Renal damage in systemic lupus erythematosus: a comparative analysis of different age groups

Renal damage in systemic lupus erythematosus: a comparative analysis of different age groups A Mak, CC Mok, WP Chu, CH To, SN Wong and TC Au Please note that the following pdf is a corrected version of the article which appears in the printed version of Lupus 16/1. An Erratum will also appear in print in Lupus; 16(2). The corrected line can be found in the abstract. It was changed from: Patients were categorized into childhood (age ≥6 years), adult (between 16 and 50 years) or late onset (≥50 years) SLE. To: Patients were categorized into childhood (age 16 years), adult (between 16 and 50 years) or late onset (50 years) SLE.The objective of this study was to compare the frequency and severity of renal damage in systemic lupus erythematosus (SLE) with regard to the age of disease onset. Among 287 patients with new onset SLE diagnosed between 1991 and 2003 in our hospital, we identified those who fulfilled the American College of Rheumatology (ACR) criteria for renal involvement. Patients were categorized into childhood (age <6 years), adult (between 16 and 50 years) or late onset (≥50 years) SLE. Clinical presentation of renal disease and cumulative renal damage as assessed by the renal domain of the Systemic Lupus International Collaborating Clinics/ACR damage index (SDI) were compared. A linear regression model was constructed to study the effect of age on renal damage. One-hundred and forty-nine patients were studied (134 women and 15 men), including 28 childhood, 107 adult and 14 late onset SLE patients. The mean age of SLE onset was 29.7 ± 14 years. The prevalence of renal disease was 53% in childhood onset, 50% in adult onset and 58% in late onset SLE patients (P = 0.66). At renal disease presentation, late onset SLE patients had significantly lower creatinine clearance and were more likely to be hypertensive. Histological classes of nephritis and initial treatment response, however, did not differ significantly among the patients. After a mean observation of 80.3 months, 32 (21%) patients developed renal damage (renal SDI ≥ 1). Late onset SLE patients had accrued more renal damage than the others. In a multiple regression model, age was not a significant determinant of renal damage after adjustment for baseline renal parameters, duration of renal disease, use of cyclophosphamide and initial treatment response. We concluded that the prevalence of renal disease was similar among SLE patients of different ages of onset. Late onset SLE patients had accrued more renal damage but age did not correlate with renal damage after adjustment for various clinical parameters.

The expression of frizzled-3 receptor in colorectal cancer and colorectal adenoma

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Background: Wnt signaling is well known for its role in colorectal cancer (CRC) formation through transcriptional activities of nuclear β-catenin. Although activation of Wnt signaling depends on specific Wnt/Frizzled receptors (FZD) combinations, the specificity of the interaction and the role of FZD in that particular interaction are still unknown. Among the 10 Wnt receptors of the FZD protein family, FZD-3 is involved in neurodevelopmental abnormalities and gastric cancer carcinogenesis. However, the expression of FZD-3 in CRC is not clear. Therefore in this study, we examined the expression of FZD-3 in CRC cell lines and CRC patient tissues with various pathological stages. The information obtained will be important for us to understand the role of FZD-3 in the development of CRC.

Methods: FZD-3 mRNA expression was studied in CRC metastatic SW620, primary SW480 and normal CCD18co cell lines using quantitative real-time polymerase chain reaction with primers and a Taqman minor grove binder probe (Applied Biosystems, Foster City, USA). Moreover, paraffin-embedded specimens of 40 CRC patient tissues, 25 colorectal adenoma (CA) tissues were retrieved from the Department of Pathology, Queen Elizabeth Hospital, Hong Kong Special Administrative Region for FZD-3 immunostaining using an anti-FZD-3 antibody (Catalog no: MAB1001, R&D systems Inc., Minneapolis, USA) in an automatic Ventana Benchmark XT immunostainer (Ventana Medical Systems Inc., Tucson, USA).

Results: FZD-3 mRNA was up-regulated in metastatic SW620 cell line (fold-change: 622) and in primary SW480 cell line (fold-change: 820) when compared to that in normal CCD18co cell line. Furthermore, immunostaining showed that FZD-3 protein was expressed in 100% (40/40) of CRC specimens and 84% (21/25) of CA specimens. Detailed analysis showed that FZD-3 protein was significantly up-regulated in CRC, CA when compared to their adjacent normal colorectal epithelial tissues (p < 0.0005, Wilcoxon matched pairs test).

Conclusions: This study provided evidence that FZD-3 is involved in CRC carcinogenesis and it is a potential therapeutic target in CRC.

No significant financial relationships to disclose.

Acute renal failure associated with prolonged intake of slimming pills containing anthraquinones

Chinese herbal medicine preparations are widely available and often regarded by the public as natural and safe remedies for a variety of medical conditions. Nephropathy caused by Chinese herbs has previously been reported, usually involving the use of aristolochic acids. We report a 23-year-old woman who developed acute renal failure following prolonged use of a proprietary Chinese herbal slimming pill that contained anthraquinone derivatives, extracted from Rhizoma Rhei (rhubarb). The renal injury was probably aggravated by the concomitant intake of a non-steroidal anti-inflammatory drug, diclofenac. Renal pathology was that of hypocellular interstitial fibrosis. Spontaneous renal recovery occurred upon cessation of the slimming pills, but mild interstitial fibrosis and tubular atrophy was still evident histologically 4 months later. Although a causal relationship between the use of an anthraquinone-containing herbal agent and renal injury remains to be proven, phytotherapy-associated interstitial nephropathy should be considered in patients who present with unexplained renal failure.

Acute renal failure related to intravenous immunoglobulin infusion in an elderly woman

Intravenous immunoglobulin infusion induces acute renal failure via a mechanism of osmotic nephrosis. Most reported cases are related to the use of sucrose-based intravenous immunoglobulin. Maltose-based intravenous immunoglobulin is thought to be a safer alternative and have a lower risk of renal toxicity than sucrose-based preparations. Maltase, but not sucrase, is present in the brush border of proximal convoluted renal tubules, where the maltose is metabolised. We report a case of maltose-based intravenous immunoglobulin-induced acute renal failure in an elderly diabetic woman. In this case, the risk factors included advanced age, hypovolaemia, sepsis, diabetes mellitus, and the high infusion rate of the intravenous immunoglobulin. Maltase is readily inhibited by hyperglycaemia; therefore, poor glycaemic control may predispose patients to develop acute renal failure even with the better-tolerated maltose-based intravenous immunoglobulin.

Misplacement of a right internal jugular vein haemodialysis catheter into the mediastinum

A 69-year-old woman with end-stage renal failure discontinued continuous ambulatory peritoneal dialysis and commenced temporary haemodialysis because of resistant peritonitis. Right internal jugular vein haemodialysis catheter placement was performed. The cuffed, tunnelled haemodialysis catheter was inserted using the modified Seldinger technique. When haemodialysis was initiated the following day, blood could not be aspirated from the catheter and the patient complained of central chest pain during the aspiration. Subsequent venography and computed tomography scan of the thorax showed that the catheter was placed extraluminally into the posterior mediastinum. The importance of a chest radiograph after placement of a central venous catheter is highlighted by this case report. Subtle deviations in catheter position from normal should alert the physician to the possibility of catheter misplacement and lead to further investigation.

SHOP2: An HTN Planning System

The SHOP2 planning system received one of the awards for distinguished performance in the 2002 International Planning Competition. This paper describes the features of SHOP2 which enabled it to excel in the competition, especially those aspects of SHOP2 that deal with temporal and metric planning domains.

Treatment of diffuse proliferative lupus glomerulonephritis: a comparison of two cyclophosphamide-containing regimens

Cyclophosphamide (CYC) has proven beneficial in preserving renal function in patients with lupus with diffuse proliferative glomerulonephritis (DPGN). However, the optimal route of CYC administration is unknown because direct comparative studies are unavailable. In this open study, we compared the renal outcome of two historical cohorts of patients with diffuse proliferative lupus nephritis (World Health Organization classes IVa and IVb) treated with either intravenous (IV) pulse CYC (group A; n = 22) or sequential oral CYC followed by azathioprine (AZA; group B; n = 21) and followed up prospectively. Both groups of patients had similar clinical, biochemical, and renal parameters at baseline. At 24 months posttreatment, significant improvements in proteinuria, creatinine clearance, serum albumin level, and lupus serological results were evident in both groups. Compared with patients in group A, patients in group B had more complete or partial remission (90% versus 73%) and less risk for treatment failure (5% versus 14%), renal flares (5% versus 14%), and doubling of creatinine levels (5% versus 9%), but the difference was not statistically significant. However, patients treated with oral immunosuppression had an insignificant increase in rates of herpes zoster infection (19% versus 9%) and menstrual disturbance (50% versus 29%). We conclude that sequential oral immunosuppression with CYC and AZA tended to have better efficacy than IV pulse CYC in the treatment of lupus DPGN but was associated with more toxicities. Additional randomized trials involving a larger cohort of patients with a longer period of observation are necessary.

Strongyloidiasis as a possible cause of nephrotic syndrome

Chronic strongyloidiasis is a mild disease and has never been reported to be associated with nephrotic syndrome. Disseminated strongyloidiasis is known to have high mortality, but it frequently is not diagnosed until autopsy. We report a patient with nephrotic syndrome developing disseminated strongyloidiasis after steroid therapy. The findings in renal biopsy, the time course of the development, and resolution of nephrotic syndrome after thiabendazole treatment suggested a possible causal relationship between chronic strongyloidiasis and nephrotic syndrome. The case also demonstrated the importance of early diagnosis in disseminated strongyloidiasis and the good clinical outcome of early treatment before the development of organ failure.

Plasmodium infection unmasked by corticosteroid therapy

In the past four years, we have encountered three patients in whom malaria parasites were found incidentally in their blood when they were receiving corticosteroid therapy. Although there is little direct evidence that corticosteroid therapy can activate human malaria, animal studies have successfully demonstrated the recrudescence effect of immunosuppression on malaria infection.

Haemophilus paraphrophilus vertebral osteomyelitis

OBJECTIVE

To report the first case of Haemophilus paraphrophilus vertebral osteomyelitis--the second reported case of osteomyelitis of any site caused by this organism.

CLINICAL FEATURES

A 41-year-old male bus driver with no significant previous medical history presented with severe abdominal and back pain, which was eventually localised to the eleventh thoracic vertebra (T11). H. paraphrophilus was isolated from pus aspirated from the vertebral body.

INTERVENTIONS AND OUTCOME

The patient was treated with penicillin given intravenously for four weeks, then with antibiotics given orally for a further three weeks, with good clinical response.

CONCLUSION

H. paraphrophilus is an infrequent pathogen which may be difficult to identify and test for antibiotic susceptibility, but can cause serious infection, including primary haematogenous osteomyelitis.

Membranous nephropathy related to hepatitis B virus in adults

BACKGROUND

The natural course of adult hepatitis B virus (HBV)-related membranous nephropathy in areas where HBV infection is endemic (characterized by vertical and horizontal transmission of HBV in early childhood) has not been fully defined.

METHODS

We evaluated the clinical features, pathological findings, serologic profiles, therapeutic responses, and prognoses of 21 patients with adult-onset HBV-related membranous nephropathy. The patients were followed for a mean of 60 months (range, 12 to 108). Only patients with evidence of glomerular capillary deposition of hepatitis B e antigen (HBeAg) in a renal-biopsy specimen were included.

RESULTS

The clinical features and serologic studies suggested that the patients had acquired chronic HBV infection in early childhood; moreover, other causes of membranous nephropathy had been excluded. All were seropositive for hepatitis B surface antigen and had high titers of antibody to hepatitis B core antigen at first clinical presentation. HBeAg was detected in the serum of 17 patients (81 percent), yet only 3 had even slightly increased plasma alanine aminotransferase levels. The clinical response to therapy with interferon alfa was disappointing; only one of the five patients treated had a complete remission with seroconversion to antibody to HBeAg. Contrary to reports of studies in children, spontaneous remission of the nephrotic syndrome or proteinuria was uncommon in the adults with HBV-related membranous nephropathy whom we studied. Proteinuria and HBV antigenemia persisted in untreated patients. During the follow-up period, 29 percent of the patients had progressive renal failure and 10 percent required maintenance dialysis therapy.

CONCLUSIONS

The course of HBV-related membranous nephropathy in adults in areas where HBV is endemic is not benign. Regardless of treatment, the disease has a slowly but relentlessly progressive clinical course in approximately one third of patients.

High prevalence of hepatitis B surface antigenaemia in nephrotic syndrome in Hong Kong

Of 61 boys and girls with relapsing or steroid-resistant nephrotic syndrome admitted for renal biopsy, 22 had persistent hepatitis B virus surface antigenaemia despite normal liver function and an absence of previous transfusion. The prevalence of hepatitis B virus surface antigenaemia amongst nephrotic patients is significantly higher than that of the general population. Membranous nephropathy remains the commonest glomerulopathy associated with hepatitis B virus antigenaemia, and boys predominate.

The clinicopathological characteristics of IgA nephropathy in Hong Kong

The clinicopathologic data of 237 Chinese patients with IgA nephropathy from Hong Kong are reviewed in an attempt to identify the features pertinent to Chinese patients. Although the nephropathy is commonest in the 26-35 year age group, 11% of the IgA nephritic patients were children below 16 years. The male predilection reported in Caucasian populations is not observed and the male:female ratio is 0.94 in our series. The commonest renal manifestation is microscopic hematuria (25%) and 19% of the patients present with macroscopic hematuria, not infrequently synpharyngitic. Nephrotic syndrome occurs in 15% of our patients and proteinuria more than 1 gm/day is documented in 58% of these IgA nephritic patients. The degree of proteinuria does not correlate with prognosis. A small proportion of these nephrotic patients respond to steroid therapy, suggesting a variant of IgA nephropathy that resembles lipoid nephrosis in its steroid-responsiveness. Seventeen percent of the patients (18/104) are hepatitis B virus carriers and 61% of these patients demonstrate viral antigens in their renal biopsies, indicating that hepatitis B virus infection may sometimes play a pathogenetic role.

Pattern of glomerulonephritis in Chinese population: the effect of renal biopsy on the therapeutic decision

A retrospective analysis of 190 consecutive renal biopsies was undertaken to assess the pattern of glomerulonephritis in Chinese, and the role of renal biopsy in paediatric nephrology. Minimal change nephropathy, IgA nephropathy and membranous nephropathy comprised 41%, 16% and 13% of primary glomerular diseases, respectively. Minimal change nephropathy accounted for only 61% of patients with idiopathic nephrotic syndrome. In 76 patients the provisional clinicopathological diagnosis was shown to be incorrect or uncertain, and correct diagnosis was made solely on histological examination. In 47 cases a substantial change in therapy occurred on the basis of biopsy results. These data suggest that the practice of renal biopsy in paediatric nephrology performed appropriately in carefully selected patients is a useful procedure.

Pattern of glomerulonephritis in Hong Kong

A retrospective analysis of all renal biopsies (961) performed in two regional hospitals in Hong Kong during 1977-1985 revealed that IgA nephropathy was the most frequently encountered glomerulopathy. Lipoid nephrosis (minimal change nephrotic syndrome) remained the commonest cause of nephrotic syndrome in children. The frequencies of mesangiocapillary glomerulonephritis, focal glomerulosclerosis, and idiopathic membranous nephropathy were lower than in other populations. Membranous nephropathy was frequently associated with hepatitis B virus antigenemia, especially in children. Other chronic infections did not have a significant pathogenetic role in glomerular diseases. Lupus nephritis was the commonest secondary glomerular disease in our study, and over seventy percent of the renal biopsies showed advanced pathologies with either diffuse proliferative glomerulonephritis or membranous nephropathy.