Biochemistry and physiology of anabolic androgenic steroids doping

Anabolic Androgenic Steroids (AASs) are chemical and pharmacological derivatives of the male hormone testosterone which are widely used for increasing burst and sprinting activities in sports. Although AASs are thought to be transversal to the plurality of sports disciplines, they are principally misused by bodybuilders, weightlifters, shot, hammer, discus or javelin throwers, rugby and American football players as well as by swimmers and runners. AAS exert a kaleidoscope of effects on human biology, principally through the 5-α-reductase-mediated conversion into dihydrotestosterone, the aromatase-mediated conversion into female sex hormones, a competitive antagonism to the glucocorticoid receptors, the potential stimulation of erythropoietin secretion as well as psychoactive effects on the brain. The influence of AASs on physical performance is still undefined, since the large number of studies published so far have described discordant and often contradictory outcomes. Nevertheless, animal and human investigations support the hypothesis that the administration of AASs might increase lean body mass, muscle mass, and maximal voluntary strength especially in men, so that they would represent an appealing form of doping for increasing power capacity, sustaining intensive training periods and, last but not least, as a cosmetic muscle makeover. The aim of this article is to review the biochemistry, physiology and the ergogenic effects of AASs.

High articular levels of the angiogenetic factors VEGF and VEGF-receptor 2 as tissue healing biomarkers after single bundle anterior cruciate ligament reconstruction

Various factors may account for the positive association between meniscal repair and anterior cruciate ligament reconstruction, one being the modulation of healing response of meniscal fibrochondrocytes by growth factors released with intra-articular bleeding and fibrin clot formation. Analysis of vascular endothelial growth factor (VEGF) and its receptors, VEGFR1 and VEGFR2, may be useful in the clinical assessment of bone and soft-tissue remodeling. We measured systemic and local levels of VEGF (VEGF165), VEGFR1 and VEGFR2 after either arthroscopic partial meniscectomy (APM) or single-bundle anterior cruciate ligament reconstruction (ACLR) in order to determine the local effect of bone tunnelling and notchplasty on the release of these growth factors. The study population included 40 patients: 20 consecutive patients had undergone ACLR with hamstring grafts and 20 had undergone APM. Thirty minutes after the end of the operation, knee joint fluid samples were collected via the drainage tube and at the same time venous blood samples were drawn. In both sets of samples, VEGF, VEGFR1 and VEGFR2 concentrations were determined by enzyme-linked immunosorbent assay (ELISA). No significant differences in VEGF, VEGFR1 or VEGFR2 concentrations in the venous blood were observed between the two treatment groups. In contrast, VEGF and VEGFR2 levels were significantly higher in the knee joint fluid of the ACLR group; furthermore, VEGF and VEGFR1 were significantly higher in the knee joint fluid than in the venous blood, whereas VEGFR2 was lower in the knee joint fluid than in the venous blood. Local release of VEGF and its angiogenetic receptor VEGFR2, but not the negative regulator VEGFR1, was significantly higher after ACLR than after APM, indicating a better vasculogenic potential for enhanced bone-graft and meniscus healing. These results could suggest that VEGF and VEGFRs could be considered as good biomarkers of tissue healing after knee joint surgery.

Growth factors in the management of sport-induced tendinopathies: results after 24 months from treatment. A pilot study

AIM

The efficacy of PRP in the treatment of tendinopathies has been already studied both in in vitro and in clinical studies. This paper describes the local and the systemic effects of US-guided autologous PRP (Platelet Rich Plasma) injections in chronic tendinopathies in sportspersons.

METHODS

Fifteen patients (13 male, 2 female) between 17 and 68 years old, affected by chronic tendinopathies at different sites were treated with an echographically guided injection of autologous PRP within the pathological area of the tendons. VISA score and MRI data were collected pre interventions and after 90 days and 24 months from treatment. Changes in different inteleukins (ILs), tumour necrosis factor α (TNF α), interferon γ, vascular endothelial growth factor (VEGF), endothelial growth factor (EGF), chemokine (C-C motif) ligand 2 (CCL2), were analysed at four time points in the peripheral blood of five patients.

RESULTS

After 90 days the VISA score significantly improved from 36±12 (range 21-64) to 74±17 (range 40-92). Reduction of irregularities was found in 80% of the tendons. After 24 months patients reported an average VISA score of 73±16 (range 42-100). No changes in IL, TNF α and interferon γ were observed. VEGF, EGF and CCL2 decreased progressively from 30m to 3 h after the treatment and returned to near the baselines after 24 h.

CONCLUSION

PRP injection allow an improvement of the clinical symptomatology, which is well maintained at least for two years from treatment. The PRP-based local therapy could influence systems homeostasis and antidoping evaluations, but, in our opinion, it doesn't represent a doping substance in itself.

Human bone disorders: pathological role and diagnostic potential of matrix metalloproteinases

Bone undergoes continuous remodeling under physiological and pathological conditions. Failure of the regulation of this process leads to several disorders involving bone erosion. This series of events is mainly based on the action of proteinases, particularly matrix metalloproteinases (MMPs). MMPs have been recently suggested as potential bone resorption markers which could be added to the commonly used ones, in order to predict outcome of disease processes and healing, and to monitor disease response to treatment. As for classical biochemical bone markers, MMPs are far from being applied in primary clinical diagnosis, but they could be promising in some cases for disease prognosis. MMPs as bone remodeling biomarkers could provide information that boosts our understanding of the prognosis, disease activity and pathogenesis of bone disorders. Clarifying the MMPs' role in bone remodeling and healing could potentially help predict disease progression and the effects of direct specific therapy.

Plasma adiponectin and leptin concentrations in professional rugby players

Adipose tissue synthesizes and secretes a number of cytokine hormones, defined adipokines, which have emerged as critical regulators of several metabolic functions, including energy homeostasis, insulin action and lipid metabolism. The present study is aimed at assessing the relationship between plasma concentrations of leptin and adiponectin and body composition in a cohort of 38 male professional rugby players (age: 22-35 years). Anthropometric evaluation included body mass index (BMI, range: 23.4-35.1 kg/m2) and whole body bioelectric impedance to determine absolute fat-free mass (FFM), absolute fat mass (FAT), relative percentage of fat mass (FAT percent) and fat-free mass (FFM percent). FAT percent ranged from 15 to 34 percent, corresponding to a FAT of 11.5-38.7 kg, whereas FFM range was 62.1-83.5 kg. Plasma leptin range was 1.2-4.3 ng/mL and adiponectin range was 2.0-16.6 microg/mL. Plasma leptin and adiponectin concentrations and their ratio did not correlate with BMI, nor with FAT, FAT percent, FFM and FFM percent, even after correction for BMI. The findings of this study suggest that in professional rugby players some additional factors, like neuroendocrine adaptations, other than adipose mass play a relevant role in the determination of adipokine levels, which in this group appear to be rather independent of body composition.

Soluble transferrin receptor values in top level soccer players and skiers: comparison with sedentary people and pitfalls of laboratory methods

AIM

Hematological assessment is crucial in athletes: the risk of sports' anemia should be monitored with hematological parameters and iron metabolism tests. The aim of this study was to evaluate soluble transferrin receptor (sTfR) efficacy, as it is highly sensitive and specific and usually utilized in sport medicine for monitoring iron metabolism.

METHODS

sTfR was studied using two immunological methods (IDeA Orion, and Biokit) on a group of professional athletes, together with hematological and iron metabolism parameters. Values have been compared with those of sedentary people, before and during competitive season. Athletes were 76 professional male soccer players plus 20 males and 14 females of the alpine ski Italian National Teams.

RESULTS

The sTfR values in athletes are similar to those found in sedentary people. Different results have been observed between the two different methods: a bias of 0.37 mg/L was found comparing them. A significant correlation between sTfR and iron, transferrin saturation, and reticulocytes was found in skiers; there was no correlation with hemoglobin, erythrocytes, ferritin. In soccer players significant differences have been retrieved among different teams' distribution of data.

CONCLUSIONS

The principal limit for using sTfR in sports medicine, but also in the general population, is the lack of standardization among methods. The quantitative differences in athletes between the two methods are high, although the behavior of the parameter is similar from the quality point of view. The differences between measured concentrations could influence the thresholds used in antidoping context.

Acute variation of leucocytes counts following a half-marathon run

There is growing interest on haematological changes following elite and recreation sports. However, no information is available on leucocyte variations after an intermediate-distance run. Complete blood cell count was assessed on 17 trained, middle-aged males before a 21-km half-marathon, at the end and 3, 6, 24 h thereafter. Statistically significant variations by one-way analysis of variance were observed for all the parameters tested. Haematocrit, haemoglobin and red blood cells and platelet count increased significantly by the end of the run and returned to pre-run values 3 h thereafter. White blood cells, neutrophils, monocytes and basophils counts increased after the run, reached the peak at 3 h and returned to the baseline after 24 h. Conversely, the eosinophils count significantly decreased after the run, reached a nadir at 3 h and slowly returned to pre-run values at 24 h. The lymphocytes count significantly increased after the run, decreased 3 h thereafter and returned to pre-run values after 6 h. These results show that an intermediate-distance run, which is a popular form of recreational sports worldwide, is associated with transitory leucocytosis, neutrophilia, monocytosis and basophilia, but it also induces acute eosinopenia, all changes being completely reversed 24 h thereafter.

Creatinine values during a competitive season in elite athletes involved in different sport disciplines

AIM

The authors aimed at studying creatinine concentrations in elite male athletes of rugby, alpine ski and cyclism, characterized from different Body Mass Index (BMI) to evaluate modifications during the competitions season.

METHODS

Creatinine was measured by Jaffe method in 44 top-level athletes (18 rugbyists, 13 skiers, and 13 cyclists) before the start of training and competitions and during the competitions season, three times for rugbyists and skiers, and two times for cyclists.

RESULTS

Creatinine concentrations were related to body mass and were significantly different among the groups of athletes of the three sports. Analysis of variance showed significant differences among groups of athletes practising different sports (P<0.0001). The analysis for repeated measures demonstrated significant differences for rugby (P<0.005) and ski (P<0.02), but not for cycling (P=0.25).

CONCLUSION

The interpretation of the creatinine concentrations in athletes should take in account the kind of sport practised, the BMI, and also the possible variations during the season. The reference intervals used for general population can not be used for athletes.

[Treatment of lupus nephritis associated with end-stage renal disease]

Approximately 10% of patients with lupus nephritis develop end-stage renal disease (ESRD). In some cases with a rapidly progressive course, treatment may result in partial recovery of renal function. The choice of aggressive treatment should be balanced against the risk of enhanced morbidity due to side effects in patients with renal insufficiency; one should therefore desist from preventing ESRD at any cost. Renal replacement therapy (both hemodialysis and peritoneal dialysis) may offer lupus patients with ESRD good chances of survival. The indications for renal replacement therapy are similar to those in other uremic patients. Systemic lupus erythematosus activity may be quenched by renal replacement therapy but it may also persist, especially during the first year. Immunosuppression and corticosteroids should be stopped when possible, as lupus patients on dialysis are liable to increased morbidity consisting of infections and cardiovascular events due to side effects of therapy. The presence of antiphospholipid antibodies may favor thrombotic events. Renal transplant offers the best rehabillitation for most lupus patients with ESRD. Many studies have reported similar patient and graft survival rates in lupus and nonlupus transplant recipients. The results are better for living-donor transplants. Patients with antiphospholipid antibodies have a higher graft failure risk. Active lupus and iatrogenic side effects are risk factors for enhanced morbidity after transplant; a 6-12 washout period before transplant is advisable for these candidates. Recurrence of lupus nephritis is a rare event which usually does not compromise the outcome of the graft.

Relation between body mass index and serum aminotransferases concentrations in professional athletes

AIM

Reference intervals commonly used for evaluating and interpreting laboratory values obtained in athletes are the same used in the general population. Aminotransferases (aspartate aminotransferase [AST], and alanine aminotransferase [ALT]) are commonly analyzed in serum for evaluating hepatic function. Some studies in the general population and in blood donors testified that ALT concentrations clearly correlated with weight and body mass.

METHODS

We compared the aminotransferase concentrations at rest of 116 male professional athletes of 7 different sport disciplines with their body mass index (BMI). The blood drawing was performed before the start of training and of the competitive season. The athletes engaged in rugby, triathlon, soccer, sailing, cycling, basketball, alpine skiing. One hundred age-matched, apparently healthy, not physically active, males chosen for general check-up were recruited as a control group.

RESULTS

The average concentrations of AST and ALT in the whole group of athletes were 24.4 U/L (standard deviation [SD]: 10.5) and 23.6 (SD: 6.5). The results in athletes were not statistically different from those of sedentary people. A positive correlation between BMI and ALT exists, whilst a very weak negative correlation between BMI and AST occurs.

CONCLUSION

High concentrations of ALT should be evaluated considering BMI values whilst high values of AST should be evaluated considering the influence of physical exercise.

Banff 07 classification of renal allograft pathology: updates and future directions

The 9th Banff Conference on Allograft Pathology was held in La Coruna, Spain on June 23-29, 2007. A total of 235 pathologists, clinicians and scientists met to address unsolved issues in transplantation and adapt the Banff schema for renal allograft rejection in response to emerging data and technologies. The outcome of the consensus discussions on renal pathology is provided in this article. Major updates from the 2007 Banff Conference were: inclusion of peritubular capillaritis grading, C4d scoring, interpretation of C4d deposition without morphological evidence of active rejection, application of the Banff criteria to zero-time and protocol biopsies and introduction of a new scoring for total interstitial inflammation (ti-score). In addition, emerging research data led to the establishment of collaborative working groups addressing issues like isolated 'v' lesion and incorporation of omics-technologies, paving the way for future combination of graft biopsy and molecular parameters within the Banff process.

Hepatitis C virus infection and rituximab therapy after renal transplantation

BACKGROUND

Rituximab, a chimeric monoclonal antibody, has been successfully given in various diseases including HCV-associated mixed cryoglobulinemia. However, only preliminary data exists on its efficacy and safety after renal transplantation.

METHODS

We report on a renal transplant recipient with chronic hepatitis C who received rituximab therapy for gastric cancer. Four rituximab infusions of 375 mg/m(2) were given.

RESULTS

Rituximab therapy was complicated by cholestatic hepatitis C with very high HCV RNA levels; liver insufficiency occurred. The patient developed bacterial pneumoniae and respiratory insufficiency was the cause of death. Although other mechanisms cannot be excluded, we found that rituximab therapy was implicated in the pathogenesis of cholestatic hepatitis C in our patient.

CONCLUSIONS

We suggest that rituximab therapy may be associated with significant side effects. More experience has to be accumulated before any conclusions on efficacy and safety of rituximab therapy after RT can be drawn.

The long-term prognosis of renal transplant in patients with systemic vasculitis

Little information is available about the long-term outcome of renal transplantation in patients with systemic vasculitis (SV). We compared the outcomes of 19 renal transplant recipients with SV with those of 38 controls matched for time of transplantation, age, gender and source of donor. The mean post-transplant follow-up was 58 +/- 57 months for vasculitic patients and 61 +/- 49 months for controls. The actuarial 10-year patient survival was 87% in vasculitic patients and 90% in controls, death-censored graft survival were 84% and 100%, respectively. The risks of acute and chronic rejection, and arterial hypertension were not significantly different between the two groups. Infection was significantly more frequent in vasculitic patients (74% vs. 34%; p = 0.01). Seven patients (36.8%) had a recurrence of vasculitis in mean 45 months after renal transplant (0.076/patients/year). After recurrence, one patient had an irreversible humoral rejection, another died from hemophagocytosis and another restarted dialysis 1 year later. Long-term patient and renal allograft survival in vasculitic patients was good. Although graft function recovered in most relapsers after reinforcement of immunosuppression, one patient died and two lost graft function.

FMECA methodology applied to two pathways in an orthopaedic hospital in Milan

INTRODUCTION

Adverse events pose a challenge to medical management: they can produce mild or transient disabilities or lead to permanent disabilities or even death; preventable adverse events result from error or equipment failure.

METHODS

IRCCS Istituto Ortopedico Galeazzi implemented a clinical risk management program in order to study the epidemiology of adverse events and to improve new pathways for preventing clinical errors: a risk management FMECA-FMEA pro-active analysis was applied either to an existing clinical support pathway or to a new process before its implementation.

RESULTS

The application of FMEA-FMECA allowed the clinical risk unit of our hospital to undertake corrective actions in order to reduce the adverse events and errors on high-risk procedure used inside the hospitals.

Behaviour of reticulocyte counts and immature reticulocyte fraction during a competitive season in élite athletes of four different sports

The role of reticulocytes (Ret) in sports medicine became important when the count of immature erythrocytes has been introduced in protocols used and officially approved for antidoping purposes. The use of modern automated analysers, which allow the easy count and the description of characteristics of reticulocytes, increased the possible use of these parameters in sports medicine. We studied the behaviour of Ret and immature reticulocyte fraction (IRF) in top-level athletes practising rugby, ski, soccer and cyclism, throughout a competitive season. We aimed at increasing the knowledge of physiological characteristics of these sportsmen and supplying valuable suggestions to trainers and sports physicians. We observed a stability of Ret counts, also during training and competitions, although some modifications, namely decrease during competitions periods in cyclists, and in rugby and soccer players, occurred. No significant correlation was found between Ret count and Hb in each sport discipline. IRF values tend to be high in athletes owing to continuous bone marrow stimulation linked to haemolysis, typical of sports activities. We confirm the validity of the use of Ret counts for antidoping purposes and also for evaluating health status and iron metabolism of sportsmen.

Free testosterone/cortisol ratio in soccer: usefulness of a categorization of values

AIM

The free testosterone:cortisol ratio (FTCR) is widely used for studying and preventing overtraining syndrome in various sports. The use of FTCR for following overtraining syndrome was proposed originally with two approaches: FTCR lower than 0.35x10(-3), calculated on free testosterone (FT) in nanomoles per liter (nmol/L) and on cortisol (C) in micromoles per liter (mmole/L) or a decrease of the ratio of 30% or more in comparison with the previous value. In our experience, the use of an absolute value as a threshold is not useful, whereas the evaluation of the concentrations of hormones and their ratio in comparison with previous ones is more useful. These classical approaches are not, however, sufficient to describe the various possible physiological modifications linked to training excess and/or incomplete recovery.

METHODS

We collected samples from 32 professional soccer players of an Italian First Division team, during the period July 2001-July 2003. We analyzed the values of 21 athletes during the season 2001-2002 and of 11 athletes during the season 2002-2003 (6 out of 11 were examined also during the previous one) always present when the 4 (first season) or 5 (second season) blood drawings have been performed. We applied an original, pragmatic and easy-to-use classification of FTCR values, in association with classical interpretations based on decreases of the values in comparison with previous athlete's result.

RESULTS

We used the traditional approaches in two consecutive seasons in a professional soccer team: the evaluation of the decrease >30% of the parameter in comparison with the previous value or with the basal (preseason) value are shown. The statistical differences between the FTCR values of the six athletes followed in both seasons were not significant.

CONCLUSIONS

The classification method we propose is advantageous in comparison with traditional interpretative schemes, because identify different risk categories, stratifying the interval between the values 0.35-0.8.

Karyomegalic interstitial nephritis: report of 3 new cases and review of the literature

Karyomegalic interstitial nephritis is a rare, but perhaps an "underdiagnosed" condition. Peculiar nuclear changes characterize it, involving mainly tubular cells along with glomeruli and blood vessels. Herein, 3 bioptically proven new cases of patients with chronic renal failure are discussed. The first case had a recently diagnosed karyomegalic nephritis which, to date, still does not require dialysis. The other 2 (brother and sister) required dialysis 4 and 1 years after diagnosis. Karyomegalic changes were found not only in the skin and duodenal biopsies of the male, in skin and liver biopsies of the female and in the urine cells of both patients, but also in several organs (brain, thyroid, lung, esophagus, arteries) as shown at the autopsy of the female. There was a fatal outcome for both patients. The data reported in this study emphasize the usefulness of pathologic investigation of both tissue and urine samples in the identification of this disease. Moreover, as karyomegalic interstitial nephritis is strongly suspected to have a genetic background, its identification may well not only be of clinical relevance, due to its ominous outcome, but may also bear eugenetic value.

Haematological parameters in elite rugby players during a competitive season

We assessed haematological parameters and possible modifications in elite rugby players throughout a competitive season for increasing the knowledge of physiological characteristics of these sportsmen. Blood samples were collected from the members of the Italian National rugby team at four consecutive training camps during a whole competitive season. Forty-four athletes were recruited for the first camp, 36 for the second, 30 for the third and 32 for the fourth. Due to turnover of the subjects during the season only 13 athletes could be examined at all four camps, and another six in the first three camps. Therefore, we selected the data of these 19 athletes. Iron and transferrin saturation were stable, whilst ferritin increased at the end of the season. The modifications of the soluble transferrin receptor (sTFR) were linked to those of haematocrit: sTFR increased after training and during the competition period when haemoglobin and haematocrit decreased, and decreased at the end of the season. Haemoglobin and haematocrit showed slightly higher levels during the first part of the season and decreased in the second half, when physical demand was high, as demonstrated by biochemical additional tests. Leucocytes and platelets were stable throughout the season. Haematological and iron metabolism parameters in the elite rugby players examined during a whole season fall within physiological range of values. The variability of the parameters during the season is related to training and competition workload. Reticulocytes and sTFR are the most sensitive parameters for studying the iron metabolism of the athletes.

Relation between serum creatinine and body mass index in elite athletes of different sport disciplines

OBJECTIVES

To document the relation between serum creatinine concentration and body mass index in elite athletes from five different sports, and to study potential differences among athletes performing different sports with different features and requirements.

METHODS

Before the start of the competitive season, serum creatinine was measured in 151 elite athletes from five different sports: rugby (n = 44), soccer (n = 27), alpine skiing (n = 34), sailing (n = 22), cycling (n = 24). Pearson's correlation analysis was used to evaluate the relation between serum creatinine and body mass index (BMI). Analysis of variance and unpaired Student's t test were used to compare creatinine concentration and BMI in different sport disciplines.

RESULTS

In the whole group of athletes, a positive correlation between serum creatinine and BMI was found (r = 0.48, p<0.001). Significant differences in creatinine concentration and BMI were found between athletes competing in different sports: their mean (SD) values were respectively 1.31 (0.12) mg/dl and 28.83 (2.41) for rugby players, 1.27 mg/dl (0.10) and 23.10 (1.01) for soccer players, 1.15 (0.11) mg/dl and 25.8 (1.50) for skiers, 1.08 (0.11) mg/dl and 26.93 (2.36) for sailors, and 0.91 (0.07)mg/dl and 21.33 (1.21) for cyclists.

CONCLUSIONS

There is a correlation between creatinine concentration and BMI in elite athletes competing in different sports characterised by different kinds of training, competitive season, and involvement of aerobic and anaerobic metabolism. Interpretation of creatinine concentrations in male athletes should consider professional status as well as the specific sport performed. All athletes should be monitored with consecutive creatinine assessments, using as the baseline the concentration determined before the start of training and the competitive season, but taking into consideration the specific sport performed and the BMI until equations that include creatinine and factors that affect its concentration are used.

Plasma oxidative stress biomarkers, nitric oxide and heat shock protein 70 in trained elite soccer players

The physiological response to the physical exercise involves a number of changes in the oxidative balance and in the metabolism of some important biological molecules, including nitric oxide (NO) and heat shock proteins (Hsp 70). With the aim to optimise previous laboratory diagnostic panels, we measured the plasma concentration of reactive oxygen metabolites (ROMs), total antioxidant status (TAS), glutathione reductase (GR) activity, and NO and Hsp 70 levels in 44 elite, antioxidant-supplemented and trained soccer players and in 15 sedentary controls. Although no statistically significant difference between athletes and controls was detected in the plasma level of ROMs and TAS, soccer players showed a significantly higher plasma GR activity, NO and Hst 70 levels than those of sedentary controls. These findings suggest that the measuring of relatively novel biomarkers in sport medicine, like GR, NO and Hsp 70, in addition to the well-known and reliable assays (d-ROMs test and TAS) may be useful to a clinician to better assess and evaluate the benefits of training and/or supplementation programs.

B-type natriuretic peptide in athletes performing an Olympic triathlon

AIM

Brain natriuretic peptide (BNP) is a cardioactive molecule produced in the myocardium. BNP is a sensitive marker of cardiac failure and its measurement in blood could be useful to the diagnosis and the treatment of this disease. Sporting activities, especially endurance ones, can induce cardiac problems, owing to the high workload for the myocardium during long and ultralong heavy effort. There are 2 papers describing the behavior of BNP in endurance events. BNP was elevated in marathoners, immediately after the race and also after 4 h. We studied the behavior of BNP in the triathlon, which is a complex sport characterized by 3 different activities (swimming, cycling, running).

METHODS

We recruited 49 athletes, all males, except for 4 females; 2 athletes did not finish the race and were not included in the statistical analysis in 2 different competitions. In these subjects we measured BNP using an immunological method before and after a triathlon.

RESULTS

No statistical significance between BNP values, before and after the triathlon, was found.

CONCLUSIONS

We found no significant differences between pre- and postcompetition BNP values. Moreover, the range of values in both the blood drawings are similar of those of the general population, representing the biological variability of the analyte. The values in regularly trained athletes,, are not different from the general population and BNP is not modified by a triathlon, a typical endurance sport performance. We can underline that BNP increases in plasma are induced by heavy pathologies and are not influenced by physical activities, even strenuous ones.

Behaviour of haematological parameters in athletes performing marathons and ultramarathons in altitude ('skyrunners')

We observed athletes performing marathons and ultramarathons in altitude over several years to study the behaviour of haematological parameters in order to screen eventual paraphysiological or pathological conditions (sports anaemia). We collected samples from 124 athletes participating in seven races; 23 athletes were recruited in different races: 16 for four times, four for three times, and three for two times. The pre- and post-race values of erythrocytes, haemoglobin and packed cell volume did not show statistically significant differences in the studied athletes. The erythrocytes' indices (MCV, MCH, MCHC) and red cell distribution width (RDW) also were not significantly modified by the strenuous effort. The leukocytes were significantly increased because of immunological involvement during the endurance performance. Platelets and relative indices were not significantly modified. The stability of packed cell volume and haemoglobin in athletes performing training and races in altitude is strong evidence for the use of these parameters as an index of general health status and for illustrating possible abnormal increase because of exogenous stimulation of bone marrow. The preanalytical and analytical accuracy is crucial to assure clinical validity of the collected data: we strictly observed international recommendations in this field.

Necrotizing glomerulonephritis in a living donor kidney transplant recipient

The occurrence of a rapidly progressive necrotizing glomerulonephritis after kidney transplantation is exceptional and usually leads to graft failure. We describe a case of necrotizing glomerulonephritis that developed 5 months after renal transplantation in a patient suffering from prolonged bowel paralysis and sepsis. After reinforcement of corticosteroid therapy and introduction of cyclophosphamide, glomerulonephritis recovered. Cyclophosphamide was stopped after 2 months and replaced by azatioprine while prednisone was progressively reduced. Three years after transplantation the patient has a stable serum creatinine of 1.7 mg/dL and mild proteinuria. To the best of our knowledge this is the first case of recovery from a necrotizing glomerulonephritis in a renal transplant recipient.

Preanalytical phase of sport biochemistry and haematology

Biochemistry and haematology are more and more important and sometimes crucial in sport medicine for diagnosing, controlling and preventing purposes. The analytical process and the global laboratory quality are heavily influenced by the preanalytical phase, including biological material collection, identification, storage and transport of the specimen, preparation for analyses of the specimen through centrifugation, freezing and thawing, aliquoting and sampling. The increasing interest of sport biochemistry should be linked to a knowledge of principal problems and pitfalls in the preanalytical phase of various parameters, commonly used in following training, diet, and performances of athletes, to avoid misinterpretation of data and to improve usefulness of biochemical investigations. We prepared a practical review of preanalytical aspects of principal analyses applied to the athletes. We include the choice of anticoagulant and its limits for haematological tests, the preparation and manipulation of specimens for hormonological investigation, especially for labile molecules, and for cardiac markers, lactate, cytokines, micronutrients, antioxidant molecules. Preanalytical phase of specimens different from blood are also showed, including urine and saliva, and some aspects of preparation of materials to be analyzed with molecular biology technology are treated. Stability of some analytes, when the parameter is fundamental for the clinical usefulness of the results, is supplied. Preparation of the subjects, however, including the possible influence of physical exercise and biological rhythms on the biochemical and haematological parameters, are not listed.

Kidney transplantation in patients with IgA mesangial glomerulonephritis

BACKGROUND

Strategies for treating IgA glomerulonephritis (IgAGN) are controversial, particularly with regards to the long-term results of kidney transplantation, including the risk of recurrence of IgAGN post-transplant and the impact of this recurrence on graft survival.

METHODS

The outcomes of 106 adults transplanted because of a biopsy-proven IgAGN and of 212 patients without IgAGN transplanted during the same period were analyzed. To evaluate the risk of recurrence, patients with hematuria, proteinuria, or an increase in plasma creatinine were submitted to allograft biopsy. Factors influencing recurrence and the impact of recurrence on graft survival were analyzed.

RESULTS

The ten-year patient (0.93 vs. 0.92) and graft survival (0.75 vs. 0.82) probabilities were not significantly different between IgAGN patients and controls. Only plasma creatinine and proteinuria at six months were associated with an increased relative risk (RR) of graft failure (RR 2.79 and 5.94, respectively). Histological recurrence of IgA glomerulonephritis was diagnosed in 37 patients. Younger age (RR 2.63), increased plasma creatinine (RR 2.39), and proteinuria (RR 6.02) at six months were associated with the risk of recurrence. If proteinuria and plasma creatinine at six months were considered in the Cox model, IgA recurrence per se was not associated with an increased risk of graft failure (P = 0.181). The main causes of graft failure were glomerulonephritis in patients with recurrence of IgAGN and chronic rejection in patients without recurrence.

CONCLUSIONS

The ten-year graft survival rate was similar in patients with IgAGN or other renal diseases. At least 35% IgAGN patients had biopsy-proven recurrence, and younger patients were more prone to the risk of recurrence. Recurrence did not affect the ten-year graft survival.

Anti-C1q antibodies may help in diagnosing a renal flare in lupus nephritis

It is still uncertain which, if any, immunologic parameters may help diagnose a renal flare of lupus nephritis. Anti-C1q antibody (Ab) titers have been elevated in patients with lupus with renal involvement, but little information is available on whether the titers are different in quiescent and active phases of lupus nephritis. In this study, we compared anti-C1q Ab titers with other serological test results in 48 patients with biopsy-proven lupus nephritis to assess which parameter could offer the best reliability for differentiating between quiescent and active phases of lupus nephritis. Serum C3 and C4 levels, as well as anti-double-stranded DNA, antiendothelial cell, anti-C1q, and antiphospholipid Ab titers, were evaluated in patients with quiescent renal disease (38 samples) and those with clinical evidence of renal activity (23 samples). Only anti-C1q Ab titers correlated with active renal disease in both univariate (P < 0.0001) and multivariate analysis (P < 0.0001), with a sensitivity of 87% and a specificity of 92%. In six patients, immunologic parameters were measured serially. In all patients, the high anti-C1q Ab titers returned to normal values after treatment-induced remission. The other serological parameters did not show a significant association with renal disease activity. In patients with biopsy-proven lupus nephritis, anti-C1q Ab titers appear to be strongly related to renal disease activity. Their measurement may be useful for confirming the diagnosis of renal flares of lupus nephritis.

Double recurrence of FSGS after two renal transplants with complete regression after plasmapheresis and ACE inhibitors

A patient who had undergone a first cadaveric donor kidney transplantation for idiopathic focal segmental glomerular sclerosis (FSGS), had an immediate recurrence of a biopsy-proven FSGS that eventually led to graft failure within 5 years from transplantation. The patient underwent a second cadaveric transplantation 10 months later. An immediate recurrence of a biopsy-proven FSGS occurred that was treated with two protracted cycles of plasmapheresis of seven months each, with the addition of an ACE inhibitor from the beginning. A complete and stable remission of FSGS was observed, which continues after more than 6 years from the end of plasmapheresis. The recurrence of FSGS after a second transplantation has a poor prognosis, but prolonged plasmapheresis treatment, by removing circulating factors altering glomerular permselectivity, and the addition of ACE inhibitors, through their potential interference with TGF-beta, might be synergistic in obtaining permanent remission.

Comparative multicentre study of a panel of thyroid tests using different automated immunoassay platforms and specimens at high risk of antibody interference

The introduction of automation for immunoassays in recent years has brought about important and evident improvements in assay precision. Increasing standardization and comparability between platforms should enable the development of clinical guidelines and diagnostic algorithms for appropriate clinical decision making. A continuing source of variation between different automated immunoassay platforms is the sporadic effect of interfering antibodies or substances, thus causing aberrant results not supporting the patient's clinical status. The aim of this study was to describe current thyroid panel variation between automated immunoassay platforms including population specimens at risk of antibody interference. A multisite design with laboratories in three different countries using four different automated immunoassay platforms (Roche-Boehringer Mannheim Elecsys (Italy), Roche-Boehringer Mannheim ES300 (Wales), Bayer Immuno 1 and the Bayer ACS:180 evaluated the thyroid panel of thyrotropin (TSH), triiodothyromine (T3), free thyroxine (FT4) and free triiodothyronine (FT3). A common set of 158 randomly selected patient samples of non-thyroid and thyroid disorders, with and without treatment, was tested. Included were 62 patient samples at risk for endogenous antibody interference with high antimicrosomal antibody, anti-TSH receptor antibody and increased rheumatoid factor sub-populations. Across all controls and between platforms, precision measurements were comparable and varied between 0.7% and 12.8% for TSH, 2.8% and 13% for FT4, 1.8% and 10.5% for FT3 and 3.1% and 16% for T3 assay. Acceptable correlation and reproducibility were found between the three Bayer Immuno 1 platforms at each country's site with all four thyroid panel assays demonstrating r-values of 0.989 to 1.000 and slopes of 0.915 to 1.078. Comparisons between the different platforms showed acceptable correlation for all thyroid panel assays. Specimens containing rheumatoid factor were associated with a significantly increased variation between systems for the FT4 and FT3 assays (p < 0.01). This effect did not appear to be selective for a given platform. For specimens with raised autoimmune antibodies and therefore at risk of assay antibody interference, no variation could be observed between the platforms.

External evaluation of LIAISON tumour marker assays on the fully automated chemiluminescent LIAISON immunoassay analyser

The LIAISON immunoassay analyser was tested in a multicentre evaluation performed by 8 laboratories. The analytes evaluated were CA 15-3, CA 19-9, CA 125II, AFP, CEA, NSE and PSA. Excellent results were obtained for within-run and between-run precision with most assays showing within-run CVs < 5% and between-run CVs between 4 and 8%. The linearity of all assays was acceptable, however, for PSA, NSE and CA 19-9 a recovery > 110% was obtained for some of the samples tested. None of the assays revealed a high-dose hook effect. Method comparisons were performed by using the routine method of the respective study centre. Results generally showed an acceptable agreement between the LIAISON system and the different methods of comparison. The reference ranges for all assays were found to be in accordance with data known from the literature. All assays showed similar results for serum, heparinised plasma and EDTA plasma. Additionally, two experiments were performed with only one of the analytes tested: the sample-to-sample carry-over, using the CA 19-9 assay (3.3 x 10(-6)-2.3 x 10(-5)) and the functional sensitivity for the PSA assay (0.2 ng/ml).

Pepsinogens: physiology, pharmacology pathophysiology and exercise

Human gastric mucosa contains aspartic proteinases that can be separated electrophoretically on the basis of their physical properties into two major groups: Pepsinogen I (PGA, PGI); and Pepsinogen II (PGC, PGII). Pepsinogens consist of a single polypeptide chain with molecular weight of approximately 42,000 Da. Pepsinogens are mainly synthesized and secreted by the gastric chief cells of the human stomach before being converted into the proteolytic enzyme pepsin, which is crucial for the digestive processes in the stomach. Pepsinogen synthesis and secretion are regulated by positive and negative feed-back mechanisms. In the resting state pepsinogens are stored in granules, which inhibit further synthesis. After appropriate physiological or external chemical stimuli, pepsinogens are secreted in the stomach lumen where hydrochloric acid, secreted by the parietal cells, converts them into the corresponding active enzyme pepsins. The stimulus-secreting coupling mechanisms of pepsinogens appear to include at least two major pathways: one involving cAMP as a mediator, the other involving modification of intracellular Ca(2+)concentration. Physiological or external chemical stimuli acting through the intracellular metabolic adenyl cyclase are more effective in inducing ' de novo ' pepsinogen synthesis than those acting through intracellular Ca(2+). The activation of protein kinase C (PK-C) would appear to be involved in regulatory processes. The measurement of pepsinogens A and C in the serum is considered to be one of the non-invasive biochemical markers for monitoring peptic secretion and obtaining information on the gastric mucosa status of healthy subjects. Recently, pepsinogen measurements have been used as an effective biochemical method for evaluating and monitoring patients with gastrointestinal diseases and for checking the effects of drug treatment. The level of PGA in the serum is always high in normal gastritis, while in atrophic gastritis it is always low. In both cases the PGC level in the serum is high. In most gastrointestinal pathologies the ratio between the PGA/PGC decreases. Various reports concerning hormone and/or enzyme modification as well as gastrointestinal distress in the case of long distance exercise have been reported. It has been suggested that the origin of the gastrointestinal distress experienced by long distance runners is a transient ischaemia of the gastric mucosa; it is also suggested that a hypobaric-hypoxic environment could contribute to induce gastric mucosa necrosis. Interrelation between gastrointestinal distress, hypobaric-hypoxic environment and modifications of PGA and PGC, gastrin and cortisol was evaluated in 13 athletes after a marathon performed at 4300 m. Gastrointestinal symptoms occurred in approximately 40% of the athletes. After the race the athletes showed a significant increase of gastrin and cortisol, while the ratio between PGA/PGC decreased. No relationship was observed between gastrointestinal symptoms and hormonal changes after the race. A control group of five subjects, who had been exposed to the same environmental conditions, showed no gastrointestinal or hormonal alteration. Conversely, control subjects presented a significant decrease of cortisol related to the circadian rhythm. The same incidence of gastrointestinal symptoms at high altitude and at sea level and the absence of pathological alteration of PGA and PGC in the serum of the athletes indicates that running a marathon and living for 6 days at 4300 m does not induce gastric mucosa necrosis. Cortisol and gastrin alteration observed in the athletes at this altitude would seem to be related to an activation of the mesopontine and forebrain structures involved in the behavioural and metabolic integration of the autonomic control and arousal and psychophysical-exercise stress. 2000 Academic Press@p$hr