Circadian rhythm of serum phosphate, calcium and parathyroid hormone levels in hemodialysis patients

BACKGROUND

Serum levels of Phosphate (P), Calcium (Ca) and Parathyroid hormone (PTH) show circadian rhythms in healthy people. The aim of this study is to investigate whether there is also a rhythm in Hemodialysis (HD) patients.

METHODS

We studied 15 (11 M, 4 F) HD patients, ages were 26 - 70 (mean 53 +/- 15) years. Two of the patients had history of parathyroidectomy operation. Serum levels of phosphate, calcium, albumin and PTH were evaluated six times at 07.00, 11.00, 15.00, 19.00, 23.00 and 03.00 on the second day after scheduled HD session.

RESULTS

The lowest serum phosphate levels were found at 15.00 (5.41 +/- 1.76 mg/dL), the highest levels were 5.97 +/- 1.77 mg/dL at 03.00. The lowest serum Ca levels were 7.90 +/- 1.31 mg/dL at 03.00, the highest levels were 8.39 +/- 1.20 mg/dL at 15.00. Serum levels of PTH increased two times in a day and then decreased. The lowest levels were 330.07 +/- 203.57 pg/mL at 07.00, the highest levels were 418.30 +/- 206.24 pg/mL at 15.00. The results of two patients who had parathyroidectomy history disclosed that the lowest levels of phosphate were 2.87 +/- 0.12 mg/dL at 15.00, the highest levels were 4.37 +/- 1.25 mg/dL at 07.00. Serum Ca levels were as; the lowest levels: 8.29 +/- 3.5 mg/dL at 03.00, the highest levels 9.30 +/- 3.50 mg/dL at 19.00. As expected, serum PTH levels were constantly low during the day disclosing no correlation with other parameters.

CONCLUSIONS

These results show that serum P, Ca and PTH levels exhibit a circadian rhythm also in HD patients. The rhythm predominantly depends on endogen factors and intravascular volume.

The impact of smoking on clinical features of Behçet's disease patients with glutathione S-transferase polymorphisms

OBJECTIVES

Various cancer studies have suggested that polymorphism of GSTM1 may influence the ability to detoxify chemicals in cigarette smoke. In the present study the effect of smoking on clinical features of Behçet's disease were investigated in patients having GST-M1 and/or -T1 null polymorphisms.

METHODS

Ninety-seven patients meeting International Study Group Criteria for Behçet's disease (63 male, 34 female) and 172 healthy controls (94 male, 78 female) were included into the study. GST-M1 and -T1 polymorphisms were investigated using polymerase chain reaction-restriction fragment length polymorphism technique.

RESULTS

Frequency of GSTM1- and/or GSTT1-null polymorphisms were comparable between the Behçet and the control groups. Smoking patients with GSTM1 null-polymorphism have decreased risk of developing papulopustuler lesions (OR=0.227 [0.063-0.818], χ2=5.463, p=0.019). Non-smoking patients with GSTM1 null-polymorphism has increased risk for having chronic arthritis (OR=5.988 [0.845-43.478]) but smoking patients with GSTM1 null-polymorphism have decreased risk (OR=0.741 [0.593-0.926]). GSTT1 null-polymorphism is associated with the presence of venous insufficiency (χ2=6.273, p=0.012, OR=2.740 [1.224-6.135]); smoking further increases the risk (χ2=7.840, OR=3.333 [1.412-7.874], p=0.005). GSTM1 null-polymorphism seemed to effect development of large vessel vasculitis (OR=1.158 [0.981-1.367], χ2=4.760, p=0.029). Male smoker Behçet patients even have more risk (OR=1.250 [0.971-1.610]).

CONCLUSIONS

Several manifestations of Behçet's disease may be influenced by smoking, and this effect can be augmented in patients carrying GST gene polymorphism, which code enzymes crucial for the detoxification of chemicals.

Analysis of vascular endothelial growth factor gene 936 C/T polymorphism in patients with familial Mediterranean fever

Vascular endothelial growth factor (VEGF) is a cytokine that promotes endothelial cell proliferation, leucocyte chemotaxis and expression of adhesion molecules and is a major mediator of vascular permeability. It has been demonstrated that VEGF directly activates neutrophils and it could promote acute recruitment of leucocytes. It is known that neutrophils are the major cell population involved in acute inflammation in familial Mediterranean fever (FMF) and the role of VEGF in these cells may be crucial. The aim of this study was to investigate whether the 936 C/T functional polymorphism of the VEGF gene is associated with susceptibility to FMF and its relationship with the main clinical features of the disease. Polymerase chain reaction-restriction fragment length polymorphism technique was used to determine 936 C/T polymorphism within the VEGF gene in 75 patients with FMF and 122 non-related healthy controls. Genotype and allele frequencies of the VEGF 936 C/T polymorphism between patients with FMF and healthy control groups were not significantly different (OR = 0.74, 95% CI = 0.40-1.37, P = 0.335 for CT genotype; OR = 1.11, 95% CI = 0.67-1.83, P = 0.700, for T allele). Although VEGF 936 TT genotype was found to be more frequent in patients with FMF than in healthy controls (6.7% vs. 1.6%, respectively), the difference was not significant (OR = 4.28, 95% CI = 0.81-22.67, P = 0.108). No associations were found between the studied polymorphism and either the clinical features such as arthritis, abdominal pain, pleuritis, myalgia, arthralgia and erysipelas-like erythema of the disease or the four common studied exon 10 mutations (M694V, M680I, V726A, M694I) of the Mediterranean fever gene. Present results suggest that VEGF gene 936 C/T polymorphism does not seem to be associated with susceptibility to FMF and its clinical manifestations.

The role of HLA-DRB1 shared epitope alleles in predicting short-term response to leflunomide in rheumatoid arthritis

OBJECTIVES

To investigate the role of shared epitope (SE) alleles in the short-term clinical response to leflunomide for the treatment of active RA.

METHODS

In an open-label, multi-centre study of 16-weeks duration, 93 patients (82% female) fulfilling ARA 1987 RA criteria were treated with leflunomide (100 mg loading dose for 3 days, then 20 mg/day as the maintenance dose). The primary efficacy criterion was the response status according to the European League Against Rheumatism (EULAR) response criteria using Disease Activity Score-28 (DAS28) activity measure. SE determinations have been undertaken by polymerase chain reaction and sequence-specific oligonucleotide genotyping methods.

RESULTS

The mean (s.d.) Disease Activity Score-28 (DAS28) was 5.1 (1.3) before the treatment, which was significantly decreased after 16 weeks [3.0 (1.1), P < 0.001]. According to the EULAR response criteria, 55 patients (59.1%) were classified as good responders. SE was positive in 51 (54.8%) of the patients, with 13 (13.9%) having SE homozygosity or carrying any two SE alleles. Among SE-positive patients, 68.6% (35/51) were good responders, compared with 47.6% (20/42) in SE negatives (P = 0.04). No difference was present according to SE hetero- or homozygosity (68.4 vs 69.2%). RF was also present significantly more frequently in the SE-positive group compared with negatives (78.4 vs 57.1%, P = 0.03). However, no significant difference was observed in the prevalence of RF positivity in patients with a good clinical response (72.7 vs 63.2%, P = 0.32).

CONCLUSIONS

The results suggest that HLA-DRB1 SE presence may favourably affect the outcome of leflunomide monotherapy in an unselected group of RA patients with an active disease and naive to leflunomide.

Analysis of CD28 and CTLA-4 gene polymorphisms in Turkish patients with Behcet's disease

In this study we aimed to investigate IVS3 +17T/C single nucleotide polymorphism (SNP) of CD28 gene, +49A/G and -318C/T SNPs of CTLA-4 gene in patients with Behçet's disease (BD) and their potential association to the main clinical features of the disease. These polymorphisms were investigated in a Turkish population of 123 patients with BD and 179 healthy controls, by using PCR-RFLP technique. HLA-B*51 genotype was also studied in both groups by using PCR-SSP. The frequency of IVS3 +17TC genotype of the CD28 gene was significantly increased in BD patients compared to controls (43.6% vs. 31.2%, OR = 1.663, 95% CI = 1.033-2.679, P = 0.039). CTLA-4 +49GG genotype frequency was found to be significantly lower in patients with BD than those of healthy controls (4% vs. 10.6%, OR = 0.357, 95% CI = 0.130-0.983, P = 0.05). Genotype and allele frequencies of the CTLA-4-318C/T polymorphism between the BD and healthy control groups were not significantly different (12.2% vs. 10.6%, OR = 1.170, 95% CI = 0.570-2.402, P = 0.713). There were no associations between the studied polymorphisms and the main clinical features of BD. The frequencies of HLA-B*51 were 60.3% and 30.7% in BD and control groups, respectively (OR = 3.429, 95% CI = 2.115-5.559, P = 0.0001). Association between HLA-B*51 and each studied polymorphism did not reach to significant levels (OR = 0.479, 95% CI = 0.228-1.004, P = 0.064 for CD28 IVS3 +17TT genotype; OR = 2.180, 95% CI = 1.025-4.639, P = 0.061 for TC genotype; OR = 1.570, 95% CI = 0.870-2.836, P = 0.146 for C allele). These results may suggest that CD28 IVS3 +17TC genotype may be a risk factor for the development of BD, on the contrary CTLA-4 +49GG genotype may be protective in the studied Turkish population.

Allogeneic stem cell transplantation improves cerebro-vascular disease in two sickle cell anemia patients

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Background: Sickle cell anemia (SCA) patients are at high risk for vaso-occlusion with cerebral vascular complications like strokes being one of the most devastating clinical events. Prophylactic transfusions might prevent strokes resp. improve cerebro-vascular status in SCA patients. Allogeneic stem cell transplantation (SCT) is considered a therapeutic option with curative intention of SCA, and thus also to improve cerebro-vascular complications by preventing further strokes, as demonstrated by two cases in our center. Methods: Transcranial Doppler sonography (TCD) and cerebral magnetic resonance angiography (MRA) were used to assess cerebro-vascular disease status prior, during and post related SCT of 2 SCA patients. Results: Two sibling SCA patients (male resp. female, aged 13 and 11 years resp.) both suffered from multiple cerebral microinfarcts during the course of their disease, the boy additionally suffered from two strokes. Prior to related SCT in 2004 with unaffected siblings, both patients were assessed by MRA and TCD. The diagnostic data revealed a hypoplastic ACI (right side) in both children as prominent pathological feature, in combination with different grades of stenosises of ACM, AV and ACI (left side), for example. The evaluation of cerebro-vascular status 3–4 months post SCT showed a persisting stenosis of right ACI in both patients, whereas circulation in the cerebrum resp. flow velocity profiles in other intracranial arteries significantly improved or turned to normal. The course of SCT was rather uncomplicated in the immediate post-transplant period except clinically controlled acute GvHD grade III in one patient. Currently, i.e. 18 resp. 21 months after transplant, the children are in good clinical condition. Conclusions: The results of allogeneic SCT in 2 SCA patients suggest that cerebro-vascular disease does not progress after SCT resp. shows major improvement by SCT. Regular follow up is necessary to assess long term results of cerebro-vascular status in these patients.

No significant financial relationships to disclose.

Vasculitis induced by zafirlukast therapy

Zafirlukast is a leukotriene inhibitor that has recently been approved for the prophylaxis of asthma. Although this new product has been well accepted because of its convenient dosing and relatively few side effects, several cases of Churg-Strauss syndrome have been reported to be associated with its use. In this paper we describe the case of a 54-year-old white man with no history of corticosteroid therapy in whom leukocytoclastic vasculitis, hepatitis and eosinophilia developed while he was on zafirlukast therapy for mild asthma.

Smoking and Behçet's disease

It has recently been claimed that some of the symptoms in patients with Behçet's disease (BD) can be activated after the patient has stopped smoking. In this study we investigated the effect of smoking on the symptoms of Behçet's disease. Fifty asymptomatic current smokers (CS) who promised to stop smoking (group 1) and 60 current non-smokers (NS) (group 2) (21 of them ex-smokers) with BD were examined at the beginning and a week later for the presence of symptoms of BD. Forty-seven of the 50 CS completed the study. Oral aphthous ulcers were observed in 31 (65.9%) of them at the end of the study period. Besides oral aphthous lesions, genital ulcers were detected in two and erythema nodosum in two other patients. Only 15 (25%) group 2 patients developed oral aphthous ulcers during the study period. The difference between the frequencies of oral aphthous lesions in these groups was significant (p=0.0002). We concluded that cessation of cigarette smoking can activate the mucocutaneous symptoms, especially oral aphthous lesions, in patients with BD.

Human MLH1 deficiency predisposes to hematological malignancy and neurofibromatosis type 1

Heterozygous germ-line mutations in the DNA mismatch repair genes lead to hereditary nonpolyposis colorectal cancer. The disease susceptibility of individuals who constitutionally lack both wild-type alleles is unknown. We have identified three offspring in a hereditary nonpolyposis colorectal cancer family who developed hematological malignancy at a very early age, and at least two of them displayed signs of neurofibromatosis type 1 (NF1). DNA sequence analysis and allele-specific amplification in two siblings revealed a homozygous MLH1 mutation (C676T-->Arg226Stop). Thus, a homozygous germ-line MLH1 mutation and consequent mismatch repair deficiency results in a mutator phenotype characterized by leukemia and/or lymphoma associated with neurofibromatosis type 1.

Serum soluble interleukin-2 receptor levels in familial Mediterranean fever

OBJECTIVE

To investigate serum soluble interleukin-2 receptor (sIL-2R) in familial Mediterranean fever (FMF) and assess its role in acute FMF crisis.

METHODS

Serum sIL-2R concentrations were measured in patients with FMF during acute crises and during inactive periods of the disease, using an immunoenzymatic assay kit. Twenty four FMF patients during acute crisis (active FMF), 17 patients with inactive FMF, 24 healthy controls, and 20 active patients with rheumatoid arthritis (as a disease control group) were studied.

RESULTS

Serum sIL-2R concentrations were increased during an acute FMF crisis compared with the values in inactive FMF patients and healthy controls (P = 0.0105 and P = 0.0012 respectively), while there was no significant difference between the mean values in active FMF and rheumatoid arthritis patients (P = 0.7325). In 14 of the FMF group whose blood samples were available in both active and inactive phases, sIL-2R concentrations were significantly higher in an acute attack than in an attack-free period (P = 0.027).

CONCLUSIONS

An increase in sIL-2R may be a result of hyperreactivity of IL-2R-expressing cells during an acute inflammatory attack of FMF.

Circulating corneal epithelium antibodies and immune complexes in immunologic eye disorders

We investigated the incidence of circulating corneal epithelial antibodies and the serum levels of immune complexes in patients with immunologic disorders associated with the eye. Fifty patients with autoimmune diseases, 29 of whom had Behcet disease, were included in our study. Twenty healthy subjects were used as controls. Twenty-four patients (48%) had detectable levels of circulating antibodies against the corneal epithelium compared with two (10%) of the control subjects. Patient age had a negative effect on the induction of antibodies, whereas there were neither positive nor negative associations of antibody positivity rates with factors such as gender, the duration of the illness, the activity of the disease, the occurrence rate of the attacks, immune suppressant therapy, and the levels of circulating immune complexes. This study clearly demonstrated the high incidence of corneal antibodies in certain diseases of immunologic origin, including Behcet disease. Further investigations should be done to reveal clues about the presumed effects of local and systemic factors on the production of anticorneal antibodies.

The association between HLA B5 and ocular involvement in Behçet's disease in southern Turkey

HLA B5 plays an important role in the aetiology of Behçet's disease. The frequency of HLA B5 differs between racial groups and geographical regions. Ocular involvement, which could lead to serious complications, is a very important feature of Behçet's disease. Various racial groups having different genetic properties live in the Cukurova region, located in southern Turkey. To investigate the role of HLA B5 in Behçet's disease in Cukurova region, HLA B5 antigens were investigated by lymphocytotoxicity assay in 65 patients and 200 healthy controls. A significantly higher frequency was found in the patient group. Neither ocular involvement, nor the type of uveitis showed any correlation with HLA B5, but it was found that patients presenting with frequent ocular attacks had significantly higher HLA B5 positivity than the patients with rare attacks. This observation suggests that HLA B5 would be a negative factor in visual prognosis in Behçet's disease.

Homozygosity for the met30 transthyretin gene in a Turkish kindred with familial amyloidotic polyneuropathy

A Turkish family is described with two members suffering from familial amyloidotic polyneuropathy. Their transthyretin genes were examined using the polymerase chain reaction, and both patients possessed the met30 mutation in both of their transthyretin genes. In this family, only individuals who are homozygous for the met30 mutation have developed symptoms.

Poisoning due to amatoxin-containing Lepiota species

Twenty-seven consecutive mushroom poisoning cases were followed up over a period of 14 days. Fourteen out of 27 died of liver failure. There were no deaths from renal failure. The mushrooms were identified as the amatoxin-containing Lepiota species. Therapeutic measures included nasogastric lavage, charcoal, vitamin C, vitamin B, penicillin G, corticosteroids, oral streptomycin and, in the case of a few patients, limited amounts of thioctic acid. Of the ten haemodialysed, nine died. Unfortunately charcoal haemoperfusion was not available. It appeared that therapeutic measures were ineffective and it also seemed that the amount of mushroom ingested was the determining factor for the prognosis. An important point to make is that renal failure does not occur and liver failure is always delayed (group II). For this reason all suspected cases of mushroom poisoning, regardless of absence of clinical signs and symptoms, must be hospitalised for a period of at least one week. The poisonous properties of wild mushrooms have been recognized since ancient times. However, despite awareness of their inherent dangers, serious poisoning continues to occur. Fatal intoxications can be attributed almost entirely to the amtoxin-containing species. Amanita phalloides have been blamed for over 90% of poisoning deaths in North America. There are reports of intoxications of other amatoxin-containing species in Europe, but fatalities due to Lepiota species are reported only rarely. It was previously acknowledged that the interval between ingestion of mushrooms and the onset of symptoms is longer than expected in serious poisonings.(ABSTRACT TRUNCATED AT 250 WORDS)

Colchicine in systemic amyloidosis

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Parasitic arthritis induced by Strongyloides stercoralis

A 40-year-old man presented with palpable purpura and symmetrical polyarticular arthritis. Histological examination of the synovial membrane and fluid unexpectedly disclosed Strongyloides stercoralis infestation of the ankle joint.