[Resistance to therapy in primary nephrotic syndrome: effect of MDR1 gene activity]

MDR1 gene encodes for a transmembranous glycoprotein, gp-170, which acts as a drug export pump and is also a cyclosporine(CsA)-binding protein. This study aimed at evaluating MDR1 expression in NS sensitive(S) and resistant(R) to therapy (steroids/S/, cyclophosphamide/C/, CsA) patients. Twenty six boys, 13 girls aged 3-8 years were included to the study. MDR1 was analysed using: 1) evaluation of gp-170 activity according to DiC2/3/ [3,3-Diethyloxa-carbocyanine Iodide] by means of flow cytometry and as 2) mRNA expression of MDR1 determined by RT-PCR. The analysis was performed in the lymphocyte subset CD4/CD45RA presenting suppressor-inducer activity. Negative control, Jurkat-T-cell line, not expressing the MDR1 phenotype, was transfected with viral expression vector containing a full-length cDNA for the human MDR1 gene. We found that: in SR-NS the high expression of MDR1 was associated mainly with the suppressor-inducer T-cells (CD45RA+CD4+) and was subsequently enhanced during an ineffective treatment with C and/or CsA. C-R-NS and CsA-R-NS were partially reversible by S- and R-Verapamil; this was in vitro confirmed by inhibition of export pump activity, gp-170. SS-NS, C-S-NS and CsA-S-NS presented the low expression and activity of MDR1 comparing to R-children (p < 0.001) and healthy controls (p < 0.00001). Resistance to therapy in NS patients seems to be resulted from the enhanced expression of MDR1 gene and subsequent high activity of export pump P-gp-170. Calcium channel blockers may reverse the MRD1-related resistance in the therapy of NS. Analysis of MDR1 may help to detect of suspected therapy resistance in NS.

[Does the changed Th1/Th2 activity in children with the assessment of body water in children with nephrotic syndrome: initial results]

T cells are involved in the pathogenesis of nephrotic syndrome (NS). The aim of the study was to determine whether the activity of T-helper-1 (Th1) and T-helper-2 (Th2) cells are predictive for steroid sensitivity in children with primary NS. These parameters were assessed at the onset of disease, before initiation of steroid therapy. Two groups of NS children were retrospectively formed according to steroid sensitivity(SS) or resistance(SR). Activity of Th1 and Th2 cells was defined by the production of IL-2, IFN-gamma and IL-4, IL-10 (ELISA), respectively, in the supernatants of the culture of CD4+ T cell cultures activated with autologous monocytes presenting tetanus toxoid (TT). Peripheral lymphocyte subsets were determined using double or triple colour flow cytometry. In SS children with NS we found the cytokine synthesis indicating the predominance of Th2 activity. We conclude that prior to treatment the Th1 and Th2 cell activity provides a useful tool to evaluate the probability of steroid sensitivity in patients with primary NS.

[Total antioxidant status (TAS) in children with nephrotic syndrome]

The aim of the study was to estimate total antioxidant status (TAS) as the most reliable factor involved in antioxidant protection in children with nephrotic syndrome. 28 children with NS (12 with first episode and 16 with relapse NS) aged 4-16 were included into the study. TAS was estimated using two-regent Randox Total Antioxidant Status test in plasma. Laboratory investigations were performed before steroid treatment.

RESULTS

1) in children with NS TAS was significantly reduced comparing to controls (0.81 +/- 0.14; 1.21 +/- 0.62 mmol/L; p = 0.002), 2) negative correlation between Tchol and LDL and TAS was found (TAS vs Tchol p = 0.0005, R = 0.61; TAS vs LDL p = 0.03, R = 0.41), 3) TAS was higher in children with the first episode of NS comparing to children with following relapse (0.88 +/- 0.07; 0.75 +/- 0.16; mmol/l; p = 0.14).

CONCLUSION

In children with NS reduced antioxidant protection is one of the factors leading to renal injury and may be a consequence a cause reason of lipids abnormalities.

Clinical and morphological (including morphometric) aspects of minimal change disease and mesangial glomerulonephritis with unfavourable course in children

Clinical and morphological analysis was made to assess 9 cases of minimal change disease (MCD) and 30 cases of mesangial glomerulonephritis (GNMES) recognized by light microscopy with unfavourable course. Case selection was based exclusively on the clinical course suggesting a possibility of early sclerosis (long-term steroid resistance, frequent recurrences, rare short-lasting remissions, hypertension, renal failure). It was found that the unfavourable clinical course was clearly more frequently associated with electron microscopic than light microscopic changes. Marked increase of the matrix was observed also in those glomeruli in which light microscopy did not reveal any changes or only the signs of immaturity. It was also noticed that in those cases in which the assessment of mesangial matrix increase (which means the onset of sclerosis) is not certain, it is useful to make a morphometric analysis of electron microscopic material.

Cyclophosphamide and other new agents for the treatment of severe aplastic anemia

Severe aplastic anemia (SAA) has a poor prognosis in the absence of treatment. Current accepted therapeutic strategies include allogeneic stem-cell transplantation and immunosuppression, both resulting in long-term survival in the majority of patients. Although human leukocyte antigen (HLA)-matched sibling stem-cell transplantation is highly effective, the 25% probability of finding a suitable sibling donor within a family renders this approach available to only a minority of patients. Transplantation using HLA-matched, unrelated donors carries a high risk of treatment failure along with considerable toxicity. While combined immunosuppression with both antithymocyte globulin (ATG) and cyclosporine A (CSA) produces hematologic improvement in most patients, relapse is common. Late evolution of aplastic anemia to other serious hematologic disorders, including paroxysmal nocturnal hemoglobinuria (PNH), myelodysplasia, and acute leukemia, is also a significant problem following treatment with ATG/CSA. Recently, results of immunosuppression in SAA with another potent immunosuppressive agent, cyclophosphamide, were reported in a small number of patients. The overall response rate was similar to that seen with ATG/CSA, but relapse and late clonal disease were not observed during a long period of follow-up. A larger randomized trial comparing sustained hematologic response rates to either conventional immunosuppression with ATG/CSA or high-dose cyclophosphamide and CSA is now underway; secondary end points include response duration, event-free survival, and overall survival. Additionally, a number of protocols designed to test the efficacy of alternative immunosuppressive or immunomodulatory agents are being developed.

Is vacuolization of podocytes and glomerular endothelial cells of prognostic value with respect to FSGS?

Focal segmental glomerulosclerosis (FSGS) poses a major problem both from the clinical and pathomorphological viewpoint. The diagnosis of FSGS in its early stage is vital mainly because of rapidly developing therapeutic modalities. In the literature various changes are discussed which may be of prognostic value (may predict the development of FSGS). One the these changes in vacuolization, mainly of podocytes and less frequently of endothelial cells. The purpose of the present study was to analyse biopsy specimens to find out to what extent vacuolization of podocytes and endothelial cells is associated with FSGS. We compared vacuolization in minimal change disease (MCD), mesangial glomerulonephritis (GNMES) and FSGS. A similar analysis was made also with respect to those cases of MCD and GNMES, in which electron microscopy suggested an early stage of FSGS. In each group electron micrographs obtained from 15 children were analysed. Electron micrographs (12-15 on average) were obtained most frequently from 3 glomeruli. Each case electron micrographs contained 90-100 podocytes. Based upon the same electron micrographs we counted capillary lumina and defined the percentage of those which contained vacuolized endothelia (we counted the capillary lumina, and not the cells, because it is most frequently impossible to identify the border of vacuolized endothelial cells). The number of capillary cross-sections was 60 on average. The results of the analysis were compared with the clinical data. This comparison did not confirm the hypothesis of other investigators that vacuolization is of a prognostic value. Additionally we evaluated the character of vacuoles. Within podocytes the vacuoles were varying in shape. Surrounded by a single membranous layer most frequently they contained material corresponding to proteins or proteoglycans, rarely to lipids. Sometimes the vacuoles were autophagosomal, occasionally they consisted of the dilated rough endoplasmic reticulum. Vacuole-like changes within the capillary lumina were related to the swelling of endothelial cytoplasm or mesangial processes. The reasons for a discrepancy between our results and those reported by other investigators necessitate further studies.

[Otolaryngologists -- victims of Stalin's NKVD crimes during World War II]

The biographies of 17 Polish ENT-doctors killed of in prisoner's of war camps in Kozielsk, Starobielsk and Ostaszkow in spring 1940 were described. Some personalities who faded into oblivion but are still important for polish otolaryngology were also presented.

Intravenous aminophylline increases the degree of saturation of urine with calcium phosphate and struvite

This study was designed to assess the effect of i.v. treatment with aminophylline (AMPH) on the risk of calcium phosphate and struvite stone formation. We administered AMPH in doses of 4 mg/kg body weight in 15-min i.v. infusions to 60 infants with clinical symptoms of obstructive bronchitis with dyspnoea. During 3 hours after infusion we observed a significant increase in urine saturation with brushite, octocalcium phosphate and struvite. This rise in urine saturation may increase the risk of kidney stone formation.

[Dysrhythmias documented by 48-hour electrocardiographic monitoring in children with mitral valve prolapse]

The association of dysrhythmias with mitral valve prolapse (MVP) in pediatric patients was examined by 48-hour ECG monitoring. Fifty unselected children with clinical diagnosis of MVP confirmed by echocardiography were studied. Eight (16%) patients manifested atrial dysrhythmias. Long runs of junctional rhythm with activity were recorded in one patient. Episodes of supraventricular tachycardia were recorded in 4 (8%) children. Seventeen (34%) patients had ventricular dysrhythmias. In 10 (20%) children, ventricular premature complexes (VPCs) were recorded. Four (8%) patients had frequent multifocal VPCs. Ventricular couplets were recorded several times in one patient (2%) and nonsustained ventricular tachycardia was recorded in two (4%) children. Clinical symptoms did not correlate with documented arrythmias. Although the prognostic implications of these findings are uncertain, this study demonstrated that potentially serious dysrhythmias are common in pediatric patients with MVP. It would appear that ambulatory ECG monitoring should be part of the complete evaluation of children with MVP.

[One center's experience with fibrinolytic treatment in children]

Fifteen children treated with fibrinolytic agents are presented. The most frequent indication was thromboembolic disease (TED). Eleven patients received streptokinase, 5-urokinase and 3-tissue plasminogen activator. Concomitant heparin was administered to 9 patients with TED. Total resolution was achieved in 9 children, partial improvement in 5; 1 child died during treatment without any improvement. Bleeding complications were observed in 6 patients, 1 of them died due to haemorrhagic stroke. According to the literature and our own experience, we recommend fibrinolytic agents as the treatment of choice for severe TED also in children.

[Thrombo-embolic disease as a complication of nephrotic syndrome in children]

Eight children with thrombo-embolic disease in the course of nephrotic syndrome were treated at II Clinic of Children's Diseases (Institute of Pediatrics, Poznań) between 1991 and 1993. The diagnosis was established on the basis of clinical examination and noninvasive imaging techniques. Two patients had an atypical localisation of the thrombus in the left ventricle and right atrium. In laboratory tests of the coagulation system, all of the children had decreased levels of antithrombin III (AT III). All children were treated with heparin and 4 with fibrinolytic agents. AT III concentrate was administered to 3 children. Total resolution of thrombo-embolic disease was obtained in 5 patients, 3 died during treatment. Thrombo-embolic disease should be taken into account in the differential diagnosis of complications of nephrotic syndrome.

[Severe hemolytic-uremic syndrome complicated by cholelithiasis treated with laparoscopic cholecystectomy in a 12-year old boy]

A case of a 12-year old boy with hemolytic-uremic syndrome complicated with cholelithiasis is presented. Due to severe course of the hemolytic-uremic syndrome (enhanced catabolism, coagulation disorders) a laparoscopic cholecystectomy as a new, modern surgical technique has been considered. Postoperative period has been uncomplicated. Therefore, laparoscopic cholecystectomy proved useful and is recommended in patients with high postoperative risk.

Morphological and clinical aspects of membrano-proliferative glomerulonephritis in children

Clinical and morphological studies were carried out in 34 children with the diagnosis of primary membrano-proliferative glomerulonephritis. The studies were prompted by an increasing incidence of this type of glomerulonephritis in Poland in the light of its regular decrease in the world. We found: (a) a number of discrepancies in the clinical manifestations and course of the disease in our children as compared with those in the literature; (b) difficulties in morphological diagnosis; (c) a frequent lack of correlation between the severity of morphological changes and the clinical course. It is of note that our series includes a large group of children below 6 years of age, which is a rare phenomenon.

Relationship between the reactivity to hepatitis B virus vaccination and the frequency of MHC class I, II and III alleles in haemodialysis patients

To study the immunoreactivity genes in a heterogeneous human population needs a large number of individuals. Associations between HLA antigens and immunoresponse to viral or bacterial antigens have been studied with controversial results. As a homogeneous population, the MHC class I, II and III allele distribution was studied in 153 end-stage renal disease patients (ESRD, average duration of renal replacement: 8.2 + 5.1 years) immunized with a recombinant hepatitis B vaccine in accordance to the standard vaccination schedule. Thirty-four patients with an antibody titre of less than 10 U/l following the last booster injection were considered as non-responders while 119 patients with antibody titre equal to or more than 10 U/l were considered as responders. The responder group was divided into two subgroups: low responders (antibody titre: < or = 1000 U/l) and high responders (antibody titre: > 1000 U/1). Marked differences were observed between responders and non-responders in the occurrence of carriers of different MHC class I, II and III alleles. Homozygotes for HLA-A1, HLA-B8, HLA-DR3 and HLA-DQ2 were found almost exclusively in the non-responder group and significantly more heterozygotes for these alleles were found in the non-responder group compared to the responders. Similar albeit less marked differences were found in the frequency of some MHC class III alleles (C4A*6, C4A*QO, Bf*F, Bf*S0.7). Within the responder group, carriers of HLA-A2, HLA-B7 and HLA-DR4 were found to be clustered in the low responder sub-group whereas carriers of HLA-A1, HLA-B27, HLA-Cw2, C4A*6 and Bf*F were observed more frequently in the group of high responders. Similar differences were found with extended haplotypes as well. For example, the extended haplotypes HLA-A1, B8, BfS, C4AQO, C4B1, DR3, DQ2 and HLA-A1, B8, BfF, C4A6, C4B2, DR3, DQ2 were present in nine of 34 cases of non-responders but only in one of 119 case of responders (P < 0.000001). These observations indicate that the presence or absence of certain MHC alleles even in heterozygous form determine the responsiveness to hepatitis B vaccination in end-stage renal disease patients, and among responders, the intensity of antibody response is also markedly influence by immunogenetic factors.

Fas antigen expression on CD34+ human marrow cells is induced by interferon gamma and tumor necrosis factor alpha and potentiates cytokine-mediated hematopoietic suppression in vitro

Activation of Fas antigen, a cell surface receptor molecule, by its ligand results in transduction of a signal for cell death. The Fas system has been implicated in target cell recognition, clonal development of immune effector cells, and termination of the cellular immune response. Fas antigen expression on lymphocytes is regulated by interferon gamma (IFN gamma) and tumor necrosis factor alpha (TNF alpha), cytokines that also have inhibitory effects on hematopoiesis. We investigated Fas antigen expression on human marrow cells and the effects of Fas activation on hematopoiesis in vitro. Freshly isolated immature hematopoietic cells, as defined by the CD34 marker, did not express Fas antigen at levels detectable by fluorescent staining. CD34+ cells, which include progenitors and stem cells, showed low levels of Fas expression in culture, even in the presence of growth factors. Stimulation by TNF alpha and IFN gamma markedly increased Fas antigen expression on CD34+ cells. Anti-Fas antibody, which mimics the action of the putative ligand, enhanced IFN gamma- and TNF alpha-mediated suppression of colony formation by bone marrow (BM) in a dose-dependent manner. This effect did not require the presence of accessory cells. Colony formation from mature (CD34+ CD38+) and immature (CD34+ CD38-) progenitor cells and long-term culture initiating cells were susceptible to the inhibitory action of anti-Fas antibody in the presence of IFN gamma and TNF alpha. Apoptosis assays performed on total BM cells and CD34+ cells showed that anti-Fas antibody induced programmed cell death of CD34+ BM cells.(ABSTRACT TRUNCATED AT 250 WORDS)

[Reactivity to hepatitis B vaccination (HBV) in patients with uremia: association with defined HLA antigen configuration and complement protein allotypes C4A, C4B and B factor (Bf)]

Genes, which are responsible for the effectivity of immune response are located on the chromosome 6 similarly as the genes of the class I and II of the major histocompatibility complex (MHC) together with the genes of some complement proteins (C4A, C4B, B factor/Bf/). The study investigates the interdependence between HLA configuration as well as complement protein allotypes (C4A, C4B, Bf) with the reactivity to HBV vaccination of ESRD [end stage renal disease]-patients. 153 ESRD-patients (68 females, 85 males; mean duration of hemodialysis therapy 8.2 +/- 5.1 years) were studied. Subjects were vaccinated (Gen-H-B-Vax-D; Merck, Sharp and Dohme, 40 micrograms/dosis i.m.) in the schedule at 0, 1, 2, and 6 month. Non-responders (NR) were defined when the anti-HBs antibody titer was below 10 U/liter. HLA typing was performed by means of microlymphocytotoxicity assay, whereas complement allotypes were estimated by using high voltage gel electrophoresis with subsequent specific immunofixation with antibodies against C4A, C4B and Bf. In the non-responders group [NR = 34] a) the significantly higher occurrence of single HLA-A1 and/or HLA-B8 and/or Cw4 or DR3 or DR7 or DQ2 have been found. In about 40% of NR HLA-A1, -B8, -DR3, or -DQ2 antigens occurred as homozygotes.

Slightly dilated acute obstructive failure of congenital solitary kidney

We present a case of a 10-year-old boy with slightly dilated obstructive acute failure of congenital solitary kidney. Obstruction of the ureter by stone was suggested as a cause of renal failure. The dilatation of the urinary tract above the obstruction was very small.

The effect of splenopentin (DA SP-5) on in vitro myelopoiesis and on AZT-induced bone marrow toxicity

Splenopentin (DA SP-5) is a pentapeptide corresponding to the amino acid sequence 32-36 (Arg-Lys-Glu-Val-Tyr) of the splenic hormone splenin. We examined the influence of DA SP-5 on bone marrow progenitor cell (BMC) proliferation. DA SP-5 acts as a co-stimulant for recombinant human granulocyte-macrophage colony-stimulating factor (rHuGM-CSF) in the induction of human BMC derived colony formation in vitro (colony-forming units). When exposed to DA SP-5 and thereafter to AZT and rHuGM-CSF, BMCs show a colony-forming response similar to that after cultivation with the rHuGM-CSF alone. In contrast, when exposed to AZT and rHuGM-CSF (and not preincubated with DA SP-5) the colony formation was reduced. A similar pentapeptide thymopentin (Arg-Lys-Asp-Val-Tyr) did not influence colony formation by human BMCs. We assume that DA SP-5 could support therapeutic effects of rHuGM-CSF.

Comparative analysis of the influences of IL-1, IL-3 and GM-CSF on the commitment of granulocyte-macrophage progenitors in vitro

Our experiments were directed towards the detection of the influence of interleukin-1 (IL-1); interleukin-3 (IL-3), and granulocyte-macrophage colony-stimulating factor (GM-CSF) on the generation of granulocyte-macrophage progenitor cells. We also set out to examine whether this process is connected with changes within the early precursor cell compartment. Bone marrow suspension cultures (12 days) supplemented with these cytokines were tested for the presence of GM colony-forming cells (GM-CFC) in a colony-forming unit assay. The percentage of CD34+ and HLA-DR+ as well as the number of blasts and promyelocytes were estimated cytofluorometrically and morphologically. The proliferative effect of GM-CSF was associated with a net increase of GM-CFC and HLA-DR+ myeloid cells and a decrease in the percentage of CD34+ early precursor cells. IL-3 acted similarly and also caused an absolute decrease of CD34+ cells in the cultures. IL-1 did not stimulate the generation of blasts or GM-CFC but elevated the number of CD34- as well as HLA-DR-expressing cells in the cultures. These results imply that GM-CSF supported the maintenance of hematopoiesis in vitro. The transition from early precursor cells to committed myeloid progenitor cells (GM-CFC) and more mature precursor cells (G-CFC, M-CFC) may be supported by GM-CSF without affecting the self-renewing capacity of CD34+ early precursors. In contrast, the blast-generating and proliferation-inducing action of IL-3 is associated with a drop in the total number of CD34+ stem cells. An efficient renewal of this population obviously depends on the presence of IL-1.