Comparison of Cyfra 21–1, Tpa and Tps in Lung Cancer, Urinary Bladder Cancer and Benign Diseases

Recently CYFRA 21–1, a new tumor marker measuring a fragment of cytokeratin 19, was introduced and proved to be suitable for therapy monitoring and follow-up of non-small cell lung carcinomas (NSCLC), in particular squamous cell carcinomas. Besides CYFRA 21–1 there are two other tumor markers, tissue polypeptide antigen (TPA) and tissue polypeptide-specific antigen (TPS), which also measure various cytokeratins in serum. In a retrospective study we investigated the clinical significance of these three cytokeratin markers in lung cancer and in carcinoma of the urinary bladder. For this purpose we investigated the sera of 50 healthy persons, 273 patients with various benign diseases, 218 patients with histologically proven lung cancer and 88 patients with carcinoma of the urinary bladder.

In a first step the specificity was established for the different reference groups and the cutoff values were fixed at a specificity of 95%. In lung cancer the single and combined sensitivities were calculated versus benign lung diseases (n = 58) as reference group. With single determinations CYFRA 21–1 proved to have the highest sensitivity in lung cancer in general (61%), in non-small cell lung carcinomas (64%), in squamous cell carcinomas (79%), in adenocarcinomas (54%) and in large cell carcinomas (65%). In small cell lung carcinomas (SCLC) NSE was confirmed to be the marker of choice (55%). With combined determinations a clear increase in sensitivity could only be reached in large cell carcinomas (CYFRA 21–1 + TPA: 77%) and in small cell carcinomas (CYFRA 21–1 + NSE: 62%). In cancer of the urinary bladder the sensitivities were established versus benign urological diseases (n = 73). CYFRA 21–1 showed with 38% true positive test results the highest sensitivity compared to TPA (27%) and TPS (23%).

From our investigations it was evident that TPA detects at least partially the same substance as CYFRA 21–1 (the sensitivities compared to the markers TPS, CEA, SCC and NSE were rather high, but not as high as for CYFRA 21–1) whereas TPS represents a completely different parameter of clinical chemistry (lowest number of true positive test results over the whole investigation), which apparently measures something completely different. These findings cleary correspond with the very recent results of immunoblotting comparing CYFRA 21–1, TPA and TPS.

A comparison of Centrifugal and Membrane-based Apheresis Formats

Membrane and centrifugal apheresis operate on different physical principles but are both capable of efficiently fractionating plasma proteins from whole blood. For therapeutic purposes, both formats yield about the same protein clearance per liter of solute exchanged and neither is significantly more rapid than the other. Only continuous centrifugation can be used to pherese cellular elements and only membrane filter can be deployed in ‘spontaneous’ circuits. Hardware for continuous centrifugation is more expensive and disposables less expensive than for the membrane methods; the ‘crossover’ occurs at 200 treatments. To date, only the centrifugal method is employed for donor apheresis; this may change in the future as membranes can yield a truly platelet-free product and appear to offer a much more rapid collection cycle.

Reverse Flux Filtration: A New Mode of Therapy Improving the Efficacy of Heparin - Induced Extracorporeal Ldl Precipitation in Hyperlipidemic Hemodialysis Patients

In the steady state after a run-in phase of 3 months, the acute effects of 3 modifications of weekly heparin-induced extracorporeal LDL precipitation (HELP) were studied in 5 ESRD and 2 non-uremic hypercholesterolemic coronary patients. In ESRD patients (n=29 sessions), HELP reduced LDL-cholesterol (LDL-C) (56 ± 7%) and fibrinogen (FIB) (54 ± 10%) by a similar percentage as compared to non-uremic controls (60 ± 4% and 61 ± 3%, resp.; n=5). In order to eliminate the need for extra HELP sessions in addition to the normal dialysis regimen, newly developed hardware was then used to perform combined synchronous HELP/HD (n=12). However, premature precipitate filter plugging probably due to hyperfibrinogenemia in ESRD patients, accentuated by ultrafiltration (UF), decreased the corresponding reductions to 26 ± 9% (LDL-C) and 34 ± 11% (FIB). Therefore, the procedure was modified by reversing the filtrate flux through the precipitate filter membrane after 900 ml of treated plasma (“reverse flux filtration”, RFF; n=11). Thus, in RFF-HELP/HD the LDL/FIB/heparin coprecipitate was deposited on both filter membrane sides which caused a significant enhancement of the filter capacity and improved reductions to 46 ± 14% for LDL-C and 51 ± 15% for FIB. Elution of the precipitate from the precipitate filter after the sessions showed that RFF-HELP/HD had trapped 1733 ± 238 mg LDL-C and 8108 ± 1876 mg FIB in ESRD patients, while HELP eliminated 1890 ± 333 mg LDL-C and only 3663 ± 369 mg FIB in non-uremics. Filter precipitate recoveries (relative to the mass removed from the patient plasma pool) amounted to 97 ± 18% for LDL-C and 158 ± 67% for FIB in the ESRD group treated by RFF-HELP/HD vs. 70 and 76% in the non-uremic HELP group. Probably, passive transport of lipoproteins and FIB from the interstitium into the vascular space caused repletion of this compartment during HELP/HD where an UF induced solvent drag is effective. In summary, the new RFF-HELP/HD procedure effectively reduced LDL-C and FIB in ESRD patients who could not be adequately treated by the conventional HELP/HD system.

Adsorption Profile of Commercially Available Adsorbents: An in Vitro Evaluation

Adsorbents from four commercially available devices, Protein A-Sepharose (Immunosorba Protein A-62,5; Excorim KB, Lund Sweden), Tryptophan-PVA (Immusorba TR-350; Asahi Medical Co., Tokyo, Japan), Phenylalanine-PVA (Immusorba PH-350; Asahi Medical Co., Tokyo, Japan), and Dextran sulfate (Liposorber LA-15; Kanegafuchi Chemical Co. Ltd, Osaka, Japan) were tested under optimal in vitro conditions to determine their adsorption capability for several plasma constituents which are usually the target of plasma therapy. The parameters of interest were: double stranded DNA-antibodies (anti-dsDNA), antiglomerular basement membrane antibodies (anti-GBM), antiacetylcholin receptor antibodies (AChRAb), circulating immune complexes (CIC), rheumatoid factor (RF), IgA, IgG, IgM, IgE, C3c, C4, LDL-cholesterol, total cholesterol, erythropoietin (EPO) and β2-microglobulin (β2M). The IgG auto antibodies, CIC and RF can be removed by Protein A-Sepharose, Try-PVA and Phe-PVA. IgG is best adsorbed by Protein A-Sepharose, while IgE can be removed effciently by Try-PVA. Dextran sulfate is without doubt the best adsorbent for LDL-cholesterol. All four adsorbents bind also complement components C3c and C4. No significant adsorption was found for EPO and β2M. The four devices exhibit a quite different adsorption profile which can be used as a guide for the optimal selection of an adsorption column in clinical apheresis.

Heparin-Free DALI LDL-Apheresis in Hyperlipidemic Patients: Efficacy, Safety and Biocompatibility

Background and Aim of Study

In routine DALI apheresis - the first technique for direct adsorption of lipoproteins from whole blood - heparin plus citrate (ACD-A) is used as anticoagulation regimen. However, recently several publications have warned of heparin-induced thrombocytopenia as a rare but potentially life-threatening complication of heparin administration (HIT type 2). The aim of the present study was therefore to test the efficacy and biocompatibility of DALI using a heparin-free anticoagulation regimen consisting exclusively of citrate.

Methods

Four symptomatic hypercholesterolemic patients on regular DALI apheresis were switched to the heparin-free protocol for two sessions each. Two of the patients were on oral anticoagulation using phenprocoumon. In the weekly sessions, 1.3 patient blood volumes were processed at a blood flow rate of 60 ml/min using ACD-A at a ratio of 1:20 (v/v) during adsorber priming and the session.

Results

Clinically, all sessions were essentially uneventful. Uncorrected lipoprotein reductions amounted to 65% for LDL-C, 62% for Lp(a), 53% for VLDL-C, 24% for HDL-C, 17% for triglycerides and 19% for fibrinogen. Cell counts remained virtually constant. No signs of hemolysis or clotting could be detected. Thromboplastin time (Quick) was slightly prolonged and partial thromboplastin time (PTT) moderately elevated in all patients. In constrast, whole blood coagulation time acc. to Lee-White and activated clotting times were increased only in orally anticoagulated patients. Biocompatibility in terms of complement, leukocyte and thrombocyte activation was excellent. Bradykinin activation was moderate peaking at 3038 pg/ml in the efferent line. Systemic thrombin-antithrombin complex (TAT) reflected perfect anticoagulation in orally anticoagulated patients and adequate anticoagulation in the patients without phenprocoumon.

Conclusion

In this pilot study, heparin-free DALI apheresis was safe and effective and may thus be performed in LDL-apheresis dependent patients who suffer from heparin intolerance.

MEIS1 and BTBD9: genetic association with restless leg syndrome in end stage renal disease

Background

Restless legs syndrome (RLS) is a sleep related movement disorder that occurs both in an idiopathic form and in symptomatic varieties. RLS is a frequent and distressing comorbidity in end stage renal disease (ESRD). For idiopathic RLS (iRLS), genetic risk factors have been identified, but their role in RLS in ESRD has not been investigated yet. Therefore, a case–control association study of these variants in ESRD patients was performed.

Methods

The study genotyped 10 iRLS associated variants at four loci encompassing the genes MEIS1, BTBD9, MAP2K5/SKOR1, and PTPRD, in two independent case–control samples from Germany and Greece using multiplex PCR and MALDI-TOF (matrix assisted laser desorption/ionisation time-of-flight) mass spectrometry. Statistical analysis was performed as logistic regression with age and gender as covariates. For the combined analysis a Cochran–Mantel–Haenszel test was applied.

Results

The study included 200 RLS-positive and 443 RLS-negative ESRD patients in the German sample, and 141 and 393 patients, respectively, in the Greek sample. In the German sample, variants in MEIS1 and BTBD9 were associated with RLS in ESRD (P_nom≤0.004, ORs 1.52 and 1.55), whereas, in the Greek sample, there was a trend for association to MAP2K5/SKOR1 and BTBD9 (P_nom≤0.08, ORs 1.41 and 1.33). In the combined analysis including all samples, BTBD9 was associated after correction for multiple testing (P_corrected=0.0013, OR 1.47).

Conclusions

This is the first demonstration of a genetic influence on RLS in ESRD patients with BTBD9 being significantly associated. The extent of the genetic predisposition could vary between different subgroups of RLS in ESRD.

Acute postinfectious glomerulonephritis associated with Campylobacter jejuni enteritis - a case report and review of the literature on C. jejuni's potential to trigger immunologically mediated renal disease

Kidney disease is a rare complication of Campylobacter jejuni (C. jejuni) enteritis. We here present the case of an 18-year-old male patient with crampy abdominal pain, vomiting, diarrhea, and fever. Three weeks later urinalysis revealed mild proteinuria and hematuria and a marked raise in serum creatinine was observed. Renal biopsy demonstrated acute endocapillary glomerulonephritis with mesangial IgM (immunoglobuline M) deposits. Extensive workup revealed no signs of skin or joint disease, thus excluding Henoch-Schönlein purpura. Due to persistent abdominal discomfort further gastro-enterological tests were performed and eventually Campylobacter jejuni was isolated from the patient's feces. In the absence of other precipitating factors for renal diseases we presumed an association between the bacterial infection and this postinfectious glomerulonephritis. Over a time period of 6 months the patient's kidney function normalized completely. However, long-term prognosis remains unclear. In addition to the case report, we conducted a review of the literature with results underlining Campylobacter jejuni's potential to trigger various types of immune mediated kidney diseases.

Long-term creatine supplementation is safe in aged patients with Parkinson disease

The food supplement creatine (Cr) is widely used by athletes as a natural ergogenic compound. It has also been increasingly tested in neurodegenerative diseases as a potential neuroprotective agent. Weight gain is the most common side effect of Cr, but sporadic reports about the impairment of renal function cause the most concerns with regard to its long-term use. Data from randomized controlled trials on renal function in Cr-supplemented patients are scarce and apply mainly to healthy young athletes. We systematically evaluated potential side effects of Cr with a special focus on renal function in aged patients with Parkinson disease as well as its current use in clinical medical research. Sixty patients with Parkinson disease received either oral Cr (n = 40) or placebo (n = 20) with a dose of 4 g/d for a period of 2 years. Possible side effects as indicated by a broad range of laboratory blood and urine tests were evaluated during 6 follow-up study visits. Overall, Cr was well tolerated. Main side effects were gastrointestinal complaints. Although serum creatinine levels increased in Cr patients because of the degradation of Cr, all other markers of tubular or glomerular renal function, especially cystatin C, remained normal, indicating unaltered kidney function. The data in this trial provide a thorough analysis and give a detailed overview about the safety profile of Cr in older age patients.

PR3-ANCA-positive necrotizing multi-organ vasculitis following cocaine abuse

A 22-year-old man with a history of cocaine abuse from 2003 to 2005 developed recurrent bleeding of the nasal septum and a progressive cough and dyspnoea. He was admitted to the intensive care unit because of fulminant pneumonia, impaired renal function and progressive general deterioration. While hospitalized, he developed cutaneous vasculitis, thrombosis of the right subclavian and right jugular veins, testicular pain and, eventually, expanding red papules and plaques on the limbs. The symptoms were a diagnostic challenge, until skin biopsy showed immunoglobulin deposits in small vessels and kidney biopsy focal and segmental pauci-immune, crescentic glomerulonephritis. This led, together with anti-neutrophil cytoplasmic antibodies (cANCA and PR3-ANCA), to the diagnosis of Wegener granulomatosis. The number of affected organ systems in our patient exceeds that commonly found in the literature. Several clinical observations of cocaine abuse followed by Wegener granulomatosis suggest an active induction of a PR3-ANCA-positive vasculitis by cocaine.

Fibrillary glomerulonephritis mimicking membranous nephropathy--a diagnostic pitfall

Kidney biopsies in 2 females with nephrotic syndrome were suggestive of membranous nephropathy at routine light microscopy and immunohistochemistry. Electron microscopy on re-embedded paraffin tissue, however, revealed that the light microscopic pattern was due to a fibrillary glomerulonephritis with a dominant membranous manifestation. These findings suggest that (a) fibrillary glomerulonephritis may be mis-/under-diagnosed at light microscopy; and (b) in reality, a subset of therapy refractory membranous nephropathies might represent fibrillary glomerulopathies. Therefore, electron microscopy is mandatory in any case of membranous nephropathy with therapy refractory nephrotic syndrome or an unusual immunohistological staining pattern, e.g. with mesangial immunoreactivity.