Pulse pressure is an independent risk factor of cardiovascular disease in renal transplant patients

Elevated pulse pressure in the general population has been shown to be associated with cardiovascular disease, which is the main cause of death in renal transplant patients. We investigated the effects that a wide pulse pressure has on cardiovascular disease after renal transplantation in a cohort of 532 transplant patients with functioning grafts for more than one year. Patients were classified into two groups depending on whether the one-year pulse pressure was less than or greater than 65 mm Hg. We analyzed patient survival, posttransplant cardiovascular disease and principle causes of death. Five- and ten-year patient survival were lower among the group with higher pulse pressures. The main cause of death was vascular disease in both groups. The presence of posttransplant cardiovascular disease was higher among the group with higher pulse pressures (RR=1.73). In addition, the incidence of an elevated pulse pressure was directly associated with recipient age and posttransplant diabetes mellitus. In conclusion, pulse pressure represents an independent risk factor for increased cardiovascular morbidity and mortality in renal transplant patients.

Assessment of glomerular filtration rate in transplant recipients with severe renal insufficiency by Nankivell, Modification of Diet in Renal Disease (MDRD), and Cockroft-Gault equations

Measurement of glomerular filtration rate (GFR) is time consuming and cumbersome. Several formulas have been developed to predict creatinine clearance (CrCl) or GFR using serum creatinine (Cr) concentrations and demographic characteristics. However, few studies have been performed to discern the best formula to estimate GFR in kidney transplantation. In this study, Cockroft-Gault (CG), Nankivell, and Levey (MDRD) formulas were tested to predict GFR in 125 cadaveric renal transplant patients with severe renal insufficiency (GFR less than 30 mL/min per 1.73 m2). The GFR was estimated as the average Cr and urea clearances. The mean GFR estimated by averaged Cr and urea clearances (22.18+/-5.23 mL/min per 1.73 m2) was significantly different from the mean values yielded by the MDRD formula (20.42+/-6.65 mL/min per 1.73 m2, P=.000), the Nankivell formula (30.14+/-11.98 mL/min per 1.73 m2, P=.000), and the CG formula (29.42+/-8.64 mL/min per 1.73 m2, P=.000). The MDRD formula showed a better correlation (R=0.741, P=.000) than the CG (R=0.698, P=.000) and the Nankivell formulas (R=0.685, P=.000). Analysis of differences using the Bland-Altmann method demonstrated that MDRD gave the lowest bias (MDRD: -1.65+/-4.4 mL/min per 1.73 m2; CG: 7.33+/-6.24 mL/min per 1.73 m2; Nankivell: 8.05+/-9.23 mL/min per 1.73 m2) and narrower limits of agreement (Nankivell: -10.41-26.51 mL/min per 1.73 m2; CG: -5.15-19.81 mL/min per 1.73 m2; MDRD: -10.61-7.31 mL/min per 1.73 m2). In transplant patients with severe renal insufficiency, the MDRD equation seems better than the other formulas to estimate GFR.

[Malignant catatonia as paradigm of neuropsychiatric disease]

Catatonia is a large neuropsychiatric syndrome with multiple etiologies (psychiatric disorder, cerebral structural lesion, systemic disease, secondary to drugs and toxic agents) and varied clinical manifestations (cognitive and behavioral disorders, motor and speech disorders and vegetative disorders). The presence of disautonomy means a situation having vital risk, that requires immediate therapeutic intervention. A 22 year old woman was admitted due to a picture of stupor, fever, maintained postures, rigidity, seizures and tachycardia and hypertension episodes; this picture initiated four weeks earlier, with psychotic and affective symptoms and she slowly developed speech and motor activity impairment. Initially, she had been treated with neuroleptics, anticholinergics and antidepressants. The CT, MRI and CSF studies were normal. The EEG revealed diffuse slow waves and right frontotemporal paroxystic activity Laboratory determinations showed elevation of CK, coinciding with the vegetative disorder phase. The picture resolved progressively in two months, after receiving 19 sessions of electroshock therapy. In all the patients, and above all in those who receive neuroleptics, with symptoms suggesting catatonia, the presence of disautonomy should be considered as an alarm situation, which would make it necessary to discontinue the neuroleptics and to adopt special control. Electroshock therapy is the most effective therapeutic option in the situation of malignant catatonia.

Serum antibodies to Dicrocoelium dendriticum in sheep from Sardinia (Italy)

An indirect enzyme-linked immunosorbent assay (ELISA) with Dicrocoelium dendriticum excretory/secretory antigens was used to evaluate the presence of serum antibodies against the trematode in 738 sheep randomly chosen in Sardinia (Italy). Coprological sedimentation was used to discover egg-output. Seropositivity was detected in 86.2% tested sheep, whereas faecal prevalence was 6.7%; all that were faecal-positive also were ELISA-positive.

Anti-inflammatory and antinociceptive activities of Loasa speciosa in rats and mice

In the range of doses of 250-500 mg/kg (given i.p.) the aqueous extract of Loasa speciosa leaves showed an inhibitory effect on leukocyte migration, and a reduction on the pleural exudate, as well as dose-dependent anti-inflammatory and peripheral antinociceptive activities.

[Kleine-Levin syndrome: contribution of brain SPECT in diagnosis]

INTRODUCTION

Kleine Levin syndrome is an infrequent disorder of uncertain aetiopathogenesis that usually affects adolescent males, producing drowsiness and alterations in behaviour, appetite and sexuality. We report a clinically typical case in which the brain SPECT showed right frontal hypoperfusion.

CASE REPORT

Male aged 17, right handed, who presented drowsiness, apathy, alterations in his sexual behaviour (masturbations in public and attempted assault of women) and hyperphagia, which coincided with his undergoing an emotionally stressful period in his life. Brain SPECT revealed reduced flow in the right frontal lobe, although MRI and CSF study were normal. The polysomnographic study revealed a destructured pattern of sleep, with a reduction in phases III and IV and in REM sleep. He was treated with lithium and evolved favourably without any relapses during the 18 month follow up.

CONCLUSIONS

Cases of Kleine Levin syndrome with structural lesions have been reported, but most of them are idiopathic. A disorder in the hypothalamus and the limbic system is suggested. In our case, the findings from the brain SPECT confirmed a non dominant hypoperfusion of the frontal lobe, which could result from a phenomenon of diaschisis brought about by a diencephalic dysfunction.

["Occult" renal insufficiency due to evaluating renal function using only serum creatinine]

Timely referral to nephrologists depends on identification of renal failure. Most primary care physicians and specialists rely on serum creatinine as the standard test for determination of renal function. Creatinine clearance requires 24 hours urine collection with many pitfalls and wrong results. We compare serum creatinine and the Cockcroft-Gault (C-G) equation as measure of glomerular filtration rate (GFR). The study included 1,053 outpatients with serum creatinine lower than 2.5 mg/dl referred to our nephrological laboratory for serum creatinine and GFR determination using the C-G formula. Patients were grouped into two groups: normal renal function (serum creatinine < 1.3 mg/dl) and "incipient" abnormal renal function (serum creatinine 1.3-2.5 mg/dl). In the group of females with normal creatinine 22% (60-70 y), 35% (70-80 y) and 57% (> 80 y) had GFR values below 50 ml/min. In the group of males 11.3% (70-80 y) and 33.3% (> 80 y) also had GFR reduction in spite of normal serum creatinine. A severe renal insufficiency with creatinine clearance lower than 30 ml/min was observed in the group with "incipient" renal failure based on serum creatinine: 22.7%, 40% and 82.9% for females and 6%, 22.7% and 57% for male (60-70 y; 70-80 y; and > 80 y respectively). In order to improve management and prevention of renal failure appropriate measurements of renal function other than serum creatinine should be emphasize.

Tumoral calcinosis presenting as an extradural mass: MR findings and pathological correlation

Two cases of idiopathic tumoral calcinosis presenting as an extradural mass are reported. There are few reports in the literature of this pathological process presenting as extradural masses, so both cases represent very unusual locations for tumoral calcinosis. Magnetic resonance imaging features and pathological correlation of these two cases are presented. Tumoral calcinosis might be considered as a rare but possible cause of extradural mass.

Enhancement of copper and cadmium adsorption on kaolin by the presence of humic acids

The competitive adsorption equilibrium isotherms of Cu2+ and Cd2+ on kaolin have been measured at 298 K, in the presence and the absence of humic acids (HAs). HAs were found to enhance the metal adsorption capacity of mineral surfaces, in particular kaolin. This enhancement was also observed in the competitive adsorption of copper and cadmium on kaolin and kaolin-HA complex. This competitive adsorption shows that the presence of Cd2+ has not an important effect on Cu2+ adsorption, whereas a dramatic decrease is observed on the adsorption of Cd2+ in the presence of Cu2+. The Freundlich isotherm equation was found to provide an excellent fit to the experimental data. These results were compared with the independent adsorption of both heavy metals.

Molecular differentiation between NS1 gene of a field strain Bluetongue virus serotype 2 (BTV-2) and NS1 gene of an attenuated BTV-2 vaccine

At the end of September 2000, clinical symptoms of Bluetongue appeared in sheep flocks of the Balearic Islands (Spain). The presence of the BTV serotype 2 in tissue and blood samples of affected animals was confirmed by laboratory techniques. A systematic vaccination were carried out in affected areas using a live monovalent serotype 2 vaccine available from Onderstepoort laboratory (South Africa). In order to perform epidemiological studies, a new method to differentiate between the NS1 genes of BTV-2 affecting the Balearic islands and that of the Onderstepoort commercial live virus vaccine (monovalent, serotype 2) has been developed. This procedure is based on the use of an RT-PCR, followed by restriction endonuclease analysis. Epidemiological data of a study carried out in the period January-October 2001 using this procedure are included.

Bone cell mitogenic action of fluoroaluminate and aluminum fluoride but not that of sodium fluoride involves upregulation of the insulin-like growth factor system

The fluoroaluminate (AlF(4)(-)) ion and sodium fluoride (NaF) have previously been shown to be bone cell mitogens. This study sought to determine whether the bone cell mitogenic action of AlF(4)(-) and/or NaF would involve the insulin-like growth factor (IGF) regulatory system. We evaluated the effect of mitogenic doses of AlF(4)(-) and NaF on the mRNA levels and the protein level (in conditioned media [CM]) of several components of the IGF system (i.e., IGF-2, IGF binding protein [IGFBP]-4, and IGFBP-5) in human TE85 osteosarcoma cells. Aluminum fluoride (AlF(3)) was included for comparison. NaF, AlF(3), and AlF(4)(-), each at 50-100 micromol/L, increased [3H]thymidine incorporation in TE85 cells. Mitogenic concentrations of AlF(3) and AlF(4)(-): (1) increased the mRNA (up to twofold after 24 h treatment) and protein (in CM) levels (up to 2.5-fold after 48 h treatment) of IGF-2; (2) increased the mRNA level (twofold) and the protein level in CM (up to threefold) of stimulatory IGFBP-5; and (3) either reduced slightly or had no effect on the mRNA and protein (in CM) levels of the inhibitory IGFBP-4. Conversely, mitogenic concentrations of NaF had no significant effects on the protein (in CM) or mRNA level of IGF-2, IGFBP-4, or IGFBP-5. The addition of an inhibitory concentration of IGFBP-4 completely abolished the bone cell mitogenic activity of AlF(3) and AlF(4)(-) but not that of NaF. The findings of this study provide strong evidence that the bone cell mitogenic activity of AlF(4)(-) and AlF(3), but not that of NaF, is mediated by the upregulation of the IGF regulatory system.

Parathyroidectomy in dialysis patients

Subtotal parathyroidectomy or total parathyroidectomy (PTx) with autotransplantation are surgical procedures considered while the patient is included on the waiting list for renal transplantation. Total PTx alone is based in the possibility that a fragment of tissue (nodular hyperplasia in particular) left in the same pathophysiological environment of long term dialysis would show the same behavior and reproduce in time the same clinicopathological picture. The persistence of uremia induces a continued growth stimulus developing residual hyperplasia and consequently a very high risk of recurrence. We performed total PTx alone in 15 uremic patients excluded for renal transplantation 10 patients with undetectable iPTH serum concentration and were followed up for 37 to 144 months. There was no evidence of clinical bone disease (bone pain or fractures). Bone mineral lumbar spine and hip density was measured at the end of follow-up. The z score data showed that all patients had a bone mass similar than that expected for their age. Bone biopsies performed in four patients showed a uniform picture of low turnover without aluminium staining. Calcification of small arteries (digital and arcade vessels in hands and feet) were evaluated pre and post total PTx alone in nine out of the 10 patients with undetectable PTH levels. The small vessel calcification was present in five patients at the moment of PTx. At the end of the long term follow-up only one patient showed progression. In conclusion, total PTx without autotransplantation is a very effective and adequate treatment for refractory severe hyperparathyroidism in patients excluded for renal transplantation. Aluminium related osteopathy post PTx is a risk to be controlled with aluminium "free" dialysis water and avoiding aluminium containing phosphate binders.