotensive episodes (42% vs. 15%, p < 0.0001). The incidence of at least one symptomatic episode was also significantly higher with captopril (10 patients vs. one patient, p = 0.029). Subgroup analyses according to age (< or = 70 years or > 70 years) or LVEF (< or = 30% or > 30%) reflected the main result.

CONCLUSION

Initiation of treatment with ACE inhibitors is associated with different haemodynamic and clinical tolerances in CHF patients, regardless of their risk for hypotension, with possible clinical implications.

Correlation of bone mineral density with the histological findings of renal osteodystrophy in patients on hemodialysis

AIMS

To examine the distribution of bone mineral density (BMD) in different histological groups of renal osteodystrophy.

PATIENTS

We prospectively studied 62 patients, 41 men and 21 women, aged 57+/-11.5 years, who had been on hemodialysis for 60+/-55 months. The women had been amenorrheic for 13+/-4 years and 7 patients (11%) had a positive fracture history.

METHODS

A bone biopsy was taken after tetracycline labelling and BMD of the lumbar spine and proximal femur was measured by dual-energy X-ray absorptiometry (DEXA); serum intact parathyroid hormone (iPTH), bone Gla protein (BGP), phosphorus, calcium and alkaline phosphatase (ALP) were also determined.

RESULTS

Histologically, 40 patients showed secondary hyperparathyroidism (sHPT), 6 mixed bone disease, 14 adynamic bone disease (A) and 2 osteomalacia. BMD of the lumbar spine was decreased in 43 patients (69%) and in 9 (14.5%) it was lower than -2 Z score units. BMD of the femoral neck was low in 55 patients (89%) and in 22 (35.5%) it was lower than -2 Z scores. BMD was lower in patients with sHPT than in those with adynamic bone disease (p<0.05) in which it was close to normal. BMD in both these sites correlated inversely with the biochemical markers (serum iPTH, BGP and ALP) and the histomorphometric indices of bone turnover.

CONCLUSIONS

Osteopenia is frequent in patients on hemodialysis, especially those with biochemical and histological findings of sHPT.

Neuropathy and quality of life in diabetic continuous ambulatory peritoneal dialysis patients

Diabetes mellitus is the commonest cause of end-stage renal failure and is associated with considerable morbidity. Neuropathy is one of the most serious complications of diabetes, linked to the incidence of nephropathy and retinopathy. The prevalence of neuropathy increases with age and duration of diabetes. Peripheral sensorimotor neuropathy is the main manifestation of neurological damage in diabetes, while autonomic neuropathy, a devastating complication, is also present in a large number of patients with long-term diabetes. Clinical features of autonomic neuropathy are mainly cardiovascular disorders and abnormal visceral function. One of the most important sequelae of neuropathy is the development of the insensitive foot at risk of ulceration, deformation, Charcot neuroarthropathy, and amputation. Prevention, education, and identification of the at-risk patient are the key elements in managing these severe complications. Dialysis, and mainly peritoneal dialysis, still remains the main renal replacement therapy for end-stage renal disease (ESRD) diabetic patients. It is obvious from many studies that diabetes and its complications are major risk factors associated with poorer survival rates, increased morbidity, and decreased quality of life. Few, if any, data are available specifically evaluating quality of life in continuous ambulatory peritoneal dialysis (CAPD) diabetic patients. Fewer data are available estimating the impact of neuropathy on the quality of life of such patients. Specific studies must be carried out to further investigate quality-of-life issues and neuropathy in this vulnerable group of patients.

Regression of massive tumoral calcinosis of the ischium in a dialysis patient after treatment with reduced calcium dialysate and i.v. administration

BACKGROUND

Tumoral calcinosis, an inherited metabolic disorder, has been described with increasing frequency over the last 20 years [Drueke 1966]. It is characterized by massive calcium phosphate deposits in periarticular tissues, usually around large joints, especially the hips, knees and elbows (editorial in Lancet 1987).

PATIENT AND METHOD

We describe a 58-year-old male patient with tumoral calcinosis of the ischium and severe hyperparathyroid bone disease, successfully treated with reduced calcium dialysate and vitamin D.

CONCLUSION

We believe that in cases of tumoral calcification with histologically proven hyperparathyroid bone disease, lowering the calcium dialysate concentration together with careful administration of vitamin analogs and monitoring of serum calcium, phosphate and parathyroid hormone levels, may be the ideal therapeutic approach. Control of hyperphosphatemia would be best achieved with measures other than administration of aluminium phosphate binders if one wishes to avoid the induction of adynamic bone.

Segmental spinal correction of idiopathic scoliosis. Luque rods and Hartshill rectangle in 30 patients followed for 2-6 years

30 patients with idiopathic scoliosis were treated by posterior spinal arthrodesis using the Luque (8 patients) and Hartshill (22 patients) rodding systems with sublaminar segmental wiring. Patients were followed for 2 to 6 years. In most cases, postoperative correction exceeded safety correction limits (lateral bending film plus 10 degrees). Final correction was 55%, while derotation was not significant (average 3 degrees). No neurological deficit was noted. Postoperative bracing was not applied and there was 1 patient with broken rods (Luque trolley system without fusion) and 1 patient with broken wires in 4 segments. Allogenic blood transfusion was avoided in 19 patients by preoperative donation of autologous blood, in combination with salvage of intraoperative shed blood. We found segmental spinal wiring with either rods or rectangles to be a safe method for correction of scoliosis in experienced hands. It offered satisfactory stability and fusion rate with no need for external support.

Biochemical markers for non-invasive diagnosis of hyperparathyroid bone disease and adynamic bone in patients on haemodialysis

The diagnostic and predictive value of serum intact parathyroid hormone (iPTH) and osteocalcin (bone Gla protein, BGP), alone or in combination, have been examined in only a small number of haemodialysis patients.

METHODS

We studied prospectively 114 patients (46 women, 68 men; mean age 52 +/- 12 years) on regular haemodialysis for a mean of 55 (6-185) months. All patients underwent labelled transiliac bone biopsy, and serum levels of iPTH, BGP and alkaline phosphatase were determined.

RESULTS

Seventy-one patients (62%) showed histological findings of hyperparathyroid bone disease, 24 (21%) mixed bone disease, six (5.5%) osteomalacia and 13 (11.5%) adynamic bone. Bone aluminium deposition over more than 25% of the trabecular bone interface was found in 66 patients (58%). Serum iPTH and BGP correlated with the majority of histomorphometric indices of bone formation, mineralization and resorption (r > 0.5, P < 0.01). iPTH levels > or = 200 pg/ml and BGP > or = 50 ng/ml were found to be indicative of hyperparathyroid bone disease, whilst iPTH levels < 65 pg/ml and BGP < 20 ng/ml were indicative of adynamic bone. However, the positive predictive value of these indices was limited (less than 80%), although their negative predictive value, especially when used in combination, was good (more than 90%) and the exclusion of hyperparathyroid bone disease and adynamic bone was possible. The diagnostic and predictive value of these bone markers were improved when patients with bone aluminium deposition were excluded.

CONCLUSIONS

Diagnosis of hyperparathyroid bone disease and adynamic bone is difficult on the basis of iPTH and BGP, especially when bone aluminium deposition is prevalent. However, using these bone markers, preferably in combination, the exclusion of these lesions is feasible.

The reactivity of the contralateral artery at the time of balloon dilation during coronary angioplasty

The response of the contralateral arteries was investigated during balloon angioplasty of the left anterior descending artery. Thirty patients were studied. Coronary arteriograms were obtained at baseline, during maximal balloon inflation and at the end of the procedure. Luminal diameter was measured by a quantitative coronary arteriography analysis system. During balloon inflation the luminal diameter of the proximal segment of the right coronary artery increased by 2.4 +/- 6% (P < 0.05), and that of the left circumflex artery increased by 0.6 +/- 6% (P = ns). Both returned to near baseline values after angioplasty. In patients with increased collaterals during balloon inflation the left circumflex proximal segment increased more significantly than in patients with unchanged collaterals. The luminal diameter of the distal segment of the right coronary artery increased by 9 +/- 8% (P < 0.001) and that of the left circumflex artery by 8 +/- 11% (P < 0.01) during balloon inflation, returning to near baseline values after angioplasty. Thus, vasodilation of the contralateral arteries during balloon inflation at the time of coronary angioplasty occurs mainly in the distal segments, and appears to be related to an increase in collateral filling.

Short-term effects of atrial versus atrio-ventricular pacing on myocardial ischaemia in coronary artery disease patients

This investigation was undertaken to evaluate the effects of short-term atrial vs atrio-ventricular pacing on myocardial ischaemia. The study was in two parts. In part one, 12 coronary artery disease patients were studied to investigate the effects of the two pacing modes on angina pectoris, coronary sinus O2 saturation and lactate. The two pacing modes were each applied for 5 min at 25 beats.min-1 more than the maximum heart rate of the exercise test. Coronary sinus O2 saturation and lactate were estimated before and after pacing. In part two, 13 patients with left anterior descending coronary artery disease were studied to investigate the effects of the two pacing modes on coronary flow reserve, using a Doppler catheter in the above mentioned branch after the administration of 10 mg intracoronary papaverine. The pacing rate was 15 beats.min-1 greater than the resting heart rate. Coronary sinus lactate and O2 saturation changes were the same and angina pectoris developed at about the same time from the beginning of pacing under both modes. Coronary flow reserve was 2.1 +/- 0.7 during atrial pacing and 2.1 +/- 1.1 during atrio-ventricular pacing (ns). It is concluded that short-term atrial and atrio-ventricular pacing have the same effects on myocardial ischaemia in coronary artery disease patients.

Intravenous atenolol in elderly patients in the early phase of acute myocardial infarction

The aim of this study was to assess the hemodynamic response to intravenous atenolol in elderly patients with acute myocardial infarction. We studied 14 elderly men, aged 64-85 years, and 14 younger men, aged 29-48 years, in the early postfibrinolytic phase of acute myocardial infarction. All the patients were in Killip class I. A triple-lumen Swan-Ganz thermodilution catheter was introduced into the right heart chambers. The patients received 5 mg intravenous atenolol over 5 minutes. All hemodynamic parameters were measured before and 10 minutes after atenolol. The hemodynamic characteristics and the location and extent of acute myocardial infarction were the same in both groups before atenolol. The hemodynamic changes after atenolol administration were the same in the two groups, but the stroke volume and cardiac indexes decreased to a greater extent in the elderly (p = .01 and p = .0001, respectively). These results indicate that intravenous atenolol in the early postfibrinolytic phase of acute myocardial infarction is safe in Killip class I elderly patients, although the cardiac and stroke volume indexes decrease, and the increase in the total systemic resistance is more in older than in younger patients.

Painless myocardial ischemia in chronic hemodialysed patients: a real event?

We investigated the incidence of painless (silent) myocardial ischemia, manifested as S-T segment deviation, by Holter ECG monitoring in patients with chronic renal failure undergoing regular hemodialysis. Forty-five patients underwent Holter ECG monitoring for a continuous 48-hour period covering dialysis and the intermediate period of everyday activity at home. ECG criteria for ischemia were found in 15.5% of patients mainly during and immediately after dialysis with a simultaneous increase of R,S,R + S amplitude. There was no correlation of S-T segment deviation with the existence of cardiac dysfunction and coronary artery disease proved by hemodynamic and angiographic studies. It is concluded that hemodialysis itself seems to play an important role in the genesis of the above ECG findings, possibly by means of serum K and Mg changes.