The Czech registry of renal biopsies. Occurrence of renal diseases in the years 1994-2000

BACKGROUND

This report describes data collected by the Czech Registry of Renal Biopsies (CRRB).

METHODS

Twenty-eight centres provided data on all biopsies of native kidneys performed in the Czech Republic (population 10.3 million) over the period 1994-2000. Data on serum creatinine concentration (sCr), 24 h proteinuria, haematuria, serum albumin level, arterial hypertension, diabetes mellitus, histological diagnosis and complications after renal biopsy were collected.

RESULTS

Altogether 4004 biopsies in 3874 patients were performed (males 57.9%, children < or = 15 years 17.7%, elderly >60 years 14.3%). Microhaematuria was present in 65.9%, macrohaematuria in 9.2%, nephrotic proteinuria (> or = 3.5 g/24 h) in 39.3%, and low-grade proteinuria (<3.5 g/24 h) in 41.4%. Among adults, hypertension was present in 45.2%, mild renal insufficiency in 23% (sCr 111-200 micromol/l) and advanced renal insufficiency in 13.7% (sCr 201-400), while 11.5% of patients had sCr >400 micromol/l. The most frequent renal diseases were primary (59.8%) and secondary (25.4%) glomerulonephritis (GN). Tubulointerstitial nephritis (TIN) was observed in 4.4% and hypertensive nephroangiosclerosis in 3.4%. The samples were non-diagnostic in 4.6%. Among primary GNs, the most frequent diagnoses were: IgA nephropathy (IgAN) 34.5%, minimal change disease (MCD) 12.4%, non-IgA mesangioproliferative GN (MesGN) 11.3%, focal segmental glomerulosclerosis (FSGS) 10.8% and membranous GN (MGN) 9.3%. Among secondary GNs, systemic lupus erythematosus (SLE) represented 23.0%, necrotizing vasculitis (NV) 15.5%, Henoch-Schonlein purpura 5.7%, thin basement membrane glomerulopathy (TBN) 19.3%, Alport syndrome 6.9%, renal amyloidosis 9.9% and myeloma kidney 2.9%. Among children, the most common were IgAN (19.2%), MCD (17.6%) and TBM glomerulopathy (12.3%), while among the elderly the most common were MGN (11.0%), NV (10.7%) and amyloidosis (9.6%). The most common in patients with nephrotic proteinuria were MCD (50.5%) among children, but IgAN (24.6%) in adults aged 16-60 years and MGN (16.8%) among the elderly. IgAN (21.3%) and FSGS (8.3%) were the most common diagnoses among patients with mild renal insufficiency, but TIN (11.6%) and NV (11.3%) were the most common in more advanced renal insufficiency. Since 1999, diabetic patients represented 12.2% of adults, with mean proteinuria 8.9 g/24 h; diabetic glomerulosclerosis was found in 42.4% (with microhaematuria present in 66%) and non-diabetic renal diseases in 47.5% (IgAN in 17.5%, MGN and NAS in 11.1% and NV in 9.5%). The mean annual incidence (per million population) was: primary GN 32.4, secondary GN 13.8, IgAN 11.2, MCD 4.0, MesGN 3.7, FSGS 3.5, SLE 3.2, MGN 3.0, TBM 2.7, TIN 2.4 and NV 2.1. Ultrasound needle guidance was used in 56%, preferably in children (79%). The frequency of serious complications (gross haematuria, symptomatic haematoma, blood transfusion) remained at 3%.

CONCLUSION

The CRRB provides important data on the epidemiology of GN based on a whole country population.

[Correlation of 99mTc-dTPA renal scintigraphy with ACE inhibitor and ultrasound findings in screening for renal artery stenosis]

BACKGROUND

ACE inhibitor renal scintigraphy is widely accepted as a useful test in screening of unilateral renal artery stenosis. Another screening examination is ultrasonography, which detects haemodynamic changes with evaluation of resistive index (RI). The aim of the present study was correlation of 99mTc-DTPA captopril renography and duplex ultrasound findings in diagnosis of renal artery stenosis before angiography, that is used as "gold standard". Angiography was performed in 35 patients and their findings were correlated with scintigraphy and ultrasonography.

METHODS AND RESULTS

93 patients (49 male and 44 female) aged 27 to 84 years were examined. Ultrasonography was performed in all patients with evaluation of RI. Estimation of scintigraphy was performed in accordance with interpretative criteria of 99mTc-DTPA captopril renography, which were established at the 9th Symposium of radionuclides in nefro-urology (Santa Fé 1995) and Guideline for diagnosis of renovascular hypertension (1998). 1) Agreement positive and negative findings on scintigraphy and ultrasonography were in 61/93 patients (66%). 2) Within the group of 35 patients with angiography, the correlation between scintigraphy and ultrasonography findings was found in 27 patients (77%). 3) When scintigraphy and angiography were correlated, the correctly diagnosed renal artery stenosis was found in 27 patients with sensitivity (77%). 4) When sonography and angiography were correlated, the correctly sonographicaly diagnosed renal artery stenosis was found in 26 patients with sensitivity (74%).

CONCLUSIONS

On the basis of our results and according to our experience with both examinations we can conclude, that screening of unilateral renal artery stenosis with using these nonivasive methods can help to select better the indicated patients for angiography.

Relationship between Natriuretic Peptides and Residual Diuresis during Continuous Hemodiafiltration

BACKGROUND

The reasons for the decrease or increase of urine output following the start of continuous venovenous hemodiafiltration (CVVHDF) have not yet been explained sufficiently. The renoprotective properties of natriuretic peptides were described.

METHODS

The levels of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) were measured in 23 mechanically ventilated patients before and during the first 48 h of CVVHDF. Samples were drawn both from the ports proximal and distal to the filter. The results were compared between the group where daily diuresis (Vu) remained low or decreased and the group where diuresis increased to the level of 1.5 ml x kg(-1) x h(-1) or higher after 48 h of treatment. Left ventricular dysfunction (LVD) was defined as LV ejection fraction below 40%. A control group consisted of 10 patients exposed to abdominal surgery.

RESULTS

The average AVdiff (%) of ANP and BNP on filter were insignificant. Patients with increasing diuresis (n = 12) had significantly lower levels of both ANP (p < 0.001) and BNP (p < 0.005) than the patients with decreasing diuresis (n = 11). Significant correlations were revealed for ANP and Vu (p < 0.01) and for BNP and Vu (p < 0.05). The levels of both peptides were grossly elevated in comparison to controls and were predictive of survival. The differences between cardiac and non-cardiac patients were significant both for ANP and for BNP.

CONCLUSIONS

The elimination of ANP and BNP by the CVVHDF is negligible. The levels of natriuretic peptides are inversely related to Vu and predict survival. ANP and BNP levels correlate with left ventricular function even during acute renal failure and CVVHDF.

[Diabetes mellitus and chronic renal insufficiency]

In the nineties of the 20th century diabetic nephropathy has become the leading cause of regular dialysis treatment (RDT) in developed countries. In particular type 2 diabetics are involved. A similar trend can be observed also in the Czech Republic which holds in this respect the first place among countries of the former eastern block (33% patients with RDT) suffer from diabetes. The cause of the increase of patients with diabetic nephropathy and renal failure caused by diabetes is not only the rising prevalence and incidence of type 2 diabetes in the population but in particular the better care provided to patients with type 2 diabetes which enables them to survive macro- and microvascular complications incl. diabetic nephropathy. It is estimated that diabetic nephropathy affects 4-8% patients attending diabetic clinics. With regard to the increasing number of diabetics in RDT, moreover associated with their high polymorbidity, this is a serious medical and economic problem. The main factors which influence in the diabetic patients the risk of development of diabetic nephropathy are long-term control of glycaemia, genetic (ethnic) factors, age and sex. The decisive factor influencing in patients with diabetic nephropathy the progression of chronic renal insufficiency is control of the blood pressure. Including diabetics in RDT is not associated only with medical problems but also with socio-economic issues. The quality of life of diabetics is much lower and the survival of diabetics treated within the framework of RDT is still almost half as compared with the survival of non-diabetic patients. Decision on the selection of the dialysis method is not easy. Medical differences are well defined but should not be considered absolute. It is important to consider also which method is preferred by the patient. Optimally the decision is taken during the period of dispensarization. Both dialyzation methods have comparable results and survival although for diabetics under 50 years of age a more favourable prognosis of peritoneal dialysis is reported. However, the risk of "failure of the method" is in general higher in peritoneal dialysis.

Cloning and expression of the haloalkane dehalogenase gene dhmA from Mycobacterium avium N85 and preliminary characterization of DhmA

Haloalkane dehalogenases are microbial enzymes that catalyze cleavage of the carbon-halogen bond by a hydrolytic mechanism. Until recently, these enzymes have been isolated only from bacteria living in contaminated environments. In this report we describe cloning of the dehalogenase gene dhmA from Mycobacterium avium subsp. avium N85 isolated from swine mesenteric lymph nodes. The dhmA gene has a G+C content of 68.21% and codes for a polypeptide that is 301 amino acids long and has a calculated molecular mass of 34.7 kDa. The molecular masses of DhmA determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and by gel permeation chromatography are 34.0 and 35.4 kDa, respectively. Many residues essential for the dehalogenation reaction are conserved in DhmA; the putative catalytic triad consists of Asp123, His279, and Asp250, and the putative oxyanion hole consists of Glu55 and Trp124. Trp124 should be involved in substrate binding and product (halide) stabilization, while the second halide-stabilizing residue cannot be identified from a comparison of the DhmA sequence with the sequences of three dehalogenases with known tertiary structures. The haloalkane dehalogenase DhmA shows broad substrate specificity and good activity with the priority pollutant 1,2-dichloroethane. DhmA is significantly less stable than other currently known haloalkane dehalogenases. This study confirms that a hydrolytic dehalogenase is present in the facultative pathogen M. avium. The presence of dehalogenase-like genes in the genomes of other mycobacteria, including the obligate pathogens Mycobacterium tuberculosis and Mycobacterium bovis, as well as in other bacterial species, including Mesorhizobium loti, Xylella fastidiosa, Photobacterium profundum, and Caulobacter crescentus, led us to speculate that haloalkane dehalogenases have some other function besides catalysis of hydrolytic dehalogenation of halogenated substances.

Developments in hematopoietic stem-cell transplantation in the treatment of autoimmune diseases

Intractable forms of autoimmune diseases follow a rapid course, with a significantly shortened life expectancy sometimes comparable to that of malignant diseases. Immunoablative therapy, including high dose cytotoxic agents and hematopoietic autologous stem-cell rescue, was recently introduced as an aggressive approach to treat autoimmune diseases that have a rapid course and are resistant to conventional therapy. The most frequent indication for this type of treatment is multiple sclerosis, seconded by systemic sclerosis. The results of immunoablative treatment with documented responses in both diseases are encouraging. The data are mature enough to begin comparative randomized studies of immunoablative versus conventional treatment to validate the benefit of the aggressive approach. A randomized trial involving SSc was recently launched (ASTIS) and a trial involving MS is in preparation. Considerably less experience with immunoablative treatment has been gained in systemic lupus erythematosus, rheumatoid arthritis, and other disorders with an autoimmune pathophysiology. Autologous hematopoietic stem cell transplantation in humans offers more long-lasting immunosuppression than reeducation of lymphocytes. In fact, allogeneic transplantation may replace the whole immune system. However, this attractive approach is still associated with considerable morbidity and mortality and is not yet justified for treatment of autoimmune diseases. Non-myeloablative allogeneic transplantation and sub-myeloblative high dose cyclophosphamide without stem cell support are alternative approaches that could be explored in pilot studies.

Transjugular renal biopsy. Our experience with 67 cases

BACKGROUND

Transjugular renal biopsy (TJRB) is still a novel technique of renal tissue sampling exploiting the transjugular route. TJRB should be performed particularly in situations when the percutaneous route is precluded, i.e. especially in patients with clotting disorders. In the past, only a few papers reported the experience with larger numbers of patients. The goal of this paper is to analyze our experience with TJRB.

METHODS AND RESULTS

From 1993 to 1999, 67 patients, mean age 49.8 years (SD +/- 10.2), male/female ratio 40/27, underwent TJRB. Fifty-two patients (78%) suffered from renal insufficiency and 19 of them (28%) were on dialysis treatment at the time of TJRB. Arterial hypertension was recorded in 42%. The combined kidney and liver biopsy (46%) and clotting disorders (39%) were the most frequent indications for performing TJRB. Renal tissue was yielded in 53 patients (79%) but a sample sufficient for histological diagnosis was taken in 49 (73%), reaching on average 10.8 glomeruli. Altogether 19 different histological entities were disclosed and out of them, vascular nephrosclerosis (12%), necrotizing and crescentic glomerulonephritis, IgA nephropathy (IgAN) and amyloidosis (three latter per 10%) represented the most frequent diagnoses. TJRB was combined with liver biopsy in 31 patients (46%) and/or hepatic vein catheterization in 22 patients (33%) confirming portal hypertension in 8. The clinically significant liver histology was found in 20 patients, of them cirrhosis/fibrosis in 8, chronic hepatitis in 4 and steatosis in 5. Among those 20 patients, IgAN was disclosed as the most common renal diagnosis (6). Clinically symptomatic complications were recorded in 12 cases (18%) but 9 of them suffered from clotting disorders. Complications included development of subcapsular hematoma in 6 cases, macroscopic hematuria in 4 cases, and hypovolemic hemorrhagic shock in 2. One patient had to undergo surgical treatment. Dividing the patients into a subgroup with or without clotting disorders, the complication rate was 34 vs. 7%.

CONCLUSIONS

TJRB is a new diagnostic method, which, looking at its indications, facilitates the diagnosis of glomerulopathies in patients who could not be considered for percutaneous renal biopsy, particularly due to clotting disorders. The technical aspect of this procedure plays a fundamental role in the final risk/benefit ratio but if done correctly it involves acceptable risk and is well tolerated.

[Clinical and economic significance of iron replacement in anemia treated with recombinant human erythropoietin in patients on hemodialysis]

BACKGROUND

Anaemia is a common phenomenon encountered in patients on hemodialysis. Although treatment with rHuEPO therapy is effective, it may fail even at high doses. As rHuEPO efficacy depends on the bioavailability of iron, we monitored the effect of consistent iron supplementation on hematocrit levels and rHuEPO dosage.

METHODS AND RESULTS

24 patients of our outpatient dialysis centre were included in this study. The mean age was 59 years. The age group over 60 included 14 patients. The mean duration of dialysis treatment was 23.8 months. The patients were followed for 6 months according to the NKF-DOQI (National Kidney Foundation Dialysis Outcomes Quality Initiative) recommendations for the treatment of anaemia. Following values were examined monthly: hematocrit, transferin saturation (TSAT) and ferritin. Iron and rHuEPO dosage was adjusted accordingly. Genetic tests for haemochromatosis were conducted in 4 patients with the highest value of TSAT and ferritin. TSAT increased from a mean of 15.9% to 35.9% (p < 0.001). In 23 patients (96%) TSAT levels were within the recommended range after the treatment. Hematocrit increased from 27.7% to 35.7% (p < 0.001). The recommended value of 33% was achieved in 18 patients (75%). The weekly dose of eHuEPO fell from 3958 IU (International Unit) to 2042 IU (p < 0.001), i.e. 1857 IU of rHuEPO were saved per week, per patient. The average dose of iron administered was 157 mg per week. The average level of ferritin rose from 457 micrograms/k to 1387 micrograms/l (p < 0.001). All results were comparable, even in the group of the senior's selected cases. Genetic testing for haemochromatosis showed mutation H63D in heterozygous state of HFE gene in 2 of 4 patients with the highest value of TSAT and ferritin. Sufficient iron supplementation leads to a significant rise in hematocrit and a concomitant decrease of required rHuEPO doses. TSAT, and not ferritin, is a good marker of iron bioavailability.

CONDITIONS

The financial savings due to decreased rHuEPO requirements are 20 times higher than the costs related to iron supplementation, calculated in relation to prices valid for the Czech Republic in 1999. Cause and effect of increased level of ferritin should be carefully studied.

Blood pressure in diabetic nephropathy--current controversies

Hypertension has been recognized as an early and constant feature of diabetic nephropathy, but recent studies also suggest that a genetic predisposition to hypertension is an important risk factor for diabetic nephropathy. Antihypertensive treatment attenuates progression in diabetic nephropathy, but there is increasing evidence that very early treatment and very low target blood pressures should be implemented. There is also evidence for local activation of the renin system in the kidney as a result of hyperglycaemia. Apart from blood pressure, proteinuria should be monitored and dosing of ACE inhibitors should be guided, also by reduction of protein excretion.

Evaluation of long-term administration of the antioxidant stobadine on exploratory behaviour in rats of both genders

Stobadine (STO) is a prospective neuro- and cardioprotective drug with high antioxidative properties. The aim of this study was to ascertain the effect of long-term administration of STO on exploratory behaviour and habituation processes in adult virgin female and male rats. Stobadine was administered by oral gavage in a single dose of 50 mg kg(-1) day(-1) for a total of 56 days. The animals were tested for exploratory behaviour-intensity of motor and vertical activity in an open field test in three blocks of measurements (initial screening; after 56 days of STO administration; and 28 days after the last treatment). The rate of decline of motor activity was evaluated during four consecutive days of testing (interrupted habituation). Administration of STO resulted in transient inhibition of exploratory behaviour in female rats without overtly detectable toxicity. Exploratory behaviour of males was not affected by STO treatment.

End-stage renal failure in type 2 diabetes: A medical catastrophe of worldwide dimensions

The incidence of patients with end-stage renal failure and diabetes mellitus type 2 as a comorbid condition has increased progressively in the past decades, first in the United States and Japan, but subsequently in all countries with a western lifestyle. Although there are explanations for this increase, the major factor is presumably diminishing mortality from hypertension and cardiovascular causes, so that patients survive long enough to develop nephropathy and end-stage renal failure. This review summarizes the striking differences between countries against the background of a similar tendency of an increasing incidence in all countries. Survival on renal replacement therapy continues to be substantially worse for patients with type 2 diabetes. A major reason for this observation is that patients enter renal replacement programs with cardiovascular morbidity acquired in the preterminal phase of renal failure. It is argued that the challenge for the future will be better patient management in earlier phases of diabetic nephropathy to attenuate or prevent progression, as well as cardiovascular complications.

Rapid detection of Salmonella in field samples by nested polymerase chain reaction

A simple and universal protocol for the rapid detection of Salmonella spp. in various samples using nested polymerase chain reaction (PCR) was developed. The protocol takes advantage of the rapid purification and concentration of Salmonella by centrifugation onto a layer of 60% sucrose solution. DNA was released by treatment with proteinase K and Triton X-100. Even without pre-enrichment, the detection limit for the nested PCR was 10(5) CFU g-1 of faeces. After pre-enrichment, it was possible to detect Salmonella in faeces where their original concentration was approximately 10(2) CFU g-1 of faeces and in meat samples, it was possible to detect Salmonella in samples where their original concentration was less than 10 cells g-1 of minced meat.

Antioxidant stobadine and neurobehavioural development of the rat offspring

Stobadine (STO) is a potential neuro- and cardioprotective drug with high antioxidative properties. The presented study investigated the effects of oral STO administration (5, 15 and 50 mg/kg/d) during pregnancy and lactation to dams on neurobehavioural development of their offspring (body growth and maturation, sensory functions, neuromotor and reflex development, levels of activity and emotional reactivity, memory and learning processes). The results of our experiments showed that long-term administration of STO had no adverse effects on the course of pregnancy and lactation in dams and on the neurobehavioural development of offspring.

[Plasma leptin levels in patients with kidney diseases of various etiologies]

BACKGROUND

Leptin is a new hormone influencing food intake, energy expenditure and body weight. This protein is produced by adipocytes, exerts its effects on brain, endocrine pancreas and other organs by activating transmembrane receptors and is cleared from plasma mainly by the kidneys. The aim of our study was to compare plasma concentrations of leptin in our nephrological out-patients and controls.

METHODS AND RESULTS

We examined 36 diabetic patients with various stages of nephropathy, 12 males with nephrotic syndrome due to membranous nephropathy, 15 dialysis patients and 11 controls. Leptin was assessed in plasma by ELISA. There was a significant difference between plasma levels of leptin in males and females (7.7 +/- 11.4 vs 17.6 +/- 17.3, p < 0.001) and in dialysis and non-dialysis patients (19.6 +/- 16.5 vs 10.7 +/- 14.5, p < 0.05). There was also a difference between dialysed and non-dialysed men (15.1 +/- 16.2 vs 5.9 +/- 9.2, p < 0.05). We found no difference between men with and without nephrotic syndrome and between BMI or age. There was a positive correlation of leptin with diabetic and non-diabetic women. There was positive correlation of P-leptin with serum creatinine in non-dialysed women (r = 0.68, p < 0.001) and a negative correlation with S-albumin in nephrotic men (r = -0.65, p < 0.05).

CONCLUSIONS

Women have higher plasma leptin concentrations than men and dialysis patients have higher concentrations than non-dialysed patients. Apart from the positive correlation with S-creatinine in non-dialysed women. There was positive correlation with S-albumin in nephrotic men there were no correlations with renal function, BMI, age, S-cholesterol, S-triglycerides and S-albumin.

[Properties of Salmonella isolates in the Czech Republic]

Based on a grant project "Use and importance of epidemiological markers in Salmonella enteritidis and Salmonella typhimurium in the spread of salmonelloses in children under two years of age" implemented in 1995 to 1997, the authors investigated epidemiological markers in 1,186 salmonella isolates; the strains were isolated from faeces of 838 sick children, from 266 faeces of their contacts, from 49 specimens of incriminated foods and from 33 smears from the children's environment. Of 1,186 Salmonella isolates 999 were strains of S. enteritidis, 39 strains of S. typhimurium and 148 strains were not identified. The markers of Salmonella isolates were investigated from the aspect of biotyping--98% S. enteritidis were formed by the biovar Jena. 2% by biovar Essen; sensitivity to antibiotics--94.5% Salmonella strains were sensitive to 12 selected antibiotics, 2.9% were resistant and in 2.6% the resistance was in the intermediate zone; phagotyping--in 808 strains of S. enteritidis PT 8--88% predominated, in S. typhimurium DT 104 and DT 141; assessment of plasmid profiles--in strains of S. enteritidis plasmid 55 kb predominated, in three strains of S. typhimurium a plasmid size 95 kb; virulence--was compared in 43 strains isolated from hospitalized children with a severe clinical course with 39 strains from children treated at home. In vitro tests revealed that hospitalization of affected children was associated with virulence of the strains (SE phagotype 8) and not with age. The presented results are discussed with regard to the epidemiological situation in the Czech Republic and in the world.

The drama of the continuous increase in end-stage renal failure in patients with type II diabetes mellitus

Type II diabetes mellitus has become the leading cause of end-stage renal failure in many countries of Western Europe. In all European countries, even in those with a relatively low prevalence of diabetic nephropathy, the number of patients with type II diabetes mellitus admitted for renal replacement therapy has recently increased continuously. Survival and medical rehabilitation of patients with type II diabetes on renal replacement therapy is significantly worse than in non-diabetic patients. It is obvious that in order to stem the tide, intense efforts are necessary (i) to inform the medical community about the renal risk of type II diabetes and the striking effectiveness of preventive measures, (ii) to provide better care for diabetic patients, and (iii) to reduce the high prevalence of diabetes in the population by modification of the Western life style.

Left ventricular hypertrophy in renal failure

In patients with terminal renal failure, left ventricular hypertrophy (LVH) is extremely common. It is found in approximately 60 to 80% of patients starting renal replacement therapy. The main causes of LVH are increased preload from hypervolemia and increased afterload from increased peripheral resistance, giving rise to a mixture of eccentric and concentric hypertrophy, but other factors (high cardiac output from anemia and arteriovenous (A-V) fistula, altered compliance of central arteries, and activation of local systems such as renin and endothelin) also play a role. The clinical importance of LVH derives from the fact that LVH is a predictor of cardiac death in dialyzed patients independent of blood pressure. LVH is accompanied by microvascular disease and by marked interstitial fibrosis (more than seen in non-renal patients with similar degrees of hypertension). Recent findings suggest that LV remodeling starts early and is seen even in normotensive patients with glomerulonephritis when GFR is still normal. The strategies to reduce LVH include reduction of hypervolemia, (near) normalization of hemoglobin and lowering of blood pressure, particularly by administration of angiotensin converting enzyme inhibitors.

Optimizing antihypertensive therapy in patients with diabetic nephropathy

The number of cases of diabetic nephropathy is increasing, especially among patients with non-insulin-dependent diabetes mellitus (NIDDM). It is difficult to prevent the occurrence or progression of NIDDM, and current levels of treatment are below standard. According to one study, actuarial 5-year survival rates are only about 38% for patients with insulin-dependent diabetes mellitus and 9% for those with NIDDM receiving renal replacement therapy. Because cardiovascular diseases are responsible for more than half of these deaths, hypertension, as a major contributing factor to cardiac death, is a crucial component in the therapy for such patients. It is well established that lowering blood pressure is an important preventive measure to be taken in patients with diabetic nephropathy; blockade of the renin-angiotensin system offers benefits beyond lowering blood pressure in type I diabetic nephropathy. Two major trials are currently underway to determine the effects of angiotensin II receptor antagonists on nephropathy in patients with NIDDM. The Irbesartan Diabetic Nephropathy Trial (IDNT) has already enrolled approximately 85% of the proposed 1650 NIDDM patients to be randomly assigned to placebo, irbesartan or amlodipine. Baseline characteristics of the initial cohort are presented. In light of the well-documented case for blockade of the renin-angiotensin system in diabetes, the potentially superior blockade afforded by angiotensin II receptor antagonists, and the superior tolerability of these agents, trials such as the IDNT take on special importance for the treatment of diabetic patients. From these data may come the justification for the belief that angiotensin II receptor antagonists impart greater benefits in the treatment of diabetes than merely their well-documented role in lowering blood pressure.

Restriction fragment length polymorphism and virulence of Czech Toxoplasma gondii strains

Restriction fragment length polymorphism analysis of chromosomal DNA from 22 strains of Toxoplasma gondii were characterised using SalI and PstI restriction endonucleases and the TGR1E specific repetitive sequence as a probe. Two virulent strains, RH and P-CZ, had previously been isolated from humans, the remaining 20 strains were isolated from animals in the Czech Republic in 1994 and 1995. Among the 20 recently isolated strains, 19 belonged to an avirulent lineage and only one strain from the wild cat Felis silvestris belonged to a virulent lineage.

Cytokines and adhesion molecules in renal vasculitis and lupus nephritis

BACKGROUND

Plasma levels of some pro-inflammatory cytokines and soluble adhesion molecules have been suggested to be useful parameters to assess the activity of antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis and lupus nephritis. We hypothesized that the renal activity of these diseases is better reflected by the urinary excretion and fractional excretion of these molecules.

METHODS

Plasma levels and urinary excretion of tumour necrosis factor-alpha (TNF-alpha), interleukin (IL)-6, IL-8, and the soluble cell adhesion molecules sICAM-1 and sVCAM-1 were measured by enzyme-linked immunosorbent assay (ELISA) in 14 patients with ANCA-positive renal vasculitis (eight active, ANCA-A; six in remission, ANCA-R), six patients with active lupus nephritis (LN), 15 patients with IgA nephropathy (IgAN) and nine healthy subjects. Fractional excretion of selected cytokines and adhesion molecules was also calculated.

RESULTS

Patients with ANCA-A had increased urinary excretion and fractional excretion of TNF-alpha (9.27 +/- 3.19% vs 0.58 +/- 0.02%, P < 0.01), IL-6 (120.79 +/- 65.83% vs 1.89 +/- 0.34%, P < 0.01) and increased fractional excretion of IL-8 (23.34 +/- 6.38% vs 2.56 +/- 1.07%, P < 0.01) and sVCAM-1 (0.81 +/- 0.33% vs 0.03 +/- 0.02%, P < 0.01) compared with controls. Urinary excretion of TNF-alpha and IL-6 and fractional excretion of TNFalpha, IL-6 and IL-8 were higher in ANCA-A than in ANCA-R. Patients with LN had increased plasma TNF-alpha (20.52 +/- 2.01 pg/ml vs 12.33 +/- 0.23 pg/ml, P < 0.05) and sVCAM-1 (1537.88 +/- 276.36 ng/ml vs 692.26 +/- 44.42 ng/ml, P < 0.05) and increased urinary excretion of TNF-alpha (2.81 +/- 0.51 microg/mol creat vs 0.98 +/- 0.05 microg/mol creat, P < 0.01), IL-8 (35.78 +/- 14.03 microg/mol creat vs 12.46 +/- 5.19 microg/mol creat, P < 0.05) and sVCAM-1 (48.98 +/- 20.20 microg/mol creat vs 2.92 +/- 1.35 microg/mol creat, P < 0.01) compared with controls. Patients with IgAN had, in comparison with controls only increased plasma TNF-alpha (18.10 +/- 0.57 pg/ml vs 12.33 +/- 0.23 pg/ml, P < 0.05).

CONCLUSIONS

Urinary excretion and fractional excretion, but not plasma levels, of selected pro-inflammatory cytokines (TNF-alpha, IL-6 and IL-8) were increased in patients with active ANCA-positive renal vasculitis, but not in ANCA positive vasculitis in remission. These parameters may be useful to monitor the activity of this disease.

Effect of 1 year cyclosporine A treatment on the activity and renal involvement of systemic lupus erythematosus: a pilot study

Our objective was to determine the effect of 1 year low-dose cyclosporine A (CSA) treatment on disease activity and renal involvement in systemic lupus erythematosus (SLE). Patients included in the pilot study had an active form of the disease as defined by the SLE Disease Activity Index (SLEDAI). Main organ involvement was represented by lupus nephritis classified in repeated renal biopsies. Eleven patients with SLE were enrolled in the study. In eight of them, previous therapy with cyclophosphamide or azathioprine had to be interrupted due to serious adverse reaction or low efficacy. Nine patients experienced clinical nephrotic syndrome, and two the nephritic syndrome. After 12 months of CSA treatment, the mean SLEDAI score had decreased significantly from 26.18 to 4.00 (P < 0.01). Similarly, the titre of antinuclear and anti-dsDNA antibodies had dropped significantly (P < 0.01). Proteinuria decreased rapidly from 9.10 to 1.70 g/24 h (P < 0.001). According to the WHO classification of renal biopsies, three patients had their class altered from IV to III in response to CSA treatment and five patients had changed the status from the high severity grade to the mild. The adverse reactions included hypertension (45%), gingival hyperplasia (18%) and hirsutism (9%). No significant increase in serum creatinine or any CSA related toxic changes were found in renal biopsies. The favourable response observed in patients with active SLE and with major renal involvement strongly suggests that low-dose CSA is a potent drug as much for the reduction of the disease activity as for lupus nephropathy treatment.

A new bacteriophage typing scheme for Proteus mirabilis and Proteus vulgaris strains. 3. Analysis of lytic properties

The lytic properties of 21 bacteriophages constituting a new typing set for Proteus were examined in 507 Proteus mirabilis and 29 P. vulgaris strains isolated from patients and healthy subjects. Comparison of their morphological, serological, genetic and lytic properties showed that, in the Myoviridae and Podoviridae families, some phages were so closely related that the presence of all of them in the set was redundant. Analysis of the lytic properties revealed that some of the bacteriophages were not active enough to facilitate the differentiation of Proteus strains. The size of the final typing set was reduced from 21 to 12 phages but it was suggested that, in order to improve the differentiation capacity of the set, new phages should be included.

[Cytokines and adhesion molecules in renal vasculitis and lupus nephritis]

BACKGROUND

Plasma levels and urinary excretion of proinflammatory cytokines and soluble adhesion molecules may be useful parameters of the activity of ANCA-positive renal vasculitis and lupus nephritis.

METHODS AND RESULTS

Plasma levels and urinary excretion of TNF alpha, IL-6, IL-8, ICAM-1 and VCAM-1 were measured by ELISA in 14 patients (pts) with ANCA-positive renal vasculitis (8 active-ANCA-A, 6 in remission ANCA-R), 6 pts with active lupus nephritis (L.N), 15 pts with IgA nephropathy (IgAN) 10 pts with autosomal dominant polycystic kidney disease and 9 healthy subjects (Co). Fractional excretion (FE) of selected cytokines and adhesion molecules was also calculated. Pts with LN had in comparison with controls increased plasma levels of ICAM-1, VCAM-1, IL-6, IL-8 and TNF alpha, increased urinary excretion of VCAM-1, IL-8 and TNF alpha and increased fractional excretion of VCAM-1 and IL-8. Patients with ANCA-A had in comparison with controls increased plasma concentrations of ICAM-1 and VCAM-1, increased urinary excretion of VCAM-1, IL-6 and TNF alpha and increased fractional excretion of VCAM-1, IL-6, IL-8 and TNF alpha. Patients with ANCA-R had in comparison with controls higher plasma levels of ICAM-1, VCAM-1, IL-6 and TNF alpha, increased urinary excretion of VCAM-1 and TNF alpha and increased fractional excretion of VCAM-1, IL-6 and TNF alpha.

CONCLUSIONS

Patients with ANCA-positive renal vasculitis had in contradistinction to pts with active LN increased fractional excretion of IL-6 and TNF alpha. Both cytokines are probably produced in renal vasculitis locally in the kidney. Increased plasma levels of soluble adhesion molecules and increased plasma levels and fractional excretion of proinflammatory cytokines in patients with ANCA-positive renal vasculitis in clinical remission may explain the strong propensity of these patients to develop relapses of the diseases on withdrawal of immunosuppressive treatment.

[Controlled clinical study of Consupren versus cyclophosphamide in chronic glomerulonephritis. II. Adverse effects]

BACKGROUND

The second part of the study was designed to assess Consupren side effects.

METHODS AND RESULTS

The groups of patients studied were described in Part I. Side affects typical of Cy-A were evaluated only in the CS group. Gastrointestinal intolerance, only mild and temporary, was observed in 31%, neurotoxicity in 44%, hypertrichosis in 37%, nephrotoxicity in 25%, and gingival hypertrophy in 19%. Mean values of systolic and diastolic blood pressure did not change significantly in the course of treatment. When changes in blood pressure were individually investigated in particular patients, they were found in 31% in the CS group and in none in the K group. Mean values of uric acid non-significantly increased in the CS group and, on individual investigation, hyperuricaemia was observed in 31%. Mean values of serum potassium did not alter significantly. Signs of possible hepatotoxicity were found in 37% patients of the CS group. In this group, there was a significant decrease in haemoglobin mean values and a decrease in haemoglobin of more than 25 g/l was observed in 44% of CS group patients. In the K group significant decrease in mean leukocyte count was noted, but no patient developed real leukopenia.

CONCLUSIONS

The occurrence of side effects was comparable to data known from the literature.

[Clinical spectrum of the antiphospholipid syndrome]

Antiphospholipid syndrome (APS) is characterized by multiple arterial and venous thromboses, repeated spontaneous abortions and thrombocytopenia, together with the presence of antiphospholipid antibodies in serum. We present three patients, two men and a woman, at the age of 43, 24 and 23 years respectively. The younger man and the woman had secondary APS and systemic lupus erythematosus, the older man had primary APS. The symptoms and course of the disease were different. The older man lives 17 years after the onset of first symptoms with multiple neurologic disorders, the younger man is symptomless. The woman died several months after the acute onset of the disease.

[Use of molecular genetics for identification and differentiation of various strains and species of bacteria]

The aim of the paper is to inform on methods and practical application of DNA fingerprinting in typing of living organisms. Methods discussed in the review include standard DNA fingerprinting, plasmid profile analysis, RAPD PCR and direct sequencing of selected parts of genomes. In each method molecular basis together with its advantages and limitations is explained. All described methods are supplemented with selected cases of their practical application.

Identification of enterotoxin-producing strains of Escherichia coli by PCR and biological methods

The polymerase chain reaction (PCR) and biological methods for detection of enterotoxigenic strains of Escherichia coli were compared. The tests for LT, STa and STb were done in the cell line Y1, suckling mice, and ligated piglet intestinal loops, respectively. The production of STb was tested only in strains negative for LT and STa. The polymerase chain reaction has proved to be specific and reliable method than the biological methods. Unlike the latter, PCR allows the detection of strains producing in vitro only low quantities of the toxin. On the other hand, PCR fails to identify strains producing toxic substances with a different structure but the same or similar biological properties.

[A controlled clinical trial of Consupren versus cyclophosphamide in chronic glomerulonephritis]

BACKGROUND

Experience gained from recent studies shows, that Cyclosporine-A (Cy-A) may decrease proteinuria (PU) in some forms of chronic glomerulonephritis (GN) with the nephrotic syndrome. The aim of this study was to test the efficacy of Czech-made Cy-A, Consupren.

METHODS AND RESULTS

30 patients with chronic GN, confirmed by biopsy and PU higher than 3 g/d, corticodependent or corticoresistant, were randomized according to the month of birth to either therapy with Consupren at an initial dose of 5 mg/kg/d (CS group, after dropout of 3 patients who did not finish the treatment, n = 16) or Cyclophosphamide at a dose of 1.5 mg/kg/d (K group, n = 11), and prednisone maintained at the original dose in both groups. The treatment was stopped after six months or after achieving remission. The main criterion of efficacy was PU. The decrease in mean values, statistically evaluated by Holm's procedure was highly significant in the CS group and non-significant in the K group. A similar evaluation of PU corrected by glomerular filtration rate was significant in both groups. Partial or complete remission was reached in 50% of CS group patients and in 34% of K group patients (NS). In the CS group a significant increase in the mean values of albumin and gama-globulin, and a decrease in cholesterol levels were observed. In the K group, these changes were non-significant.

CONCLUSIONS

In patients with chronic GN and the nephrotic syndrome, the efficacy of Consupren treatment gives comparable, or even better results versus treatment with Cyclophosphamide.

Effect of long-term administration of stobadine on exploratory behaviour and on striatal levels of dopamine and serotonin in rats and their offspring

Stobadine (STB), a cardioprotective drug, was evaluated for its effect on the intensity and habituation of exploratory behaviour in open field testing and on the levels of striatal dopamine (DA), serotonin (5-HT) and their metabolites (3,4-dihydroxyphenylacetic acid, homovanillic acid, 5-hydroxyindole-3-acetic acid) in rats and their offspring. Dams were treated by oral gavage with STB (50 mg kg-1) for a total of 56 days from 14 days before mating to day 21 postpartum (pp). The first open field measurements of the dams were performed over 4 days at the beginning of the experiment, the second on days 21-24 pp and the third on days 49-52 pp (recovery period). Their offspring were tested on postnatal (pn) days 30-33 and 60-63. The biochemical analysis (HPLC with electrochemical detection) in the dams was performed at the same time schedule as given for the open field testing, but in their offspring only on pn day 60. Motor activity of the dams was decreased on days 21-24 pp. The increase of motor activity in female offspring was observed on pn days 30-33. Neurochemical analysis of the striatum of the dams revealed a significant increase of the levels of DA, 5-HT and 5-hydroxyindole-3-acetic acid. In male offspring the levels of DA were significantly decreased, whereas in females the levels were increased. These results suggest that maternal administration of STB resulted both in dams and their offspring in minor alterations in spontaneous behaviour components and changes in the dopaminergic and serotonergic system, but without inducing overtly detectable toxicity.

The influence of cyclosporin on lipid peroxidation and superoxide dismutase in adriamycin nephropathy in rats

Cyclosporin A (CsA) was shown to reduce proteinuria in nephrotic syndrome, but its potential to increase lipid peroxidation may play a role in cyclosporin nephrotoxicity. The influence of cyclosporin treatment on the lipid peroxidation (assessed as malondialdehyde (MDA) in plasma and kidney homogenates using HPLC and reaction with thiobarbituric acid) and the activity of superoxide dismutase (SOD) in erythrocytes was studied in rats with nephrotic syndrome induced by single intravenous injection of adriamycin. Rats with nephrotic syndrome treated from the beginning with cyclosporin had lower proteinuria than untreated nephrotic rats. Free MDA in blood and kidney homogenates was significantly elevated in untreated nephrotic rats in comparison with controls. Activity of SOD in erythrocytes was significantly elevated in nephrotic rats treated with cyclosporin (113.40 +/- 34.31 mU/10(6) erythrocytes) in comparison with the control group (55.63 +/- 9.90 mU/10(6) erythrocytes, p < 0.001), rats treated with cyclosporin (65.7 +/- 17.49 mU/10(6) erythrocytes, p < 0.01) and untreated nephrotic rats (65.07 +/- 17.49 mU/10(6) erythrocytes, p < 0.001). In conclusion, cyclosporin reduced proteinuria in rats with mild adriamycin nephropathy (similar to human minimal change disease). Cyclosporin also partially counteracted adriamycin-induced lipid peroxidation probably due to the stimulation of antioxidant enzyme SOD. The possible contribution of decreased lipid peroxidation to the antiproteinuric effect of cyclosporin deserves further study.

[Long-term administration of cyclosporine A in patients with IgA nephropathy]

BACKGROUND

IgA nephropathy is the most common glomerulonephritis all over the world and a considerable proportion of the patients reaches end-stage renal failure. Yet the standard treatment for the patients with progressive course and/or great proteinuria is currently lacking. All suggested treatment protocols, including short-term treatment with cyclosporine A had equivocal results. Therefore we decided to try long-term cyclosporine treatment.

METHODS AND RESULTS

We treated 6 patients (4 males, 2 females, age 21-31 years) with bioptically proven IgA nephropathy and proteinuria over 3.5 g/24 hrs with or without nephrotic syndrome non responding to corticosteroid therapy administered for at least 3 months. Patients with serum creatinine greater than 200 mumol/l and/or glomerulosclerosis in more than 50% of glomeruli in renal biopsy were excluded. Pts were given cyclosporine A in initial dose 5 mg/kg bw/day then titrated aiming to the serum concentration of 70-150 ng/ml. Prednisone 5-10 mg on alternate days was given with cyclosporine. Proteinuria decreased during first month of therapy from 4.66 +/- 0.43 g/day to 1.38 +/- 0.29 g/day (p < 0.01) and remained low after one year of treatment (0.59 +/- 0.14 g/day, p < 0.001). Glomerular filtration rate (creatinine clearance) did not change during first month of therapy (1.25 +/- 0.21 ml/s vs. 1.38 +/- 0.29 ml/s), but slightly decreased after one year of treatment (1.05 +/- 0.14 ml/s, p < 0.05). We also calculated ratio of proteinuria to glomerular filtration rate (g/l) to assess the role of hemodynamic changes in the decrease of proteinuria. This ratio was 53.80.10(-3) +/- 15.20.10(-3) before cyclosporin therapy, it decreased significantly after one month (11.56.10(-3) +/- 3.24.10(-3), p < 0.05) and achieved the lowest value after one year of therapy (6.78.10(-3) +/- 4.25 .10(-3) +/- 4.25.10(-3), p < 0.01). Serum cholesterol also significantly decreased after 12 months of therapy (6.21 +/- 0.62 vs. 5.41 +/- 0.45 mmol/l, p < 0.05).

CONCLUSIONS

CyA significantly lowered moderate to high proteinuria with much less decrease of glomerular filtration rate in 6 patients with IgA. Significant decrease of proteinuria/GFR ratio strongly suggests some non-hemodynamic mechanisms of cyclosporine action in these patients. Therapy was well tolerated and side-effects were not so severe to require cyclosporine withdrawal.

Rapid method for isolation of high molecular weight plasmids suitable for digestion with restriction endonucleases

The described method is a modification of the hot alkaline method (Kado and Liu, 1981). The modification lies in replacement of SDS with Triton X- 100. The DNA purified by this method was readily digested with restriction endonucleases for a variety of applications, e. g. restriction analysis of plasmid DNA in epidemiological studies, restriction mapping and cloning of high molecular weight plasmids, and for identification of transpozon mutants.

Effect of long-term administration of stobadine to rats on selective variables of spontaneous behaviour of their offspring

The present study investigated the effect of long-term administration of the cardioprotective drug stobadine (STB) to dams on selective variables of spontaneous behaviour of their offspring in open field (horizontal and vertical activities, frequency and duration of grooming, and duration of total activity and immobility) tested on day 60 of age. The treatment of dams with STB significantly increased horizontal activity of offspring in both sexes. The other variables studied were not affected, with the exception of a significant increase in the frequency and duration of grooming and in the duration of total activity in females compared to males from STB treated dams.

The influence of pefloxacine on experimental adriamycin-induced nephrotic syndrome in rats

Initial reports on antiproteinuric effect of pefloxacine in small groups of patients with minimal-change nephropathy (MCN) and focal and segmental glomerulosclerosis (FSGS) have not been confirmed in other papers. To assess its antiproteinuric effect in experimental animals we administered pefloxacine to rats with adriamycin nephropathy showing morphological changes resembling human minimal-change disease or focal segmental glomerulosclerosis, and clinically with full-blown nephrotic syndrome. Pefloxacine treatment was at least partially effective in preventing further increase of proteinuria in rats with adriamycin nephropathy. The mechanism of this effect remains unclear and deserves further studies concentrating on the glomerular cytokine network and glomerular production of reactive oxygen species.

[Renal vasculitis and glomerulonephritis with anti-neutrophil cytoplasmic antibody positivity]

BACKGROUND

Anti-neutrophil cytoplasmic antibodies (ANCA) define pathogenetically related group of renal vasculitides and glomerulonephritides mostly with serious prognosis. If unrecognized, these life-threatening diseases may cause loss of independent renal function and other dangerous extrarenal complications (e. g. pulmonary haemorrhage). We concentrated on the diagnosis, treatment and log-term follow-up of these patients.

METHODS AND RESULTS

Renal biopsy was performed in 46 ANCA-positive patients. Age and sex distribution, type of ANCA, organ involvement, renal biopsy findings, renal function and effect of therapy were analyzed in these patients. Twenty three patients suffered from renal vasculitis, most commonly Wegener's granulomatosis (14 patients) and microscopic polyarthritis (7 patients). IgA nephropathy (7 patients) and idiopathic necrotizing/crescentic glomerulonephritis (8 patients) prevailed in patients with limited renal involvement. Renal morphology and function was most seriously impaired in patients with Wegener's granulomatosis. Immunosuppressive treatment was able to control the activity of the disease with the negativization of ANCA and improvement or stabilization of renal function in more than 90% of patients.CONCLUSIONS. ANCA-positive renal vasculitis and glomerulonephritis is relatively common. Clinical signs of extrarenal involvement are present in about 50% of patients with ANCA-positive glomerulonephritis. Rapidly introduced immunosuppressive treatment effectively controls renal and extrarenal manifestations of the disease.

[The effect of pefloxacin on nephrotic syndrome in experimental adriamycin nephropathy]

BACKGROUND

Antiproteinuric effect of pefloxacine was demonstrated in a small group of patients with minimal change nephropathy (MCN) and focal and segmental glomerulosclerosis (FSGS). This finding was not, however, confirmed by other papers. Adriamycine nephropathy is an experimental model of nephrotic syndrome with morphological changes resembling MCN and/or FSGS in patients.

METHODS AND RESULTS

Nephrotic syndrome was induced in rats by the i.v. administration of adriamycine. One part of nephrotic animals was treated from the beginning of the 4th week by daily intraperitoneal application of pefloxacine. Administration of adriamycine led in experimental animals after 3 weeks to the development of full-blown nephrotic syndrome with further progression of proteinuria in the next 3 weeks (from 1.4 +/- 1.25 to 2.23 +/- 1.89 g of protein/mmol of urinary creatinine, p < 0.05). Proteinuria did not change in nephrotic rats treated by pefloxacine (from 1.04 +/- 0.97 to 1.26 +/- 1.11 g of protein/mmol of urinary creatinine, p = n.s.). The difference in proteinuria between both groups was also significant (0.83 +/- 0.73 vs. 0.23 +/- 0.67 g of protein/mmol of urinary creatinine, p < 0.05).

CONCLUSIONS

Pefloxacine was antiproteinuric in experimental adriamycine nephropathy. The mechanism of this effect remains unclear and deserves further studies concentrating on glomerular cytokine network and glomerular production of reactive oxygen species.

[Diagnostic and pathogenic significance of antineutrophil cytoplasmic antibodies in vasculitides]

OBJECTIVES

The study represents a complex report on diagnostic and pathogenic significance of antineutrophil cytoplasmic autoantibodies (ANCA). Our report is founded on the results of our clinical and experimental studies.

METHODS

ANCA was examined by indirect immunofluorescence, or ELISA-anti MPO. The data for evaluation of diagnostic ANCA associations were gained by means of questionnaires. The experimental part involved examination of the impact of sera containing ANCA and monoclonal antibodies (MoAb) against proteinase 3 and control MoaB specific for neutrophils.

RESULTS

Within the course of 1 year we have examined 1010 samples, ANCA was found in 65 patients: 26 cases of systemic vasculitis, 12 cases of other autoimmune diseases, 9 cases of isolated glomerulonephritis, 7 cases of inflammatory intestinal diseases, 6 cases of ophthalmic inflammatory diseases, and 6 cases of other diseases. Vasculitis of small vessels found in our group of patients are concomitted by ANCA positivity in 90% (Wegener's granulomatosis 15/16, Churg--Strauss's syndrome 3/5, MPA 9/9), vasculitis of medium vessels 12% (classical polyarteritis nodosa 1/2, Kawasaki disease 0/2, Henoch--Schönlein's purpura 0/4, Takayasu's arteritis 1/4). The ANCA-containing sera inhibit the candidacidal activity by 65% in average. THe inhibitory impact is yielded by anti-proteinase MoAb, in contrast to the control MoAb.

CONCLUSION

c-ANCA in high concentration is specific for active form of Wegener's granulomatosis, other types of ANCA in low titres are not of diagnostic value for vasculitis. ANCA is concomitted especially by small vessels vasculitis. The proved inhibition of microbicidal PMN activity by ANCA can participate in some clinical signs of immunodeficiencies in vasculitis. (Tab. 5, Ref. 18.).

[Adhesion molecules and cytokines in vasculitides]

Renal vasculitis syndromes include particular characteristic changes in concentrations of some cytokines in plasma or urine. Preliminary results suggest that the systemic lupus erythematodes with affliction of the kidneys is specifically concomitted by the increase in IL-8, both in plasma and urine. ANCA-positive renal vasculitis syndromes appear to coincide with a typical increase in the synthesis of interleukin-6 in the kidneys. We suggest that the monitoring of individual cytokine levels in plasma and urine will enable to study in greater detail the immunopathogenesis of renal vasculitis syndromes and the extent of local production of cytokines which may cause further progression of renal lesions. (Fig. 4, Tab. 1, Ref. 10.).

[The spectrum of diseases associated with antineutrophil cytoplasmic antibodies]

BACKGROUND

Antineutrophil cytoplasmic antibodies (ANCA) are considered as a diagnostic marker of systemic vasculitis and rapidly progressing glomerulonephritis. They are frequently associated with other pathological conditions. The author's objective was to analyze a group of patients examined at the Department of Clinical Immunology of the First Medical Faculty Charles University in the course of one year and evaluation of the diagnostic asset of the ANCA examination.

METHODS AND RESULTS

ANCA was assessed in serum using the method of indirect immunofluorescence. In cases of p-ANCA the ELISA test was used to assess antimyeloperoxidase antibodies. Clinical data were evaluated on the basis of analysis of a questionnaire sent to doctors of patients where ANCA was detected. In 1992 1010 specimens were examined and in 115 ANCA was detected. This was the case in a group of 65 patients with the following diagnoses: systemic vasculitis 26x, systemic immunopathological diseases 12x, renal diseases 9x, inflammatory bowel diseases 7x, inflammatory eye diseases 6x, monoclonal paraproteinaemia 2x, other 4x. The patients had renal affections (45%), affections of the joints (20%), skin (18%), eyes (14%), lungs (12%), GIT (11%), ENT (9%), and nerves (9%). Type c in titres above 1:160 was always associated with the diagnosis of Wegener's granulomotosis, in other instances c- or x-types titres of 1:20 were involved. Antibodies against myeloperoxidase were detected in four instances.

CONCLUSIONS

The authors confirmed that c-ANCA in high concentrations are specific for the predominantly active form of Wegener's granulomatosis. The group of patients with p-ANCA is too small to generalize the diagnostic impact. Low ANCA concentrations are found in many other diseases. The importance of ANCA can be evaluated only in a clinical context and the importance of their presence must not be overestimated.

Antineutrophil cytoplasmic antibody-positive sera inhibit candidacidal activity of granulocytes

Antineutrophil cytoplasmic antibodies (ANCA) are suspected of being involved in the pathogenesis of tissue injury in systemic vasculitis. We have investigated the effect of 10 sera from 8 patients with ANCA-associated diseases on the capacity of neutrophils derived from healthy persons to kill ingested Candida albicans. ANCA-containing sera inhibited candidacidal activity by 55-80% in comparison to control sera. This phenomenon could lead to the depression of antimicrobial resistance of patients with ANCA and could be involved in the pathogenesis of granuloma formation.

A new phage typing scheme for Proteus mirabilis and Proteus vulgaris strains. 1. Morphological analysis

A new bacteriophage typing set, composed of 22 phages, was established as a tool for differentiation of Proteus strains. All the phages were tailed and included 4 morphological types (A1, A2, B1 and C1). They were classified into the families Myoviridae, Siphoviridae and Podoviridae. From the set, 19 phages had double-stranded DNA and 3 were single-stranded DNA phages.

[Serum antineutrophil cytoplasmic antibodies inhibit the ability of granulocytes to kill C. albicans]

BACKGROUND

According to several experimental studies, antineutrophil cytoplasmic antibodies (ANCA) are involved in the pathogenesis of tissue injury in some systemic vasculitis and glomerulonephritis by stimulating oxygen radical release and secretion of lysosomal enzymes from neutrophilic granulocytes. In our work, we studied the effect of ANCA-positive sera on the ingestion and killing of C. albicans by granulocytes from healthy persons. METHODS AND RESULTS. Neutrophils isolated from the blood of healthy persons were incubated with live C. albicans in ratio 1:1 in the presence of pooled sera (controls) and 10 sera from 8 patients with ANCA-associated diseases: 6x Wegener's granulomatosis, 1x idiopathic rapidly progressive glomerulonephritis, 1x rapidly progressive glomerulonephritis concomitantly ANCA and anti-GBM (glomerula bas. membrane) positive. ANCA-positive sera did not influence the ingestion of C. albicans, but strongly inhibited killing of C. albicans (55-80% in comparison to controls). Sera from 2 patients in the time of ANCA-negativization showed lower inhibition (5 and 35%, respectively).

CONCLUSIONS

We demonstrated inhibitory effect of ANCA-positive sera on candidacidal activity of neutrophils from healthy persons. This fact could be one of the pathogenetic mechanisms of granuloma formation in Wegener's granulomatosis. Results of our experiment could be an additional rationale for the administration of trimethoprim/sulfamethoxazole as prevention of relapses of systemic vasculitis.

[Rapidly progressive glomerulonephritis in a solitary kidney positive for anti-glomerular basement membrane antibodies and antineutrophil cytoplasmic antibodies]

The authors describe the case-report of a 72-year-old female patient with acute failure of a solitary kidney with complete functional breakdown which developed within several days and was due to rapidly progressive glomerulonephritis (RPGN) with concurrent positivity of antineutrophil cytoplasmatic autoantibodies (ANCA) and anti-glomerular basement antibodies (AGBMA). Intensive combined immunosuppressive therapy with methyl prednisolone, cyclophosphamide and azathioprine and concurrent plasmaphereses led to negativity of both types of antibodies but were not able to restore sufficient renal function and regular dialysis treatment to be started. Subsequently AGBMA remained negative, while ANCA became again positive. Despite this partial restoration of renal function was manifested by an increased diuresis and the frequency of dialyses could be reduced. The case-report has several remarkable features. An uncommon RPGN of the antirenal type is involved, moreover in a solitary kidney with concurrent C-ANCA positivity. The concurrent presence of ANCA and AGBMA autoantibodies in RPGN has been described in the literature only in several tens of cases. So far it was not described in our country. Based on their experience the authors conclude: 1. a solitary kidney cannot be considered in case of suspected RPGN as a strict contraindicatio of renal biopsy, 2. RPGN with concurrent positivity of ANCA and AGBMA is indicated for long-term immunosuppressive therapy on account of a more favourable prognosis than simple antirenal RPGN, and also with regard to a possible suspected systematic vasculitis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Transjugular renal biopsy--initial experience]

BACKGROUND

Transjugular renal biopsy (TJRB) is a new method designed to obtain bioptic specimens of the kidney. It has defined indications in situations where application of the standard percutaneous technique involves an increased risk. It is used in particular in cases with impaired haemocoagulation with a different aetiology. The method was not used so far in this country. The authors describe the initial experience with TJRB.

METHODS AND RESULTS

After cannulation of the right internal jugular vein under continuous skiascopic control a catheter was inserted into the right renal vein. Through the lumen of the catheter a special bioptic needle is inserted. The collection proper of renal tissue is made by the puncture- aspiration technique. The authors performed TJRB in 10 patients, in 8 specimens of the renal cortex were collected, on average seven glomeruli. The histological examination was a significant contribution to diagnosis in seven patients. The development of subcapsular haematoma with a clinical symptomatology was recorded in three patients, other complications were not observed.

CONCLUSIONS

TJRB is a new diagnostic method, which with regard to its indications, no doubt, facilitates the diagnosis of glomerulopathies. Although the method is demanding from the technical aspect, if done correctly, it involves little risk. It is well tolerated and reduced the risk of possible complications of renal biopsy.