Amino acid sequence of k Sci, the Bence Jones protein isolated from a patient with light chain deposition disease

Light chain Sci was isolated from the urine of a patient affected by light chain deposition disease with an apparent exclusive localization to the kidney. Sci protein is an intact light chain: it consists of 214 amino acid residues and has an Mr of 23.65. Its complete primary structure has been determined by sequence analysis of the corresponding tryptic peptides and by partially sequencing the intact protein. Sequence comparison shows that Sci protein is strictly related to the light chains of kIIIa family (88% structural identity) which are usually expressed in autoimmune rheumatoid syndromes. Computer graphics model suggests a perturbation in k Sci three-dimensional structure due to the unusual replacement of residues 53 and 77.

The impact of prolonged immunosuppression on the outcome of idiopathic focal-segmental glomerulosclerosis with nephrotic syndrome in adults. A collaborative retrospective study

In this retrospective study we report the outcome of 59 adults with idiopathic focal-segmental glomerulosclerosis (FSGS) and nephrotic syndrome (NS) treated with corticosteroids and/or immunosuppressive drugs. Twenty-seven patients were initially treated with corticosteroids alone for 9.3 +/- 8 months; nineteen patients received corticosteroids and immunosuppressive agents associated or every other month for 5.5 +/- 4 months; thirteen patients received either azathioprine or cyclophosphamide alone for 25 +/- 27 months. At the end of a mean follow-up of 75 +/- 51 months, 35 patients (60%) were in complete (CR) or partial (PR) remission, 6 (10%) were stable and 18 (30%) had either chronic renal failure (CRF) or end-stage renal failure (ESRF). Out of 36 patients (61%) initially responsive to therapy, 30 (83%) obtained CR, 4 (11%) PR, one (2.7%) developed CRF and one (2.7%) ESRF. Only 10 of the responders (28%) attained remission within 8 weeks of treatment. Out of the 23 (39%) patients originally resistant to therapy, only one (4%) had CR, 6 (26%) remained unchanged, 6 (26%) developed CRF and 10 (43%) ESRF. The presence at initial renal biopsy of interstitial fibrosis was the only feature which could predict a poor renal outcome. These data show that prolonged treatment of FSGS can obtain sustained remission of the disease and improved renal survival in a consistent proportion of adult patients which would be considered refractory to a two-month course with corticosteroids.

Renal vascular lesions as a marker of poor prognosis in patients with lupus nephritis. Gruppo Italiano per lo Studio della Nefrite Lupica (GISNEL)

The frequency of renal vascular lesions (RVL) and their relevance in the progression of renal damage were evaluated by the Pathology Group of the "Gruppo Italiano per lo Studio della Nefrite Lupica" (GISNEL). Of 285 patients with lupus nephritis collected from 20 nephrology centers in Italy and classified according to World Health Organization (WHO) criteria, 79 cases (27.7%) with RVL were identified and classified as follows: (1) lupus vasculopathy (n = 27); (2) hemolytic-uremic syndrome/thrombotic thrombocytopenic purpura (HUS/TTP) malignant hypertension-like lesions (n = 24); (3) vasculitis (n = 8); (4) arterio-arteriosclerosis (n = 20). At the time of renal biopsy, patients with RVL had mean serum creatinine levels significantly higher than patients without RVL (201.8 +/- 195.9 mumol/L [2.2 +/- 2.2 mg/dL] v 108.1 +/- 108.0 mumol/L [1.2 +/- 1.2 mg/dL]; P less than 0.01). Hypertension was more frequent in patients with RVL than in those without (68.4% v 30.5%; P less than 0.01). The probability of kidney survival assessed according to the Kaplan-Meier method at 5 and 10 years was, respectively, 74.3% +/- 5.9% and 58.0% +/- 8.9% in patients with RVL, compared with 89.6% +/- 2.7% and 85.9% +/- 3.7% in patients without RVL. However, the two groups did not differ significantly as regards overall survival, the probability of survival at 5 and 10 years being 86.5% +/- 4.5% and 78.8% +/- 6.6% in patients with RVL and 92.2% +/- 2.2% and 83.3% +/- 4.4% in patients without RVL.(ABSTRACT TRUNCATED AT 250 WORDS)

The impact of azathioprine and cyclosporine on long-term function in kidney transplantation

To assess the impact of cyclosporine on long-term kidney function in transplant patients, we retrospectively analyzed 273 patients on azathioprine and 308 on CsA with graft functioning at 1 year. To balance the length of follow-ups, the observation of patients was cut at 5 years. Actual graft survival rate at 5 years was similar in Aza and CsA (88% vs. 90%). Multivariate analysis in Aza pts showed that proteinuria (P = 0.006) and hypertension at 1 year (P = 0.002) increased the probability of irreversible graft failure by 2.47 and 2.85, respectively. In CsA patients, proteinuria (P = 0.007) and plasma creatinine higher than 2.5 mg/dl (P = 0.006) increased the probability of graft failure by 5.12 and 6.48, respectively. In both Aza and CsA patients with a follow-up of at least 5 years, plasma creatinine levels were significantly worse at 5 years vs. 1 year (P = 0.004). The slopes of plasma creatinine values plotted vs time were not different between the two groups. Chronic graft dysfunction (CGD) was defined as a stable increase of plasma creatinine of at least 50% above stable values at 1 year. The probability of remaining without CGD at 5 years was 75% for CsA and 80% for Aza patients (P = N.S.). Multivariate analysis of factors influencing the development of CGD showed that hypertension (P = 0.003) and proteinuria at 1 year (P = 0.081) increased the probability of developing CGD by 2.19 and 1.76, respectively, in Aza, while in CsA patients proteinuria only (P = 0.063) increased the probability of developing CGD by 2.29. Graft survival at 5 years after development of CGD was 34% in Aza and 53% in CsA-treated patients. These data confirm that in the long-term CsA does not cause a higher prevalence of CGD and show that, in the presence of CGD, CsA has a superior protective effect than Aza.

Isotopic and nonisotopic assays for measuring somatotropin compared: re-evaluation of cutoff value in provocative tests

Measurement of human growth hormone (hGH; somatotropin) concentrations in serum after provocative tests is crucial for diagnosing deficiencies in production of this hormone. Serum hGH can be measured by various immunoassays, isotopic and nonisotopic, with monoclonal or polyclonal antibodies: a cutoff value of 10 micrograms/L after provocative testing is usually used to distinguish normal from hGH-deficient children. Previous studies demonstrated discrepancies in hGH measurement by different radioisotopic immunoassays. Here we evaluated the responses of six different commercial assays, radioisotopic and nonisotopic, with monoclonal or polyclonal antibodies in a series of 16 provocative tests (stimulation with clonidine) in short children. A wide range of discrepant values was obtained with the different kits. A cutoff of 10 micrograms/L produced discordance of diagnosis among assays for two children, whereas complete agreement was reached for a cutoff value of 7 micrograms/L. Parallelism tests performed with hGH international standard, pure recombinant hGH, and a serum with high hGH content suggest that heterogeneity of the antibodies used by the manufacturers, even among monoclonal antibodies, is the main source of discordant results. Cutoff values and reference values must be established separately for each method proposed for routine use.

Tumor-associated trypsin inhibitor as a possible marker in male infertility

The concentrations of tumor-associated trypsin inhibitor (TATI) in the seminal plasma of infertile males was studied. The TATI levels in seminal plasma were not correlated with either sperm count or ejaculate volume. High levels were observed in some men with unexplained infertility and high or normal sperm counts, whereas normal levels were observed in males with antisperm antibodies. The concentrations in seminal plasma were stable in the same subjects. These results suggest that TATI may be an important marker of reproductive pathology in men.

Tumor-associated trypsin inhibitor in induced and acquired immunodeficiency. Studies on transplanted and HIV-infected patients

A new tumor marker, tumor-associated trypsin inhibitor (TATI), was studied in 5 patients who received successful kidney or pancreas grafts and in 30 subjects with antibodies against human immunodeficiency virus. Serum TATI concentrations were very high during the four first days after transplantation. Thereafter the serum levels decreased when the peptide was eliminated through the kidney. Consequently, the urine values were very high. The TATI concentrations of HIV positive subjects were compared with serum levels of HIV antigen and antibody, by Western blotting and determination of peripheral T-lymphocyte subpopulations. The occurrence of high concentrations of TATI in some HIV positive subjects and especially in AIDS patients, suggests that TATI could be useful in exploring physiopathological aspects of severe immunodeficiencies even if TATI levels were not correlated with the commonly used markers of the immune system status. The increased levels of TATI in immunological disorders suggests its possible use in assessing the immune response against cancer.

The recurrence of focal segmental glomerulosclerosis in kidney transplant patients treated with cyclosporine

To evaluate the rate of recurrence of focal segmental glomerulosclerosis (FSGS) in renal transplant patients treated with cyclosporine, we reviewed the outcome of 25 renal Tx performed in 24 patients who had FSGS as their original renal disease. After Tx, 6 patients were treated with steroids and azathioprine (follow-up: 42 +/- 34 months) and 19 with CsA (follow-up: 30 +/- 31 months). Two of 6 Aza treated patients (33%) developed recurrence of FSGS and nephrotic syndrome (NS). Both patients lost their graft because of FSGS 24 and 25 months after Tx. Ten of 19 patients (55%) given CsA showed recurrence of FSGS; one of them had had recurrence in the first graft treated with Aza. One patient lost his graft a few weeks after Tx because of acute rejection and 3 lost their graft because of FSGS 4-28 months after NS developed. One patient with NS died from pneumonia 14 months after Tx when his plasma creatinine was 2.7 mg/dl. Three other patients now have NS and plasma creatinine between 1.9 and 2.4 mg/dl 15-37 months after Tx. The last two patients have NS and normal renal function 10 and 31 months after Tx. In both groups, most patients developed NS within the first week after Tx. The patients with recurrence, given Aza or CsA, tended to be younger at the onset of the disease and to have a shorter duration of the disease, when compared with those without recurrence, but the differences were not statistically significant. In our experience neither CsA nor Aza showed any effect on the outcome of FSGS recurring in the graft.

Plasma sex hormone binding globulin in patients with prostatic carcinoma

The concentrations of sex hormone binding globulin (SHBG) were measured in the plasma of 56 men, who were 47 to 85 years of age, by time-resolved immunofluorometric assay with a monoclonal antibody. Twenty-five of the men had untreated carcinoma of the prostate and 17 had untreated prostatic hyperplasia. There were 14 healthy control subjects. SHBG levels were significantly higher in patients with prostatic carcinoma (37.6 +/- 8.4 nmol/l) than in those with prostatic hyperplasia (24.5 +/- 5.2 nmol/l; P less than 0.05) or control subjects (14.9 +/- 2.8 nmol/l; P less than 0.01). It is not known why SHBG levels are higher in patients with carcinoma or hyperplasia of the prostate. The contradictory results obtained in other studies may be due to heterogeneity of the binding globulin causing its values to vary in the different assays used.

Enhanced chemiluminescence in the measurement of proteins and haptens: evaluation of choriogonadotropin (hCG) and free thyroxin

We evaluated the Amerlite system (Amersham, Bucks, UK) for hCG and FT4. The within-run imprecision (CV%) for hCG was 4.05 at 19.6 U/l (n = 10), 6.28 at 43.45 U/l (n = 10) and 4.62 at 298.57 U/l (n = 10). The between-run imprecision (five replicates for ten days) was 4.8%, 15% and 11%, respectively. The system was linear up to 200 U/l. A good correlation between Amerlite hCG and an IRMA assay (Becton Dickinson, r = 0.91), Delfia (Pharmacia, r = 0.91) and an automated ELISA assay on ES 600 (Boehringer, r = 0.92) was observed on 70 samples. Within-run imprecision for FT4 was 3.8% at 0.7 ng/dl (n = 10), 3.3% at 1 ng/dl (n = 10) and 4.32% at 5.15 ng/dl (n = 10), and between-run was 5.95%, 4.4% and 8.2%, respectively. The comparison with a commercial direct RIA (Becton Dickinson) showed good correlation (r = 0.90, n = 100 samples). The diagnostic value of the association of thyrotropin and FT4, in comparison with the traditional thyroid tests (T3, T4, thyrotropin, FT4, FT3) has been assessed in various thyroid diseases.

Relationship between antibodies to dsDNA and to soluble cellular antigens and histologically defined glomerulonephritis in patients with SLE

To better define the relationships between circulating autoantibodies and renal involvement in systemic lupus erythematosus (SLE), antibodies to both dsDNA and soluble cellular antigens were detected in sera from a large series of SLE patients. Significantly higher dsDNA binding activities and lower complement levels at onset were found in patients with renal disease; however, this was uniquely due to subjects with diffuse or focal proliferative glomerulonephritis. Patients with membranous nephropathy (MGN) showed very low dsDNA binding activities (6/9 of them being negative for dsDNA antibodies) and normal mean C3 and C4 levels. A comparison between patients with proliferative nephritis and patients without renal involvement with high dsDNA binding activities revealed significantly lower complement levels in the former group. No significant difference was observed in the prevalence of antibodies to soluble cellular antigens between patients with or without renal disease; however, nRNP antibody was two-fold more frequent in patients with MGN than in all other subgroups. This study highlights the close relationship between concurrently high anti-dsDNA and low complement levels and proliferative glomerulonephritis in SLE, and suggests that subjects with MGN may represent a subgroup of SLE patients showing peculiar serological features. Different mechanisms possibly involved in the pathogenesis of MGN in SLE are discussed.

Alloalbumin in cerebrospinal fluid: report of a case and remarks on physiopathology

Alloalbumin Tagliacozzo (313 Lys------Asn) was detected in the cerebrospinal fluid of a 27-yr-old woman. We studied this rare finding by means of high-resolution electrophoresis, isoelectric focusing, and immunofixation. We herein discuss the importance of molecular mass versus superficial electrical charge in the transfer of plasma proteins through the blood-brain barrier.

Detection of a case of pseudolymphocytosis due to cryoglobulins

A new type of interference of cryoglobulins on hemocytometric tests is described. The precipitation of temperature-dependent proteins produced a pseudolymphocytosis on a three-part differential leukocyte count of Coulter S-Plus VI, whereas unaffected results, identical to the microscopical count, were obtained using the cytometer Coulter VCS. The laboratory detection of cryoglobulin interference on hematological data is very important in patients with underlying diseases, where the accuracy of absolute and differential leukocyte counts is critical for follow-up. Histograms from the Coulter S-Plus VI can help detect these cases.

Comparison of immunofluorescent findings in kidney after snap-freezing and formalin fixation

Two types of tissue preparation for immunofluorescent staining were compared with sections of the same kidney. In one, formalin-fixed paraffin-embedded kidney sections were incubated with pronase (IF-PRON). The optimal pronase exposure for bright, specific IF and a mild background IF, suitable for the whole set of antisera was determined (pronase 0.75 g/l of Tris buffer for 60 min) and this was used for the subsequent steps of the study. Snap-frozen sections were also stained (IF-FROZ). Positive and negative cases, IF intensity, distribution and location in IgA nephropathy, membranous nephropathy, proliferative lupus nephritis were compared by the 2 methods. The main antigens for each disease were adequately revealed by IF-PRON, so that a correct diagnosis was possible in all cases. IF-PRON was also applied to sections before and after prolonged storage of blocks in the files, to see whether or not retrospective analysis is possible. Only minor differences were found between the 2 series of sections. Finally, the exposure of the sections to the continuous fluorescent light showed that IF fading was less in fixed sections. We conclude that IF-PRON is a reliable method for renal pathology with some advantages over the IF-FROZ.

Detection of cryoglobulins by Coulter Counter model S-Plus IV/D

Cryoglobulins may produce interference in results from electronic particle counters. Depending on their size, cold-precipitable globulin crystals can be counted as leucocytes and/or platelets. The Coulter Counter model S-Plus IV/D permits detection of this interference and its associated spurious counts by producing a characteristic WBC histogram accompanied by a leucocyte 'flag'. Using this instrument over a 1-year period, 10 cases of cryoglobulinaemia were detected, four from patients with lymphoproliferative disease and one from a patient with autoimmune disease. The remaining five were classified as essential mixed cryoglobulinaemia. The reproducibility of this instrument anomaly permits identification of the presence of cryoglobulins.

EDTA-dependent pseudothrombocytopaenia: a 12-month epidemiological study

The phenomenon of in vitro platelet clumping and consequent pseudothrombocytopaenia in the presence of EDTA has been studied in 33,623 subjects referring to a general hospital in a 1-year period. The observed frequency was 0.13%. EDTA-dependent pseudothrombocytopaenia (PTP) was suspected when a routine blood counting by the Coulter S-Plus IV/D showed a peculiar leucocyte histogram and pseudoleucocytosis. Confirmation was obtained by the manual count and by the finding of platelet aggregates in a stained blood smear. EDTA-dependent PTP was diagnosed when the platelet number and the morphological examination of blood anticoagulated with sodium citrate from the same patient were normal. EDTA-dependent PTP was found in 23 subjects aged from 19 to 79 years (0.068% of the study population): 17 were patients suffering from miscellaneous diseases, while six were apparently healthy. As a rule, platelet clumping was evident within 60 minutes from blood collection, but a longer latency (2-3 h) was observed in a few cases. EDTA-dependent PTP is a rare, but misleading phenomenon, the recognition of which is important in order to avoid expensive and potentially harmful procedures.

A randomized trial comparing triple-drug and double-drug therapy in renal transplantation

A controlled trial was carried out in 86 cadaveric and 14 living haploidentical renal transplant recipients to compare the effects of low doses of cyclosporine (CsA), azathioprine (Aza) and steroids with those of higher doses of CsA plus steroids. Patients were followed for 12-26 months after transplantation. The actuarial 2-year patient and graft survival rate was 100% for living-donor transplants. In cadaver renal transplants the 2-year patient survival rate was 100% for patients assigned to the triple regimen and 93% for those allocated to the double regimen. The actuarial 2-year cadaver graft survival rates were 86% and 90.6%, respectively. There were significantly more patients who had severe infections (P less than 0.05), particularly interstitial pneumonia (P less than 0.005), in the double-therapy group. On the other hand, there were more patients who rejected and more patients with severe rejections; more pulses of steroids were also required for patients on the triple regimen, although these differences were not significant. The mean trough blood levels of cyclosporine at the various times were about half as high in patients on triple therapy. There were no differences between the two groups in creatinine clearance at any time. A control renal biopsy, taken from patients with stable renal function after 6-12 months, showed only mild abnormalities. The lesions were semiquantitatively assessed. There was a higher score for interstitial infiltrate in patients on triple therapy (P less than 0.05). On the other hand, the incidence and the mean score of interstitial fibrosis were greater in patients on double therapy, although these differences were not significant. Thus, although similar results were obtained with both regimens, at the doses we used double therapy seems to have more powerful immunosuppressive effects and may prevent rejection, either acute or chronic, better. However, it might expose the patient to a greater risk of infection and of cyclosporine-related nephrotoxicity than triple therapy.

Long-term prognosis of diffuse lupus nephritis

The follow-up of 43 patients with diffuse proliferative lupus nephritis is reported. After histological diagnosis, all patients were treated with 3 intravenous high-dose methylprednisolone pulses and then with low-dose oral steroids and 31 with cytotoxic drugs. Renal and extra-renal exacerbations were also treated with intravenous high-dose steroids. Patients were followed for 1 to 13 years. At 10 years the patient survival rate was 87% and the kidney survival rate was 79%. If 3 extra-renal deaths are excluded, the actuarial 10-year kidney survival rate is 91%. At present, 21 patients do not show any renal abnormalities, 13 patients have normal plasma creatinine but proteinuria, 3 patients have stable renal function impairment, 2 patients have worsening of their renal function, 1 is on regular dialysis. The other 3 patients died (from cardiac failure, cerebral hemorrhage and a car accident). The incidence of flare-ups was low (0.1 episodes per year). Severe side effects were rare in this series. It is concluded that the long-term prognosis of diffuse lupus nephritis is becoming considerably better. Therapy based on a short course of intravenous high-dose methylprednisolone and on a maintenance regimen with low doses of steroid and cytotoxic agents can contribute to preserving renal function while avoiding severe side effects.

The coexistence of rheumatoid arthritis and systemic lupus erythematosus

A 29-year-old white female with longstanding classical rheumatoid arthritis (RA) developed clinical and serological manifestations of systemic lupus erythematosus (SLE) with prominent signs of diffuse proliferative lupus nephritis. She fulfilled the ARA criteria for the classification of SLE as well as the ARA criteria for classical RA. The concomitant presence of these two affections in the same patient is rare and the discriminating features suggest that this coexistence may be coincidental. With respect to treatment, our patient had good relief of symptoms by a combined administration of methylprednisolone pulses and cyclophosphamide.

Plasma protein glycation as measured by fructosamine assay

The fructosamine test for assessing control of glucose in blood has been extensively evaluated, but some questions remain regarding its validity. From the analytical and clinical evaluation we present here, we conclude that: the test is sensitive to variations in the composition of the sample protein; the fructosamine reaction is almost completely unaffected by labile fractions; the concentrations of fructosamine correlate well with the degree of glycation of total serum proteins, especially with glycated albumins and glycated immunoglobulins, as determined by affinity chromatography; the correlation with glycated hemoglobin (Hb A1c), measured as the stable fraction, is very poor, in diabetics treated with insulin (r = 0.373), or with oral hypoglycemic agents (r = 0.390); and (e) fructosamine and Hb A1c are, in fact, expressions of different periods of metabolic control and therefore have different clinical meanings.

Prognostic factors and effectiveness of treatment in acute renal failure due to multiple myeloma: a review of 50 cases. Report of the Italien Renal Immunopathology Group

We studied 50 patients with myeloma acute renal failure to investigate possible prognostic factors and to evaluate the effectiveness of the various treatment schedules used. Renal failure was reversible 1 month after the onset in 50% of the patients considered. The patients treated with chemotherapy and plasma exchange recovered renal function more frequently (61% of the cases) than those treated only with chemotherapy (27%). The most important clinical prognostic factors were total proteins, serum creatinine values and myeloma type. Considering the histological findings, the prognosis correlated with the severity of the lesions and number of tubular casts. Survival at 1 year was higher in the patients who regained renal function than in those in whom renal function did not improve.

Plasma protein glycation as measured by fructosamine assay

The fructosamine test for assessing control of glucose in blood has been extensively evaluated, but some questions remain regarding its validity. From the analytical and clinical evaluation we present here, we conclude that: the test is sensitive to variations in the composition of the sample protein; the fructosamine reaction is almost completely unaffected by labile fractions; the concentrations of fructosamine correlate well with the degree of glycation of total serum proteins, especially with glycated albumins and glycated immunoglobulins, as determined by affinity chromatography; the correlation with glycated hemoglobin (Hb A1c), measured as the stable fraction, is very poor, in diabetics treated with insulin (r = 0.373), or with oral hypoglycemic agents (r = 0.390); and (e) fructosamine and Hb A1c are, in fact, expressions of different periods of metabolic control and therefore have different clinical meanings.

Laboratory investigation of monoclonal gammopathy during 10 years of screening in a general hospital

Protein electrophoresis was carried out on 102,000 samples from the patients of a district general hospital over 10 years, and a monoclonal protein was detected in 730 cases; of these, 114 could be classified as B cell malignancies and 261 as monoclonal gammopathy of undefined significance (MGUS). The various clinical and laboratory features of monoclonal gammopathy were examined with respect to distinguishing the malignant conditions from MGUS at first presentation.

[Alloalbuminemia associated with myeloma]

Alloalbuminemia occurring together with paraproteinemia in a case of proven myelomatosis is described. The clinical and laboratory findings of this case are listed. The importance of the reported case is emphasized.

Renal histological lesions and clinical syndromes in multiple myeloma. Renal Immunopathology Group

This retrospective multicenter study, based on 42 patients affected by renal damage due to multiple myeloma, analyzes the renal biopsy results, the clinical data at the time of biopsy and the subsequent renal outcome in order to clarify the correlations existing between clinical and histological changes. Plasmocytoma components were Bence Jones alone in 55% of the patients and light-chain excretion was present in over 90%. Rapidly progressive renal failure was the most frequent clinical presentation (27 cases). The histological lesions directly attributable to multiple myeloma were subdivided into 3 basic categories: related to light-chains, direct tumor involvement of renal parenchyma and attributable to systemic effects of neoplastic disease. Light-chains seemed to cause renal lesions in 59.4% of the cases. Myeloma cast nephropathy was the prominent bioptic diagnosis established (20 cases). Among the clinical, laboratory and histological parameters studied, only the degree of tubular-interstitial damage was significantly correlated to the renal outcome in the 32 patients who had an adequately documented follow-up period.

Comparison between magnetic resonance imaging and other techniques in 39 multiple sclerosis patients

Till now there are no specific laboratory tests to confirm the diagnosis of Multiple Sclerosis (MS). For this reason the diagnosis of MS is based on the clinical evidence of central nervous system white matter disease with temporal and spatial dissemination of the lesions. Recent advances in neurophysiology and imaging techniques can provide more objective criteria towards more accurate and earlier diagnosis, detecting clinically unsuspected lesions. We evaluated 39 MS patients (23 definite, 7 probable, 9 possible) by Magnetic Resonance Imaging (MRI), CT scan, Evoked Potentials (EPs) testing and Cerebrospinal Fluid analysis. MRI was abnormal in 34 cases (87%) and CT scan in 14 (36%); EPs were also abnormal in 34 cases. 30 patients had both EPs and MRI alterated and 4 patients had alterated only one of the two investigations. The frequency of EPs alterations was: VEP 74%, Median SEP 44%, Tibial SEP 59% and BAEP 54%. The BAEP was more sensitive than MRI in detecting brainstem involvement. On the other hand MRI was more sensitive than SEPs in detecting somatosensory pathways involvement. The combined use of the two techniques allowed a reclassification of 10 out of 16 possible or probable MS cases.

Gold nephropathy and renal amyloidosis in a patient with rheumatoid arthritis

A 71-year-old Caucasian woman with rheumatoid arthritis, who had been treated with gold salts for 19 months, developed a significant proteinuria associated with nephrotic syndrome and renal impairment. Her renal biopsy revealed the unusual simultaneous occurrence of gold nephropathy and renal amyloidosis and she was treated by gold withdrawal, methylprednisolone pulses and azathioprine, with a good remission of symptoms. We describe the case and discuss the possible cause(s) of similar renal involvement and the results obtained with the combined therapy of steroids and cytotoxic drugs.

Glomerular disease and pregnancy. A study of 123 pregnancies in patients with primary and secondary glomerular diseases

The clinical course of 123 pregnancies in 86 patients with biopsy-proven glomerular diseases have been studied. In 35 women the onset of nephropathy occurred during pregnancy. No complications were observed in more than half of the pregnancies. In the others, one third of the complications were obstetrical or fetal accidents, one third were renal manifestations (hypertension or deterioration of renal function) and one third were both causes. The lowest incidence of complications was observed in patients with membranous nephropathy and the highest in membranoproliferative glomerulonephritis patients. There were 6 spontaneous late abortion, 6 stillbirths and 5 neonatal deaths. 17 deliveries were preterm and 7 fetuses were small for gestational age. Hypertension appeared in 24 pregnancies, in 13 of which it was reversible and related to superimposed preeclampsia and in 11 it persisted after delivery (5 of these 11 pregnancies were in patients with IgA nephropathy). Renal function deteriorated in 10 cases during pregnancy. The deterioration was reversible in 6 and progressive in 4 (2 of whom had membranoproliferative glomerulonephritis). It is suggested that in most patients pregnancy does not change the natural history of glomerular disease.

Extracapillary glomerulonephritis with necrotizing vasculitis in D-penicillamine-treated rheumatoid arthritis

Rapidly progressive glomerulonephritis occurred in a woman with rheumatoid arthritis (RA) who had been treated with D-penicillamine for 3 months. Light microscopy study of the kidney showed severe glomerulonephritis with crescent formation in 50% of glomeruli and necrotizing vasculitis. Immunoflurescence revealed IgA and C3 granular deposits diffusely distributed along the capillary walls. The patient was treated with steroid 'pulse', antiplatelet agents and heparin and a partial recovery of renal function was observed after 2 months of anuria. This renal picture is unlike that reported in RA and a causative role for D-penicillamine is suggested.

Disposition of pulse dose methylprednisolone in adult and paediatric patients with the nephrotic syndrome

The disposition of a large pulse-dose of methylprednisolone was examined in paediatric and adult patients with the nephrotic syndrome. Plasma concentrations and urinary excretion rates were measured by high performance liquid chromatography. Most of the dose was metabolized, as indicated by urinary recovery of less than 10 percent of the dose. There was only slight age-dependence of the plasma clearance and volume of distribution of the steroid, although the T1/2 and mean transit time were shorter in younger patients. The pharmacokinetic parameters of the large doses (12-20 mg/kg) were similar to low dose (0.5-1 mg/kg) data from asthmatic patients. The limited variability of the pharmacokinetics of methylprednisolone suggests that tissue sensitivity may be a more important indicator of drug dosage needs in nephrotic syndrome.