Influence of external factors in resistance of Corynebacterium urealyticum to antimicrobial agents

Corynebacterium urealyticum is usually resistant to multiple antibiotics. We analyzed whether previous hospitalization and/or the use of antibiotics was a factor associated with the appearance of resistance to different antibiotics in C. urealyticum. Our findings suggest that resistant strains of C. urealyticum are likely to be acquired directly from the hospital environment and that the use of antibiotics in the hospital setting could favor the appearance of multiresistant strains.

Cyclosporine nephrotoxicity and rejection crisis: diagnosis by urinary enzyme excretion

The urinary enzymes alanine aminopeptidase (AAP; EC 3.4.11.2) and N-acetyl-B-D-glucosaminidase (NAG; EC 3.2.1.30) were measured daily in 35 renal transplant recipients during the early postoperative period. Each peak value of fractional excretion was corrected for its baseline value (CFE). CFE values above normal for both NAG and AAP were more frequently found in episodes of acute rejection than in cyclosporine acute nephrotoxicity episodes (76 vs. 0%; p < 0.001). Consequently, a rise in CFE levels for both NAG and AAP is strongly suggestive of acute rejection crisis.

Lipoprotein(a) and vascular access survival in patients on chronic hemodialysis

Lipoprotein(a) [Lp(a)] is an independent risk factor for atherosclerotic and cardiovascular complications in the general population and in hemodialysis patients. Increased Lp(a) levels have been also described as a possible predictor of vascular access occlusion in patients on chronic hemodialysis. We have studied prospectively the relationship between vascular access survival and Lp(a) levels in 40 hemodialysis patients. The Lp(a) plasma concentrations were measured by enzyme-linked immunosorbent assay in all patients in April 1993. Throughout the following year, evolution and survival of their vascular accesses were analyzed. Failure of vascular access was established when there were complications requiring surgical repair or transluminal angioplasty. Fourteen patients showed failure of vascular access, and the cumulative survival of vascular accesses after 1 year of follow-up was 63.8%. The Lp(a) levels were higher in patients with failure of vascular access than in the others (35.2 +/- 31 vs. 22.4 +/- 25 md/dl), but this difference did not reach statistical significance (p = 0.064). The vascular access survival in patients with Lp(a) levels > 75th percentile (52.5 mg/dl) was significantly lower than in the remaining patients (40 vs. 72%; p = 0.045). This difference increased when we analyzed the patients with Lp(a) levels > 90th percentile (76 md/dl; 25 vs. 68%; p = 0.002). Our results suggest that patients with the highest levels of Lp(a) are at risk of developing complications in their vascular accesses, and they also have lower vascular access survival.

[Corynebacterium urealyticum in kidney transplant patients]

BACKGROUND

Corynebacterium urealyticum may produce severe urinary tract infections (UTI) in patients with renal transplantation (RT). The aim of this study was to define the prevalence, clinical spectrum and risk factors for the development of symptomatic UTI in RT receptors with bacteriuria by C. urealyticum.

METHODS

The clinical data of RT patients with bacteriuria by C. urealyticum diagnosed in the Hospital Doce de Octubre in Madrid from January 1990 to September 1993 were retrospectively reviewed. The patients corresponded to two clearly differentiated periods. In the first, the presence of C. urealyticum was not actively sought in the urine sample while in the second an intentional search was carried out in all the RT with a selective culture medium containing different antibiotics, Tween-80 and urea to facilitate C. urealyticum identification and growth.

RESULTS

C. urealyticum was isolated in the urine of 46 patients (14% of the RT performed in the study period). In the first phase 16 cases were diagnosed with 30 being found in the second with the selective medium. Bacteriuria by C. urealyticum was symptomatic in 18 patients (39%): 12 acute cystitis, one encrusted cystitis (IC), and 5 encrusted pyelitis (IP). Of the symptomatic patients 39% had a history of prolonged vesical catheterization, 27% carried ureteral catheterization and 50% had undergone other urologic manipulations. The clinical consequences were important with development of obstructive uropathy and alteration in renal function (28%), need for surgery (33%) and graft loss (5.5%). All the C. urealyticum strains were sensitive to vancomycin and teicoplanin which were useful in the treatment although the most severe cases (IC, IP) required surgery.

CONCLUSIONS

The prevalence of UTI by Corynebacterium urealyticum is high in RT patients. Occasionally, these infections may have severe consequences, particularly in patients with a history of urologic manipulation, if early diagnosis is not performed and adequate antibiotic treatment given. A selective culture medium should be used to isolate C. urealyticum in RT patients.

Transplantation of kidneys from donors with hepatitis C antibody into recipients with pre-transplantation anti-HCV

Hepatitis C virus (HCV) is transmitted by organ transplantation. Consequently, several organ procurement organizations have imposed a moratorium on use of organs from anti-HCV positive donors. Because of the inadequate supply of cadaver kidneys for transplantation, we adopted a policy to transplant kidneys from anti-HCV donors into anti-HCV positive recipients. During the period between March 1990 and December 1992, 24 anti-HCV positive dialysis patients received a kidney from anti-HCV positive donors (group I) and 40 anti-HCV positive patients received a kidney from anti-HCV negative donors (group II). We compared the prevalence of liver disease, anti-HCV, HCV RNA, graft and patient survival between groups. Pre-transplantation 17 of 24 (71%) patients in group I and 31 of 40 (79%) of patients in group II had serum HCV RNA. Post-transplantation follow-up was 26 +/- 8 months and 30 +/- 10 months in groups I and II, respectively. During follow-up, elevated ALT levels were present in 7 of 24 (29%) and 16 of 40 (40%) of patients in groups I and II, respectively (P > 0.05). Post-transplantation, all patients in both groups retained anti-HCV. The prevalence of HCV RNA post-transplantation was 22 of 23 (96%) patients in group I and 30 of 39 (77%) of patients in group II (P > 0.05). Graft and patient survival in group I (96% and 100%, respectively) were not significantly different from those in group II (93% and 98%, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

The screening of mild dementia with a shortened Spanish version of the "Informant Questionnaire on Cognitive Decline in the Elderly"

Most of the present screening tests for the detection of dementia fail with mild dementia. Jorm et al. recently presented the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), a simple instrument with good diagnostic validity that uses a close relative to obtain information on the cognitive decline of a patient. We used a Spanish adaptation of this questionnaire (S-IQCODE) validated in a population-based sample, and a shortened form (SS-IQCODE) obtained after analyzing the items and reducing them to only 17. The S-IQCODE and the SS-IQCODE have greater diagnostic validity for mild dementia than the Mini-Mental State Examination (MMSE) (sensitivity: 86% for both versus 57%; specificity: 92 and 91% versus 84%, positive predictive value: 54 and 50% versus 29%; negative predictive value: 91 and 90% versus 81%) and, unlike the MMSE, are independent of the age, education, and previous intelligence of the subjects. According to the results of this study, the SS-IQCODE could be a useful screening test for the detection of mild dementia in the Spanish-speaking aged population, with greater diagnostic power and less contamination by independent variables than the MMSE.

[Thrombophlebitis of the cavernous sinus secondary to polysinusitis. Report of a new case]

Cavernous sinus thrombophlebitis syndrome is uncommon nowadays. Despite the wide range of antimicrobial agents it carries a high mortality. The disease frequently arises from infection of face, mouth, nose and paranasal sinuses, reaching the cavernous sinus by venous spread. Involvement of adjacent anatomic structures accounts for most of the clinical findings. Meningeal involvement, bilateral orbital edema and ocular cranial nerves palsy are very helpful in the differential diagnosis. Streptococcus spp., Staphylococcus spp., Haemophilus influenzae and anaerobic organisms are considered to be the most frequent etiological agents. In the present paper we report a case of cavernous sinus thrombophlebitis following left side polysinusitis. The patient presented with the main clinical features of the syndrome along with Streptococcus equisimilis and Fusobacterium necrophorum bacteremia. Urgent surgery of infected sinuses and appropriate antibiotic therapy led to a favorable outcome. The patient made and excellent progress and was discharged completely recovered two weeks after admission.

Activation of the cloned muscarinic potassium channel by G protein beta gamma subunits

Acetylcholine released during parasympathetic stimulation of the vagal nerve slows the heart rate through the activation of muscarinic receptors and subsequent opening of an inwardly rectifying potassium channel. The activation of these muscarinic potassium channels is mediated by a pertussis toxin-sensitive heterotrimeric GTP-binding protein (G protein). It has not been resolved whether exogenously applied G alpha or G beta gamma, or both, activate the channel. Using a heterologous expression system, we have tested the ability of different G protein subunits to activate the cloned muscarinic potassium channel, GIRK1. We report here that coexpression of GIRK1 with G beta gamma but not G alpha beta gamma in Xenopus oocytes results in channel activity that persists in the absence of cytoplasmic GTP. This activity is reduced by fusion proteins of the beta-adrenergic receptor kinase and of recombinant G alpha i-GDP, both of which are known to interact with G beta gamma. Moreover, application of recombinant G beta gamma, but not G alpha i-GTP-gamma S, activates GIRK1 channels. Thus G beta gamma appears to be sufficient for the activation of GIRK1 muscarinic potassium channels.

Technique for management of an axilloaxillary by-pass graft complicating a median sternotomy

A technique is presented for intraoperative management of an axilloaxillary by-pass graft when performing a median sternotomy for myocardial revascularization. This method allows continual perfusion of both upper extremities during the operation thereby preventing the potential complications of upper extremity or cerebral ischemia.

Lipophilic dihydropyridines provide renal protection from cyclosporin toxicity

AIM

To review cyclosporin nephrotoxicity and its prevention by calcium antagonists.

METHOD

Review of published and unpublished studies.

RESULTS

Cyclosporin A nephrotoxicity is the most important side effect of this potent immunosuppressive drug. Several mechanisms have been implicated in the production of this adverse effect but elevated endothelin release is perhaps the most frequently cited cause. Calcium antagonists have demonstrated a beneficial effect in preventing cyclosporin A nephrotoxicity in renal cadaveric transplants, during both short- and long-term follow-up. Lacidipine, a lipophilic dihydropyridine calcium antagonist, prevents the reductions in the glomerular filtration rate and renal plasma flow that are often seen after cyclosporin A administration. This effect is not related to endothelin suppression.

CONCLUSIONS

Calcium antagonists can provide renal protection in patients who undergo renal cadaveric transplantation and are treated with cyclosporin.

Encrusted pyelitis and cystitis by Corynebacterium urealyticum (CDC group D2): a new and threatening complication following renal transplant

We evaluated the pathogenic role of Corynebacterium urealyticum in the development of encrusted pyelitis (EP) and encrusted cystitis (EC), and their clinical consequences in renal transplant recipients. During a 4-year period, we studied seven renal transplant recipients with EP and two with EC. The records of 320 other renal transplant patients studied during the same period were used as a control group. C urealyticum (> or = 10(5) CFU/ml) was isolated from 4 patients with EP (urine 3, blood 1) and from 1 patient with EC (urine). Alkaline urines with struvite crystals, microscopic hematuria, and sterile conventional urine cultures were present in all our cases. All the patients with EP developed obstructive uropathy with deterioration of the renal function and pyelonephritis (4 patients) or renal abscesses (3 patients). Chronic urinary discomfort and macroscopic hematuria were present in the 2 patients with EC. Long-term vesical and ureteral catheterization were considered the most important risk factors for the development of EC and EP, respectively. Vancomycin was successfully used in 5 cases, but all the patients required a derivative procedure or a surgical resection of the incrustations to improve. We conclude that EP and EC should be investigated in renal transplant patients who develop pyelonephritis, obstructive uropathy, or chronic urinary symptoms. EP and EC could lead to the loss of their grafts. C urealyticum appears to have a pathogenic role in these entities.

[A meta-analytical review of the response by sex to vaccination against hepatitis B in hospital personnel]

OBJECTIVE

To study the influence of gender on the immunogenic response to the hepatitis B vaccine in healthy persons.

DESIGN

Meta-analysis.

SETTING

Primary care: prevention.

PARTICIPANTS

The results published between 1983 and 1991 by several authors dealing with staff in Spanish hospitals were reviewed.

MAIN MEASUREMENTS AND RESULTS

It was observed that the frequency of women's antibody response differed significantly from that of men (chi-squared = 23.35; p < 0.001) with an odds ratio of 2 (95% confidence intervals: 1.64-2.46) and a risk difference of 7.69% (95% CI: 5.2-10.19%).

CONCLUSIONS

The response rate to the hepatitis B vaccine is significantly higher among women than men. However, several factors (e.g. age and weight) may affect these findings. These have not been examined because they were not described in the findings of the preliminary studies.

Calcium antagonists and renal protection

AIM

To review the renal benefits of calcium antagonists.

METHODS

Review of published studies.

RESULTS

Both experimental and clinical studies have indicated that, apart from being highly potent antihypertensive agents, calcium antagonists may also provide tissue protection and preservation. In three well defined clinical situations, the use of calcium antagonists has proved to be of value. First, in acute renal failure we and others have shown that the administration of dihydropyridine or diltiazem can, by preventing an intracellular calcium overload, avoid the renal damage induced by the use of a radiographic contrast agent. Second, in chronic renal failure, the administration of a calcium antagonist has been shown to be safe and at least similar in efficacy to other commonly used antihypertensive drug classes. Third, in renal transplant patients, calcium antagonists have been shown to prevent both acute and chronic cyclosporin nephrotoxicity. Calcium antagonists have a clear advantage in the case of acute toxicity because they allow faster renal function recovery and a shorter hospitalization time. The mechanisms by which this class reduces cyclosporin toxicity may be related to a reduction in the calcium influx into cells during ischaemic and reperfusion periods, which would reduce the generation of oxygen-free radicals and perhaps reduce thromboxane production.

CONCLUSIONS

Calcium antagonists have potential renal protective effects that favour their use in many clinical situations where renal function is impaired.

Hemodialysis for treatment of accidental hypothermia

Accidental hypothermia is defined as a spontaneous decrease in core temperature to 35 degrees C or below. Several techniques of active core rewarming have been described. We present the case of a 34-year-old man with severe hypothermia (27 degrees C) caused by cold environment exposure and barbiturate intoxication treated with general supportive measures and active core rewarming with hemodialysis. Core temperature increased by 2.15 degrees C/h with hemodialysis and became normal in 4 h. The clinical situation clearly improved during the hemodialysis session and the patient recovered without any defect. Hemodialysis is a rapid and effective treatment for accidental hypothermia.

Tubular dysfunction in nephrotic syndrome: incidence and prognostic implications

Although some cases of tubular dysfunction (TD) associated with nephrotic syndrome have been described, the incidence and the characteristics of this complication remain unknown. We investigated the presence of TD (renal glycosuria, aminoaciduria, metabolic acidosis with normal anion gap, hypouricaemia, and throughout hypophosphataemia) in 36 patients with nephrotic syndrome. Ten patients (group 1) showed glycosuria at some time during the course of their illness, ranging from 2.5 to 11.2 g/24 h. In addition, seven of them had metabolic acidosis with normal anion gap, five aminoaciduria, and two hypouricaemia. Membranous glomerulonephritis was the most frequent aetiology in group 1 patients (7 of 10). Proteinuria and serum creatinine (SCr) were significantly higher in group 1 patients than in the 26 remaining patients without TD (group 2): 10.2 +/- 3.7 versus 6.7 +/- 2.9 g/24 h (P less than 0.01) and 3.2 +/- 1.9 versus 1.6 +/- 0.9 mg/dl (P less than 0.05) respectively. The appearance of TD coincided with a clear worsening of renal function in most of group 1 patients. In addition, at the end of follow-up, SCr had increased from 3.2 +/- 1.9 to 5.6 +/- 3.3 mg/dl (P less than 0.05) in this group. In contrast, SCr did not show significant changes in group 2 (1.6 +/- 0.9 versus 2.1 +/- 2.2 mg/dl). In conclusion, a significant proportion (27.7%) of patients with nephrotic syndrome present TD data at some moment of their course; the appearance of this complication appears to be a sign of poor prognosis.

Does calcium antagonist improve established early ciclosporin nephrotoxicity after renal transplantation?

We report a case of prolonged oliguric acute renal failure after renal transplantation under steroids and ciclosporin (Cs) immunosuppression. In the 2nd week when low fractional excretion of sodium values in the presence of oliguria (as expression of Cs nephrotoxicity) and high Cs blood levels were seen, a calcium antagonist drug was administered. Also, a Cs dose adjustment was made. Then, the diuresis and fractional excretion of sodium increased together with a progressive renal function. Although this evolution could be explained as a spontaneous resolution of postischemic renal failure, we speculated that in this case of established early Cs nephrotoxicity the effect of a calcium antagonist drug, such as nifedipine, could be beneficial.

Senior-Loken syndrome (nephronophthisis and pigmentary retinopathy) associated to liver fibrosis: a family study

We present two sisters with nephronophthisis and pigmentary retinopathy (Senior-Loken syndrome) and associated liver fibrosis. Clinical and histological findings are discussed, as well as the importance of family studies. A comparative analysis with previous published cases is made; we found only three other references with this triad. Our report underlines the need to investigate liver disorders in all patients with nephronophthisis and the existence of liver fibrosis as an element of the hereditary 'nephronophthisis complex.'