Proteinuria in membranous lupus nephritis: the pathology is in the podocyte

BACKGROUND

Patients with membranous lupus glomerulonephritis (MLN) can present with a broad range of urine protein excretion. The glomerular lesion underlying this functional abnormality has been presumed to be immune complexes which aggregate in the subepithelial area. However, the amount of proteinuria often fails to correlate with the quantity of immune deposits demonstrable on fluorescent and electron microscopy. The purpose of this study is to determine the correlation of alterations of the morphologic components of the glomerular capillary wall with the amount of proteinuria in MLN.

DESIGN

We conducted a retrospective clinicopathologic study of patients with lupus nephritis (n=236). In those with pure MLN and proteinuria (n=20), the degree of immune aggregates in the capillary walls and mesangium was detailed using fluorescent and electron microscopy. The degree of foot process effacement (FPE) was detailed using electron microscopy.

RESULT

Eleven patients had nephrotic range proteinuria (≥ 3 g proteinuria/g creatinine (g/g)) and nine demonstrated subnephrotic range proteinuria (<3 g/g) (nephrotic, 8.3 ± 5.1 g/g vs. subnephrotic, 1.63 ± 0.83 g/g, p=0.001). All patients demonstrated peripheral capillary wall granular deposits by immunofluorescence microscopy, and the degree of moderate (2+) to severe (3+) deposition was not different (nephrotic, 8/11, 73% vs. subnephrotic, 5/9, 55%, p=0.64). By electron microscopy, FPE (88.6 ± 11% vs. 48.3 ± 36.1%, p=0.002) and foot process width (1798 ± 736 nm vs. 1000 ± 333 nm, p=0.008) was greater in the nephrotic group compared with subnephrotic. There were no other histopathologic differences between the groups.

CONCLUSIONS

In patients with MLN, a distinguishing morphologic feature of those with nephrotic range proteinuria is diffuse visceral epithelial cell FPE. We conclude that nephrotic range proteinuria in patients with MLN may be a manifestation of concomitant glomerular visceral epithelial cell dysfunction.

Epidemiology, risk factors, and outcomes of Clostridium difficile infection in kidney transplant recipients

BACKGROUND

We sought to describe the epidemiology and risk factors for Clostridium difficile infection (CDI) among kidney transplant recipients (KTR) between 1 January 2008 and 31 December 2010.

METHODS

A single-institution retrospective study was conducted among all adult KTR with CDI, defined as a positive test for C. difficile by a cell cytotoxic assay for C. difficile toxin A or B or polymerase chain reaction test for toxigenic C. difficile.

RESULTS

Among 603 kidney transplants performed between 1 January 2008 and 31 December 2010, 37 (6.1%) patients developed CDI: 12 (of 128; 9.4%) high-risk (blood group incompatible and/or anti-human leukocyte antigen donor-specific antibodies) vs. 25 (of 475; 5.3%, P = 0.08) standard-risk patients. The overall rate of CDI increased from 3.7% in 2008 to 9.4% in 2010 (P = 0.05). The median time to CDI diagnosis was 9 days, with 27 (73.0%) patients developing CDI within the first 30 days after their transplant, and 14 (51.8%) developing CDI within 7 days. A case-control analysis of 37 CDI cases and 74 matched controls demonstrated the following predictors for CDI among KTR: vancomycin-resistant Enterococcus colonization before transplant (odds ratio [OR]: 3.6, P = 0.03), receipt of an organ from Centers for Disease Control high-risk donor (OR: 5.9, P = 0.006), and administration of high-risk antibiotics within 30 days post transplant (OR: 6.6, P = 0.001).

CONCLUSIONS

CDI remains a common early complication in KTR, with rates steadily increasing during the study period. Host and transplant-related factors and exposure to antibiotics appeared to significantly impact the risk for CDI among KTR.

Role of omega-3 ethyl ester concentrate in reducing sudden cardiac death following myocardial infarction and in management of hypertriglyceridemia: an Indian consensus statement

INTRODUCTION

Sudden cardiac death (SCD) is the most lethal manifestation of heart disease. In an Indian study the SCDs contribute about 10% of the total mortality and SCD post ST elevation myocardial infarction (MI) constitutes for about half of total deaths.

OBJECTIVE

Given the limitations of existing therapy there is a need for an effective, easy to use, broadly applicable and affordable intervention to prevent SCD post MI. Leading cardiologists from all over India came together to discuss the potential role of n-3 acid ethyl esters (90%) of eicosapentaenoic acid (EPA) 460 mg & docosahexaenoic acid (DHA) 380 mg in the management of post MI patients and those with hypertriglyceridemia.

RECOMMENDATIONS

Highly purified & concentrated omega-3 ethyl esters (90%) of EPA (460 mg) & DHA (380 mg) has clinically proven benefits in improving post MI outcomes (significant 15% risk reduction for all-cause mortality, 20% risk reduction for CVD and 45% risk reduction in SCD in GISSI-Prevenzione trial) and in reducing hypertriglyceridemia, and hence, represent an interesting option adding to the treatment armamentarium in the secondary prevention after MI based on its anti-arrhythmogenic effects and also in reducing hypertriglyceridemia.

Abstract 1582: Therapeutic vaccine for pancreatic cancer

Cadi-05 (Heat killed mycobacterium w) is a potent TLR 2 agonist and induces pure potent Th1 response. In advanced Non small cell lung cancer, Cadi-05 is found to potentiate efficacy of chemotherapy (Paclitaxel + Cisplatin) with improvement in response rate and overall survival in a randomized controlled clinical trial. Cadi-05 is also a potent vaccine adjuvant for prophylactic vaccines providing faster, higher and sustained antibody titers in animals and humans. The therapeutic vaccine for pancreatic cancer, with killed pancreatic cancer cells as an antigen with Cadi-05 as an adjuvant was evaluated for its ability to induce cell mediated immune responses (by ELISPOT for IFN - α, IL-2 and Granzyme B) and effector function (By BrDu incorporation). The vaccine made using Mia PaCa-2 cell line induced cell mediated immune responses against the Mia PaCA-2 as well as against the other cell lines (Panc-1, ASPC-1, SW-1990). The vaccine also generated effector function of similar magnitude against all four cell lines. Effect of vaccine on tumor size and survival following intradermal immunization was also studied. For evaluating efficacy, C57BL/6 BYJ mice were injected Pan-02 cells (1x106) subcutaneously for developing pancreatic cancer model. At day 10 post tumor induction tumor size achieved was∼200-225 mm3. Mice were randomized to receive vaccine or placebo (18 mice each) on day 10. No other therapy was used in the experiment. In Vaccine arm tumor regression was seen in 61% of animals before progression. Tumor regression was not seen in placebo arm. Tumor progression was found to be slower in vaccinated animals with mean tumor size 35% and 59% of placebo arm on day7 (633 mm3 vs. 223 mm3) and day 12 (740 mm3 vs. 437 mm3) respectively resulting in survival benefit of 36% on day 40 following immunisation.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 1582. doi:1538-7445.AM2012-1582

Donor-derived organ transplant transmission of coccidioidomycosis

Coccidioidomycosis in solid organ transplant recipients most often occurs as a result of primary infection or reactivation of latent infection. Herein, we report a series of cases of transplant-related transmission of coccidioidomycosis from a single donor from a non-endemic region whose organs were transplanted to 5 different recipients. In all, 3 of the 5 recipients developed evidence of Coccidioides infection, 2 of whom had disseminated disease. The degree of T-cell immunosuppression and timing of antifungal therapy initiation likely contributed to development of disease and disease severity in these recipients. This case series highlights the importance of having a high index of suspicion for Coccidioides infection in solid organ transplant recipients, even if the donor does not have known exposure, given the difficulties of obtaining a detailed and accurate travel history from next-of-kin.