Serum IgG2 antibody multicomposition in systemic lupus erythematosus and lupus nephritis (Part 1): cross-sectional analysis

OBJECTIVES

Serum anti-dsDNA and anti-nucleosome IgGs have been proposed as signatures for SLE and LN in limited numbers of patients. We sought to show higher sensitivity and specificity of the same antibodies with the IgG2 isotype and included IgG2 antibodies vs specific intracellular antigens in the analysis.

METHODS

A total of 1052 SLE patients with (n = 479) and without (n = 573) LN, recruited at different times from the beginning of symptoms, were included in the study. Patients with primary APS (PAPS, n = 24), RA (RA, n = 24) and UCTD (UCTD, n = 96) were analysed for comparison. Anti-nucleosome (dsDNA, Histone2A, Histone3), anti-intracellular antigens (ENO1), anti-annexin A1 and anti-C1q IgG2 were determined by non-commercial techniques.

RESULTS

The presence in the serum of the IgG2 panel was highly discriminatory for SLE/LN vs healthy subjects. Serum levels of anti-dsDNA and anti-C1q IgG2 were more sensitive than those of IgGs (Farr radioimmunoassay/commercial assays) in identifying SLE patients at low-medium increments. Of more importance, serum positivity for anti-ENO1 and anti-H2A IgG2 discriminated between LN and SLE (ROC T0-12 months), and high levels at T0-1 month were detected in 63% and 67%, respectively, of LN, vs 3% and 3%, respectively, of SLE patients; serum positivity for each of these was correlated with high SLEDAI values. Minor differences existed between LN/SLE and the other rheumatologic conditions.

CONCLUSION

Nephritogenic IgG2 antibodies represent a specific signature of SLE/LN, with a few overlaps with other rheumatologic conditions. High levels of anti-ENO1 and anti-H2A IgG2 correlated with SLE activity indexes and were discriminatory between SLE patients limited to the renal complication and other SLE patients.

TRIAL REGISTRATION

The Zeus study was registered at https://clinicaltrials.gov, NCT02403115.

Serum IgG2 antibody multi-composition in systemic lupus erythematosus and in lupus nephritis (Part 2): prospective study

OBJECTIVES

Circulating anti-ENO1 and anti-H2A IgG2 have been identified as specific signatures of LN in a cross-over approach. We sought to show whether the same antibodies identify selected population of patients with LN with potentially different clinical outcomes.

METHODS

Here we report the prospective analysis over 36 months of circulating IgG2 levels in patients with newly diagnosed LN (n=91) and SLE (n=31) and in other patients with SLE recruited within 2 years from diagnosis (n=99). Anti-podocyte (ENO1), anti-nucleosome (DNA, histone 2 A, histone 3) and anti-circulating proteins (C1q, AnnexinA1-ANXA1) IgG2 antibodies were determined by home-made techniques.

RESULTS

LN patients were the main focus of the study. Anti-ENO1, anti-H2A and anti-ANXA1 IgG2 decreased in parallel to proteinuria and normalized within 12 months in the majority of patients while anti-dsDNA IgG2 remained high over the 36 months. Anti-ENO1 and anti-H2A had the highest association with proteinuria (Heat Map) and identified the highest number of patients with high proteinuria (68% and 71% respectively) and/or with reduced estimated glomerula filtration rate (eGFR) (58% for both antibodies) compared with 23% and 17% of anti-dsDNA (agreement analysis). Anti-ENO1 positive LN patients had higher proteinuria than negative patients at T0 and presented the maximal decrement within 12 months.

CONCLUSIONS

Anti-ENO1, anti-H2A and anti-ANXA1 antibodies were associated with high proteinuria in LN patients and Anti-ENO1 also presented the maximal reduction within 12 months that paralleled the decrease of proteinuria. Anti-dsDNA were not associated with renal outcome parameters. New IgG2 antibody signatures should be utilized as tracers of personalized therapies in LN.

TRIAL REGISTRATION

The Zeus study was registered at https://clinicaltrials.gov (study number: NCT02403115).

A clinical retrospective study of Caparinia tripilis (Psoroptidae) mite dermatitis in pet African pygmy hedgehogs (Ateletrix albiventris) in southern Italy

BACKGROUND

Caparinia tripilis is a common ectoparasitic mite affecting African pygmy hedgehogs, and is associated with pruritus and self-trauma. There have been no published surveys on the prevalence of such mites in pet African pygmy hedgehogs in Italy.

OBJECTIVE

To evaluate the prevalence and clinical signs of C. tripilis infestation in African pygmy hedgehogs.

ANIMALS

Clinical records of hedgehogs examined between December 2017 and December 2020 were searched retrospectively.

METHODS AND MATERIALS

The prevalence of C. tripilis infestation was evaluated and exposure variables were assessed using stepwise conditional logistic regression and odds ratios (OR) were calculated.

RESULTS

The overall prevalence of C. tripilis was 39.5% (81 of 205) in client-owned and 81.5% (66 of 81) in pet shop-housed affected hedgehogs. Fifty-two hedgehogs (64.2%) showed clinical signs of pruritus, scales, erythema, spine loss, crusting, alopecia and lichenification, while 29 infested hedgehogs (35.8%) were asymptomatic. The head was the most frequently affected area in 30 of 81 (37%) animals. In a multivariable analysis, affected hedgehogs were significantly younger [OR 0.27, 95% confidence interval (CI) 0.1-0.73; P = 0.0097] and more likely to be from a pet shop (OR 2.1, 95%CI 1-4.4; P = 0.04) than unaffected hedgehogs.

CONCLUSIONS AND CLINICAL IMPORTANCE

The results of this study indicate a prevalence rate of C. tripilis infestation that is consistent with trends observed in other studies. African pygmy hedgehogs, especially younger animals and those originating from a pet shop, should always be evaluated for C. tripilis.

Monocyte to HDL ratio: a novel marker of resistant hypertension in CKD patients

BACKGROUND

Inflammation, oxidative stress (OS), atherosclerosis and resistant hypertension (RH) are common features of chronic kidney disease (CKD) leading to a higher risk of death from cardiovascular disease. These effects seem to be modulated by impaired anti-oxidant, anti-inflammatory and reverse cholesterol transport actions of high-density lipoprotein cholesterol (HDL). HDL prevents and reverses monocyte recruitment and activation into the arterial wall and impairs endothelial adhesion molecule expression. Recently, monocyte count to HDL-cholesterol ratio (MHR) has emerged as a potential marker of inflammation and OS, demonstrating to be relevant in CKD. Our research was aimed to assess, for the first time, its reliability in RH.

METHODS

We performed a retrospective study on 214 patients with CKD and arterial hypertension who were admitted between January and June 2019 to our Department, 72 of whom were diagnosed with RH.

RESULTS

MHR appeared inversely related to eGFR (ρ = - 0.163; P = 0.0172). MHR was significantly higher among RH patients compared to non-RH ones (12.39 [IQR 10.67-16.05] versus 7.30 [5.49-9.06]; P < 0.0001). Moreover, MHR was significantly different according to the number of anti-hypertensive drugs per patient in the whole study cohort (F = 46.723; P < 0.001) as well as in the non-RH group (F = 14.191; P < 0.001). Moreover, MHR positively correlates with diabetes mellitus (ρ = 0.253; P = 0.0002), white blood cells (ρ = 0.664; P < 0.0001) and C-reactive protein (ρ = 0.563; P < 0.0001).

CONCLUSIONS

MHR may be a reliable biomarker due to the connection between HDL and monocytes. Our study suggests that MHR is linked with the use of multiple anti-hypertensive therapy and resistant hypertension in CKD patients, and can be a useful ratio to implement appropriate treatment strategies.

Vitamin D Boosts Alendronate Tail Effect on Bone Mineral Density in Postmenopausal Women with Osteoporosis

Vitamin D modulates bisphosphonate (BP) efficacy, but its contribution to bone mineral density (BMD) after BP discontinuation is not known. To address this topic, we performed a retrospective analysis of postmenopausal women exposed to alendronate (ALN) to treat osteoporosis who regularly continued the supplementation of cholecalciferol or calcifediol at recommended doses. In the ninety-six recruited women (age 61.1 ± 6.9 years), ALN was administered for 31.2 ± 20.6 months and then discontinued for 33.3 ± 18.9 months. The modification of 25(OH)D serum levels over time was associated with a change of alkaline phosphatase (r = −0.22, p = 0.018) and C-terminal collagen type 1 telopeptide (r = −0.3, p = 0.06). Women in the tertile of the highest increase in 25(OH)D level showed a 5.7% BMD gain at lumbar spine, that was twice as great in comparison with participants with a lower 25(OH)D variation. At a multiple regression analysis, BMD change was associated with time since menopause (ß = 2.28, SE 0.44, p < 0.0001), FRAX score for major fracture (ß = −0.65, SE 0.29, p = 0.03), drug holiday duration (ß = −2.17, SE 0.27, p < 0.0001) and change of 25(OH)D levels (ß = 0.15, SE 0.03, p = 0.0007). After ALN discontinuation, improving the vitamin D status boosts the ALN tail effect on BMD.

MO466A NOVEL PREDICTION MARKER OF 10-YEAR RISK AND LIFETIME RISK OF RECURRENT CARDIOVASCULAR EVENTS IN PATIENTS WITH CKD AND DIABETES MELLITUS

Background and Aims

Chronic kidney disease (CKD) is one of the most prevalent complication of Diabetes Mellitus and patients with both diseases are more exposed to atherosclerosis injury and premature death from cardiovascular disease (CVD).

CVD is worsened by inflammation, oxidative stress, lipid accumulation and high-density lipoprotein cholesterol (HDL) reduction: patients with altered lipid metabolism more often present monocyte profile changes, with an altered pro-inflammatory phenotype leading to a significant risk of plaque formation and atherosclerosis. The alteration of the balance between monocyte and HDL, represented by the Monocyte/HDL ratio (MHR), is an easy way to evaluate the inflammatory status and to study appropriate strategies to treat high-risk patients.

Method

We evaluated 150 consecutive diabetic patients with CKD hospitalized in the Unit of Nephrology and Dialysis of the Policlinic G. Martino of Messina, Italy, with a history of CVD. We used the SMART-REACH SCORE, a model created to estimate life expectancy without recurrent cardiovascular events for individuals with a history of CVD. We performed a retrospective analysis of the MHR status of our patients to study its correlations with the 10-year risk and lifetime risk for myocardial infarction, stroke or vascular death, recurrent CVD events and free life-expectancy if standard care is provided.

Results

In the entire cohort of patients, MHR appeared to be positively correlated with ten-year risk (ρ=0.469; P &lt;0.0001) (Figure 1) and lifetime risk of myocardial infarction, stroke, or CV death (ρ=0.428; P &lt;0.0001) (Figure 2). Furthermore, patients with higher MHR levels had a significantly smaller number of years of CVD-free life expectancy (ρ=-0.364; P &lt;0.0001) (Figure 3).

Conclusion

MHR can represent a valid tool to predict the recurrence of CVD in CKD patients with diabetes. This easy-to-perform marker of oxidative stress and CVD risk can be used alone or in a multiple biomarker panel, improving the stratification and management of patients with comorbidities and risk of life- threatening conditions.

MO139INDOLE-3-ACETIC ACID CORRELATES WITH MONOCYTE TO HIGH-DENSITY LIPOPROTEIN (HDL) RATIO (MHR) IN CHRONIC KIDNEY DISEASE (CKD) PATIENTS AND MAY BE EFFICIENTLY REMOVED BY ACETATE-FREE BIOFILTRATION

Background and Aims

Indole-3-acetic acid (IAA, also called auxin) is a protein-bound indolic uremic toxin deriving from tryptophan metabolism by the intestinal bacteria. Previous studies have shown that increased IAA is associated with enhanced tissue factor synthesis in endothelial and peripheral blood mononuclear cells, oxidative stress and endothelial inflammation with resulting higher risk of thrombotic events and both cardiovascular and all-cause mortality. An emerging biomarker of cardiovascular disease is the monocyte to high-density lipoprotein (HDL) ratio (MHR). Its prognostic value is related to the ability of monocytes to release several cytokines involved in inflammation and atherogenesis and to the protective role of HDL through removal of cholesterol from peripheral tissues and suppression of both monocyte progenitor cell proliferation and differentiation and monocyte activation. In this single-centre cross-sectional observational study, we investigated the potential association of IAA with MHR and other markers of cardiovascular risk in a cohort of patients with CKD and evaluated the effect of a single midweek dialysis session with AFB (Acetate-free Biofiltration) technique on IAA serum concentrations.

Method

We enrolled 61 non-dialysis CKD adult patients and 6 dialysis patients treated with AFB technique. IAA levels were measured using an enzyme-linked immunosorbent assay (ELISA) kit (Cat. number abx150354; Abbexa Ltd, Cambridge, UK). Post-dialysis IAA levels were corrected for haemoconcentration.

Results

In the whole cohort of 67 patients, IAA was directly related to creatinine (ρ = 0.247; P = 0.0441), potassium (r = 0.2871; P = 0.0185), Ca x P product (ρ = 0.256; P = 0.0365) and MHR (ρ = 0.321; P = 0.0082).

After adjustment for creatinine, the correlation between IAA and potassium became not significant (r = 0.1968; P = 0.1133). Stratifying patients according to the history of cardiovascular disease, in the 40 patients with previous cardiovascular events IAA levels correlated significantly with uric acid (r = 0.3952; P = 0.0116) and MHR (ρ = 0.380; P = 0.0157).

In the remaining 27 patients without history of cardiovascular disease, IAA only correlated with potassium (r = 0.3912; P=0.0481) and, though borderline significantly, with creatinine (ρ = 0.349; P = 0.0805). To assess whether IAA would independently predict MHR values, we evaluated potential correlations of MHR with risk factors for cardiovascular disease. MHR was related with fibrinogen (ρ = 0.426; P = 0.0010), arterial hypertension (ρ = 0.274; P = 0.0251), C-reactive protein (ρ = 0.332; P = 0.0061), gender (ρ = -0.375; P = 0.0017; 0 = male, 1 = female), and CKD stage (ρ = 0.260; P = 0.0337). A multiple regression analysis identified IAA as an independent predictor of MHR. Lastly, IAA levels were higher in dialysis patients compared to non-dialysis CKD patients (97.44 ± 21.58 versus 65.08 ± 24.38 ng/ml respectively; P = 0.0026) and it was significantly removed by a single AFB session (97.44 ± 21.58 versus 54.59 ± 21.74 ng/ml; P = 0.0028) with a reduction ratio of 43.80 ± 17.47%.

Conclusion

This study shows a statistically significant association between IAA and MHR. Based on previous experimental studies, such relationship could be explained by the activation of the transcription factor aryl hydrocarbon receptor. Indeed, IAA is a potent ligand of aryl hydrocarbon receptor and the latter has proinflammatory and proatherogenic activities and can reduce HDL levels. Moreover, AFB efficiently removes IAA during a single dialysis session. Prospective studies with appropriate sample size and sufficiently long period of observation are required to evaluate if decreasing IAA levels, through targeted therapeutic strategies in non dialysis CKD patients or by optimization of dialysis techniques and prescriptions in patients receiving renal replacement therapy, may reduce MHR levels and cardiovascular events and improve clinical outcomes and survival.

Gender Differences in Diabetic Kidney Disease: Focus on Hormonal, Genetic and Clinical Factors

Diabetic kidney disease (DKD) is one of the most serious complications of both type 1 (T1DM) and type 2 diabetes mellitus (T2DM). Current guidelines recommend a personalized approach in order to reduce the burden of DM and its complications. Recognizing sex and gender- differences in medicine is considered one of the first steps toward personalized medicine, but the gender issue in DM has been scarcely explored so far. Gender differences have been reported in the incidence and the prevalence of DKD, in its phenotypes and clinical manifestations, as well as in several risk factors, with a different impact in the two genders. Hormonal factors, especially estrogen loss, play a significant role in explaining these differences. Additionally, the impact of sex chromosomes as well as the influence of gene-sex interactions with several susceptibility genes for DKD have been investigated. In spite of the increasing evidence that sex and gender should be included in the evaluation of DKD, several open issues remain uncovered, including the potentially different effects of newly recommended drugs, such as SGLT2i and GLP1Ras. This narrative review explored current evidence on sex/gender differences in DKD, taking into account hormonal, genetic and clinical factors.

Kidney Biopsy in Type 2 Diabetic Patients: Critical Reflections on Present Indications and Diagnostic Alternatives

Roughly 3% of patients worldwide with a new diagnosis of type 2 diabetes mellitus (T2DM) already have an overt nephropathy at diagnosis and about 20-30% of the remaining ones develop a complication of this kind later in life. The early identification of kidney disease in diabetic patients is important as it slows its progression, which is important not only because this reduces the need for renal replacement therapy, but also because it decreases the high rate of mortality and morbidity associated with a reduction in kidney function. The increasing prevalence of type 2 diabetes and the consequent greater probability of finding different types of kidney diseases in diabetic patients frequently gives rise to overlapping diagnoses, a definition encompassing the differential diagnosis between diabetic and non-diabetic kidney disease. The issue is made more complex by the acknowledgement of the increasing frequency of presentations of what is termed "diabetic kidney disease" without relevant proteinuria, in particular in T2DM patients. Distinguishing between diabetes related and non-diabetes related forms of kidney disease in diabetic patients is not only a semantic question, as different diseases require different clinical management. However, while the urologic and macrovascular complications of diabetes, as well as overlapping parenchymal damage, can be diagnosed by means of imaging studies, often only a kidney biopsy will make a differential diagnosis possible. In fact, the coexistence of typical diabetic lesions, such as nodular glomerulopathy or glomerulosclerosis, with different glomerular, vascular and tubulo-interstitial alterations has been extensively described, and an analysis of the dominant histological pattern can contribute to determining what therapeutic approach should be adopted. However, due to the high frequency of kidney diseases, and to the fact that T2DM patients are often affected by multiple comorbidities, a kidney biopsy is not generally performed in T2DM patients. What follows is a review aiming to discuss the diagnostic work-up, on the base of clinical, laboratory and imaging criteria, and evaluate the present indications and alternatives to renal biopsy.

Uncertainty analysis of rising sewer models with respect to input parameters and model structure using Monte Carlo simulations and computational fluid dynamics

Modelling conversion processes in sewers can help minimize odour and pipe corrosion issues, but model uncertainties and errors must be understood. In this study, the Wastewater Aerobic/Anaerobic Transformation in Sewers (WATS) model is implemented in two different frameworks; 1-D (CSTR-in-series) and computational fluid dynamics (CFD) to study the uncertainties due to model parameters and its mathematical form. The 1-D model is used to conduct uncertainty/sensitivity analysis using Monte Carlo simulations. Time-averaged outputs were represented using a general linearized model to quantify the importance of specific parameters. The sulfide formation rate per unit area of the biofilm is the most influential parameter. Parameters controlling anaerobic hydrolysis and fermentation are also significant. Uncertainty due to model structure is studied using CFD to explore the influences of non-homogeneous surface reactions and solids settling. These showed that the 1-D model provides a reasonable characterisation of the process for simple flows in pressure mains.

Oxygen transfer and plant-wide energy assessment of primary screening in WRRFs

Primary screening is gaining interest as a method to achieve removal performances comparable to primary clarification while reducing the footprint and increasing operational elasticity. Aeration efficiency indicators in a pilot sequential batch reactor (SBR) and a full scale water resource recovery facility (WRRF) were investigated after the implementation of rotating belt filters/screens (RBF). To compare the impact between screened (350 μm) and nonscreened primary influent, two identical treatment lines were monitored using off-gas and respirometric measurements. The study provides the first result on improved oxygen transfer efficiency due to primary screening. Consistent aeration efficiency improvements of 27% and 20% between screened and nonscreened were obtained at pilot and full scale, respectively. Changes in aeration efficiency and carbon redirection were integrated into a set of models to investigate the primary screening impact on the WRRF energy balance. While the plant-wide assessment for different scenarios improved the energy balance up to 15%, a detailed comparative analysis between various treatment schemes gained insight into the advantages and limitations of the energetic sustainability of primary screening. PRACTITIONER POINTS: Aeration efficiency improved 27% at pilot scale Aeration efficiency improved 20% at full scale. Use of primary screening can improve the energy balance up to 15 Assessment of advantages and limitations of primary screening.

Evaluation of the cutaneous expression of IL-17, IL-22, IL-31, and their receptors in canine atopic dermatitis

Interleukins (IL)-17, IL-22, and IL-31 play roles in human atopic dermatitis (AD), but scant information is available on canine AD. Histopathological assessment for interleukin expression is a challenge due to a lack of canine specific antibodies. To evaluate the mRNA and protein expression of IL-17 and IL-22, and mRNA expression of IL-31 and their receptors in the skin of healthy and atopic dogs, seventeen atopic (10 with and 7 without an active infection) and 13 healthy privately owned dogs were sampled. RNAscope® In situ hybridization (ISH) for IL-17, IL-22, IL-31, and their receptors was performed on archived canine skin samples. Simultaneously, indirect immunofluorescence (IIF) was performed for IL-17 and IL-22. RNAscope® ISH probes were validated by RT-PCR and RNAscope® ISH on cytospin preparations of peripheral blood mononuclear cells from atopic dogs. IL-17, IL-22, IL-31, and their receptors were successfully detected by RNAscope® ISH and by IIF (IL-17 and IL-22) in both atopic and healthy canine skin. There was no significant difference in the expression of interleukins and their receptors between healthy and atopic skin with or without active infection. Data from both methodologies were similar. The role and the relationship among those proteins in atopic skin is unclear from this study results. Data from IIF and ISH were overlapping and support each other. Fresh skin samples taken at different times during the development of atopic dermatitis might better assess the role that interleukins and their receptors play in AD.

Kidney Disease in Diabetic Patients: From Pathophysiology to Pharmacological Aspects with a Focus on Therapeutic Inertia

Diabetes mellitus represents a growing concern, both for public economy and global health. In fact, it can lead to insidious macrovascular and microvascular complications, impacting negatively on patients' quality of life. Diabetic patients often present diabetic kidney disease (DKD), a burdensome complication that can be silent for years. The average time of onset of kidney impairment in diabetic patients is about 7-10 years. The clinical impact of DKD is dangerous not only for the risk of progression to end-stage renal disease and therefore to renal replacement therapies, but also because of the associated increase in cardiovascular events. An early recognition of risk factors for DKD progression can be decisive in decreasing morbidity and mortality. DKD presents patient-related, clinician-related, and system-related issues. All these problems are translated into therapeutic inertia, which is defined as the failure to initiate or intensify therapy on time according to evidence-based clinical guidelines. Therapeutic inertia can be resolved by a multidisciplinary pool of healthcare experts. The timing of intensification of treatment, the transition to the best therapy, and dietetic strategies must be provided by a multidisciplinary team, driving the patients to the glycemic target and delaying or overcoming DKD-related complications. A timely nephrological evaluation can also guarantee adequate information to choose the right renal replacement therapy at the right time in case of renal impairment progression.

Intradermal immunotherapy with actinomycetales preparations as treatment for feline atopic syndrome: a randomized, placebo-controlled, double-blinded study

BACKGROUND

Feline atopic syndrome (FAS) is a common disease. Single intradermal injections of heat-killed actinomycetales have shown beneficial effects in canine allergies.

HYPOTHESIS/OBJECTIVE

To evaluate the clinical effects of heat-killed actinomycetales [Gordonia bronchialis (GB) and Rodococcus coprophilus (RC)], alone or in combination, in FAS.

METHODS AND MATERIALS

Privately owned cats with a diagnosis of FAS were assigned randomly in three treatment groups (GB, RC and GB/RC combination) or placebo. Five intradermal injections were performed over a one year period. At each visit [Day (D)0, D20, D40, D60, D90, D180 and D365], clinical signs, global owner assessment score, use of rescue medications, clinical adverse effects, skin hydration and cutaneous pH were assessed.

RESULTS

Seventeen cats were enrolled. When compared to the placebo group and improvement in treatment GB was sustained from D90. When compared with D0 significant improvement in the GB group was seen from D60. Over one year, a complete remission of the clinical signs was seen in 30-67% of cats in the treatment groups. A reduction in the pruritus score was seen for RC after 365 days of treatment (P = 0.04). Differences in the other variables were not seen.

CONCLUSIONS AND CLINICAL IMPORTANCE

The use of multiple intradermal injections of heat-killed GB shows promise as effective and well-tolerated treatment for FAS. Because of the low cost and the lack of adverse effects, GB could be a beneficial treatment option for FAS. A larger study is needed to confirm these data and to evaluate the immunological changes occurring in the treated cats.

Rituximab or Cyclophosphamide in the Treatment of Membranous Nephropathy: The RI-CYCLO Randomized Trial

BACKGROUND

A cyclic corticosteroid-cyclophosphamide regimen is the first-line therapy for membranous nephropathy. Compared with this regimen, rituximab therapy might have a more favorable safety profile, but a head-to-head comparison is lacking.

METHODS

We randomly assigned 74 adults with membranous nephropathy and proteinuria >3.5 g/d to rituximab (1 g) on days 1 and 15, or a 6-month cyclic regimen with corticosteroids alternated with cyclophosphamide every other month. The primary outcome was complete remission of proteinuria at 12 months. Other outcomes included determination of complete or partial remission at 24 months and occurrence of adverse events.

RESULTS

At 12 months, six of 37 patients (16%) randomized to rituximab and 12 of 37 patients (32%) randomized to the cyclic regimen experienced complete remission (odds ratio [OR], 0.4; 95% CI, 0.13 to 1.23); 23 of 37 (62%) receiving rituximab and 27 of 37 (73%) receiving the cyclic regimen had complete or partial remission (OR, 0.61; 95% CI, 0.23 to 1.63). At 24 months, the probabilities of complete and of complete or partial remission with rituximab were 0.42 (95% CI, 0.26 to 0.62) and 0.83 (95% CI, 0.65 to 0.95), respectively, and 0.43 (95% CI, 0.28 to 0.61) and 0.82 (95% CI, 0.68 to 0.93), respectively, with the cyclic regimen. Serious adverse events occurred in 19% of patients receiving rituximab and in 14% receiving the cyclic regimen.

CONCLUSIONS

This pilot trial found no signal of more benefit or less harm associated with rituximab versus a cyclic corticosteroid-cyclophosphamide regimen in the treatment of membranous nephropathy. A head-to-head, pragmatic comparison of the cyclic regimen versus rituximab may require a global noninferiority trial.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

Rituximab versus Steroids and Cyclophosphamide in the Treatment of Idiopathic Membranous Nephropathy (RI-CYCLO), NCT03018535.

Copy Number Variant Analysis and Genome-wide Association Study Identify Loci with Large Effect for Vesicoureteral Reflux

BACKGROUND

Vesicoureteral reflux (VUR) is a common, familial genitourinary disorder, and a major cause of pediatric urinary tract infection (UTI) and kidney failure. The genetic basis of VUR is not well understood.

METHODS

A diagnostic analysis sought rare, pathogenic copy number variant (CNV) disorders among 1737 patients with VUR. A GWAS was performed in 1395 patients and 5366 controls, of European ancestry.

RESULTS

Altogether, 3% of VUR patients harbored an undiagnosed rare CNV disorder, such as the 1q21.1, 16p11.2, 22q11.21, and triple X syndromes ((OR, 3.12; 95% CI, 2.10 to 4.54; P=6.35×10^-8) The GWAS identified three study-wide significant and five suggestive loci with large effects (ORs, 1.41-6.9), containing canonical developmental genes expressed in the developing urinary tract (WDPCP, OTX1, BMP5, VANGL1, and WNT5A). In particular, 3.3% of VUR patients were homozygous for an intronic variant in WDPCP (rs13013890; OR, 3.65; 95% CI, 2.39 to 5.56; P=1.86×10^-9). This locus was associated with multiple genitourinary phenotypes in the UK Biobank and eMERGE studies. Analysis of Wnt5a mutant mice confirmed the role of Wnt5a signaling in bladder and ureteric morphogenesis.

CONCLUSIONS

These data demonstrate the genetic heterogeneity of VUR. Altogether, 6% of patients with VUR harbored a rare CNV or a common variant genotype conferring an OR >3. Identification of these genetic risk factors has multiple implications for clinical care and for analysis of outcomes in VUR.

Dynamic impact of cellulose and readily biodegradable substrate on oxygen transfer efficiency in sequencing batch reactors

Aeration is a major contributor to the high energy demand in municipal wastewater treatment plants. Thus, it is important to understand the dynamic impact of wastewater characteristics on oxygen transfer efficiency to develop suitable control strategies for minimizing energy consumption since aeration efficiency is influenced by the biodegradation of pollutants in the influent. The real-time impact of acetate as a readily biodegradable substrate and cellulose as a slowly biodegradable substrate were studied at different operational conditions. Cellulose in the influent wastewater can be removed efficiently using primary treatment technologies, such as the rotating belt filter (RBF). At an ambient DO of 2 mg l^-1 and air flow of 1.02 m³h^-1 (0.6 SCFM), the α-factor was more sensitive to readily biodegradable substrates than to cellulose. On average, α-factor decreased by 48% and 19% due to the addition of acetate and cellulose, respectively. At a DO of 4 mg l^-1 and air flow of 1.7 m³h^-1 (1 SCFM), α-factor remained constant irrespective of cellulose and acetate concentrations. Without active biomass, α-factor decreased by 47% and 43% at a DO of 2 mg l^-1 (air flow of 1.02 m³h^-1) and high DO of 5 mg l^-1 (air flow of 1.7 m³h^-1), respectively. An inverse correlation between α-factor and sCOD was defined and incorporated into a dynamic model to estimate the real-time airflow rates associated with the improvement of the oxygen transfer efficiency due to biodegradation. Finally, the RBF operated with a 158-μm mesh selectively removed cellulose, thus reducing air requirements, and energy by 25%.

Efficacy of Fluralaner in the Treatment of Sarcoptic Mange (Sarcoptes scabiei) in 12 Pet Rabbits

Sarcoptes scabiei var. cuniculi are cutaneous mites of companion rabbits. In rabbits, sarcoptic mange is characterized by intense pruritus, alopecia, erythema, scales, and crusts around the head, neck, trunk, feet, and genitals. The goal of this study was to evaluate the effectiveness of oral fluralaner in pet rabbits naturally infested by S scabiei var. cuniculi. Twelve privately owned pet rabbits with a definitive diagnosis of sarcoptic mange were included in the study if they had compatible clinical signs and positive superficial skin scrapings for S scabiei. Clinical and parasitological evaluations were performed on days 0, 7, 14, 21, 30, 60, and 90 after receiving a single oral dose of 25 mg/kg of fluralaner. On day 7, 5 of 12 rabbits had positive skin scrapings, while 8 of 12 had clinical signs (alopecia and erythema) still present. By day 14 none of the rabbits had positive skin scrapings and only 1 of 12 had persistent clinical signs. By day 21 none of the rabbit had positive skin scrapings nor had clinical signs. A reoccurrence of the clinical signs or positive skin scrapings was not observed for the duration of the study (day 90). A single oral dose of fluralaner was effective for the treatment of naturally occurring sarcoptic mange in rabbits over a 90-day period.

Enhancing sludge dewaterability and phosphate removal through a novel chemical dosing strategy using ferric chloride and hydrogen peroxide

In this study, we replicated full-scale centrifuge dewatering utilized in water resource recovery facilities (WRRFs) by using the Higgins modified centrifuge technique and demonstrated that analogous cake solid content and centrate suspended solids were attainable while applying a lower polymer dosage. Furthermore, we demonstrated a dramatic reduction in the concentration of phosphate (P) in anaerobically digested sludge (ADS) under various reaction conditions. H₂ O₂ was employed to convert embedded iron in ADS, in the form of FeS, to Fe (II) and Fe (III), which subsequently reacted to precipitate phosphate compounds, dropping the in situ P concentration by nearly 50%. Adding ferric chloride (220 mg/L) in ADS enhanced the P-removal to more than 80%. Finally, simultaneous dosing of Fe and H₂ O₂ boosted P-removal efficiency to higher than 90%. The role of Fe in strengthening the flocs and increasing the dewaterability was also substantiated by demonstrating a 2% growth in the cake solid content when ADS was conditioned with Fe + H₂ O₂ preceding polymer treatment. The outcome of this work confirms that a deeper understanding of centrifuge operational parameters and physico-chemical properties of wastewater sludge would result in improved performance of municipal WRRFs. PRACTITIONER POINTS: Dosing hydrogen peroxide effectively converted iron embedded in sludge from Fe (II) to Fe (III). Simultaneous dosing of iron and hydrogen peroxide boosted P removal efficiency. The role of iron in strengthening flocs and enhancing dewaterability was observed, as it increased cake solid content in centrifuged sludge. An advanced bench-scale test protocol was employed to optimize polymer dose, simultaneously reducing polymer consumption while maximizing cake solid content and centrate quality.

Clinical signs and diagnosis of feline atopic syndrome: detailed guidelines for a correct diagnosis

BACKGROUND

Feline atopic syndrome (FAS) describes a spectrum of hypersensitivity disorders characterised by highly diverse clinical presentations including skin, gastrointestinal and respiratory systems. Among these disorders is feline atopic skin syndrome (FASS), in which hypersensitivity is typically associated with environmental allergens, although food allergy may coexist. Involvement of other organ systems (e.g. asthma) also may occur. Because of its highly heterogeneous clinical presentation, diagnosis of FASS can be challenging.

OBJECTIVES

A subgroup of the International Committee on Allergic Diseases of Animals was tasked to summarise the most current information on the clinical presentations of FASS and to develop diagnostic guidelines.

METHODS AND MATERIALS

Online citation databases and abstracts from international meetings were searched for publications related to feline allergic conditions. These were combined with expert opinion where necessary.

RESULTS

A total of 107 publications relevant to this review were identified. Compilation of these data enabled development of a detailed description of the clinical features of FASS and development of guidelines focusing on systematic elimination of other skin conditions with similar clinical characteristics. As allergen tests are frequently used by dermatologists to support a clinical diagnosis of FASS, a brief review of these methodologies was also performed.

CONCLUSIONS AND CLINICAL IMPORTANCE

In a similar way to atopic dermatitis in dogs, FASS is a clinical diagnosis based on the presence of compatible clinical signs and exclusion of other diseases with similar clinical features. Elimination or exclusion of fleas/flea allergy, other parasites, infections and food allergy is mandatory before reaching a diagnosis of FASS.