Renal cell carcinoma and paraneoplastic IgA nephropathy

Paraneoplastic nephropathy is rarely associated with human tumors. Little is known about the pathogenetic background of this relationship. To our knowledge, no conclusive study of the association of potentially 'immunogenic' renal cell carcinoma (RCC) and paraneoplastic nephropathy has been published. For this reason, we performed an immunohistochemical analysis of native resected kidneys of 60 patients with RCC, paying special attention to their pre- and postoperative records. Sixteen (27%) of the 60 tumor patients had immune complex nephropathy (11 IgA nephropathy [IgA NP] and 5 focal segmental glomerulosclerosis [FSGS]). Preoperative proteinuria and/or hematuria observed in 11 of 16 cases disappeared in 6 IgA NP patients within a 2- to 3-month follow-up after nephrectomy. Eleven of 16 tumors stained with the anti human immunoglobulin (IgA or IgM) of the same isotype as that present in glomerular immune complexes. In 3 IgA NP patients RCC-associated von Hippel-Lindau (VHL) protein and IgA staining were found simultaneously in the tumor and glomeruli, with the clinical and laboratory findings disappearing after nephrectomy. Immune injury of the glomeruli due to a tumor-induced antigen-antibody response was demonstrated in these 3 IgA NP patients.

Sensitivity of three recent questionnaires to mild traumatic brain injury-related effects

OBJECTIVE

To evaluate the sensitivity of three recently developed questionnaires to mild traumatic brain injury (MTBI)-related effects.

DESIGN

Comparison of an MTBI group, within 3 weeks of injury, to a normal control group.

SETTING

Outpatient rehabilitation clinic.

SUBJECTS

120 MTBI patients and 120 age, education, sex, and preinjury socioeconomic status-matched normal control subjects.

MAIN OUTCOME MEASURES

The Problem Checklist (PCL) from the New York Head Injury Family Interview to assess MTBI symptoms, the Short Form-36 Health Survey (SF-36) to assess functional burden associated with health problems, and the Community Integration Questionnaire (CIQ) to assess home, social, and productive activities.

RESULTS

Patients' self-ratings on the PCL and SF-36, but not the CIQ, were generally worse than those of the normal controls. The largest differences were obtained on SF-36 measures that appear to assess musculoskeletal injury effects.

CONCLUSIONS

The PCL and SF-36 show promise as sensitive measures of MTBI-related effects. The SF-36 may be particularly useful in evaluating associated musculoskeletal injuries, which might otherwise be overlooked by MTBI health care providers.

[Paraneoplastic nephropathy associated with adult renal carcinoma (immunologic and clinicopathologic study)]

Rare "paraneoplastic nephropathies" are associated with a wide variety of human tumors. Little is known about the pathogenetical background. To our knowledge no systematic study about the association of potentially "immunogenic" renal cell cancer (RCC) and "paraneoplastic nephropathy" has been published so far. An immunohistochemical analysis of native kidneys and a nephrological follow up of 60 patients with renal cell cancer (RCC) treated at the Department of Urology, medical University, Pécs (Hungary) between 1993-1998 has been performed. Cellular and humoral immunity was analysed by immunohistochemistry. Clinical/laboratory parameters of the patients with tumor associated nephropathy were pre- and postoperatively registered. Eleven IgA-nephropathy (IgA-NP) and 5 focal segmental glomerulosclerosis (FSGS), manifested in preoperative clinical signs in 11 out of 16 cases were found. Clinical symptoms disappeared in 6 out of 8 IgA-NP patients by tumor nephrectomy in a follow up of 38.7 (18-51) months. Eleven out of 16 tumors were stained with the identical anti human immunoglobulin (IgA or IgM) present in the glomerular immune complexes. The RCC-associated VHL (von Hippel-Lindau) protein was detectable in 3 out of 8 IgA-NP patients as an antigen component of their nephritogenic immune complexes. Tumor infiltrating lymphocytes (TIL) considered as a local sign of cellular tumor immunity were more frequently present in tumors associated with nephropathy than without it (69% vs 25%). Pathogenetic correlation between the tumor immunity in renal cell carcinoma and "paraneoplastic IgA-nephropathy" has been demonstrated in some of the cases. Tumor nephrectomy excluding the need of post-operative single kidney biopsies should be a safe tool in the differential diagnosis of tumor-associated nephrological conditions.

Ambulatory blood pressure monitoring and progression in patients with IgA nephropathy

BACKGROUND

Hypertension is a recognized marker of poor prognosis in IgA nephropathy.

METHODS

The present study investigated the prevalence of white-coat hypertension, the diurnal rhythm of blood pressure (BP), the effectiveness of antihypertensive drug therapy, and the effect of the above on the progression of the kidney disease in IgA nephropathy. One hundred twenty-six IgA nephropathy patients were selected consecutively for 24-h ambulatory blood pressure monitoring (ABPM). Fifty-five patients were normotensive and 71 were treated hypertensives. Their antihypertensive drugs were angiotensin-converting enzyme inhibitors (ACEI) alone or in combination with calcium-channel blockers (CCB).

RESULTS

The mean night-time BP of normotensives (108+/-9/67+/-6 mmHg) was significantly lower than their day-time BP (125+/-8/82+/-7 mmHg, P<0.05). There was no significant difference between the mean day-time and night-time BP in hypertensive patients (125+/-9/82+/-7 mmHg vs 128+/-10/85+/-9 mmHg). The circadian variation of BP was preserved ('dippers') in 82% of the normotensive and 7% of the hypertensive patients (P<0.001). There were 10 'white-coat hypertensives' among the patients classified as normotensives with ABPM (mean office blood pressure 149+/-7/96+/-8 mmHg, 24-h blood pressure 127+/-6/83+/-5 mmHg, P<0.05) and 14 among treated hypertensives (mean office BP 152+/-8/98+/-6 mmHg, 24-h BP 130+/-4/85+/-8 mmHg, P<0.05). There was no difference in mean day-time BP among normotensive and treated hypertensive patients (125+/-8/81+/-5 mmHg vs 128+/-10/85+/-9 mmHg). Hypertensives had significantly higher night-time BP (125+/-9/85+/-9 mmHg) than normotensives (108+/-9/67+/-6 mmHg, P<0.001). There was no difference in serum creatinine levels among the different groups at the time of the ABPM. However, thirty-six+/-4.1 months after the ABPM, hypertensive patients (n=52) had higher serum creatinine levels (124+/-32 micromol/l) than at the time of the ABPM (101+/-28 micromol/l). The serum creatinine of normotensive patients (n=43) did not change during the follow-up period. 'Non-dipper' normotensives (n=10) had significantly higher serum creatinine levels at the end of the follow-up period than at its beginning (106+/-17 micromol/l vs 89+/-18 micromol/l, P<0.05). There was no increase in serum creatinine of 'dipper' normotensives. The mean serum creatinine of 'white-coat hypertensives' was significantly higher at the end of the study period than at its beginning.

CONCLUSIONS

There is no diurnal blood pressure variation in most of the hypertensive IgA nephropathy patients. ACEI and CCB treatment have better effect on day-time than night-time hypertension. The lack of the circadian rhythm and 'white-coat hypertension' seems to accelerate the progression of IgA nephropathy.

Synthesis of peptide and pseudopeptide amides inhibiting the proliferation of small cell and epithelial types of lung carcinoma cells

Small cell lung cancer (SCLC) cell lines produce and secrete various peptide hormones, e.g. bombesin (BN)/gastrin releasing peptide (GRP) like peptides that are proposed to function as their autocrine growth factors. To inhibit the proliferative effect of these hormones we have synthesized short chain BN[7-14]-analogues replacing the C-terminal peptide bond by a methylene-amino (-CH2NH-) unit and introducing D-Phe or D-Ser into position 12. As several substance P (SP) analogues were found to inhibit the growth of SCLC cells, some short chain SP-analogues have been synthesized. (Pseudo)octapeptides were synthesized in solution, by fragment condensation using the DCC/HOPfp method. Fragments and SP-analogues were synthesized stepwise using pentafluorophenyl esters. The resistance to hydrolysis of the reduced peptide bond made permitted exact quantification of the Leupsi(CH2NH)Leu pseudopeptide in hydrolysates. The binding ability of both types of peptides to BN-receptors on Swiss 3T3 mouse fibroblast cells and their antiproliferative effect on NCI-H69 human SCLC cell line have been tested and compared with a short chain SP-antagonist pHOPA-D-Trp-Phe-D-Trp-Leu-Leu-NH2 (R) previously described as a potent inhibitor of SCLC proliferation. While BN-analogues showed weak activity in inhibition of proliferation of SCLC cells, SP-analogues 6: D-MePhe-D-Trp-Phe-D-Trp-Leu(psi)(CH2NH)-Leu-NH2 and 7: D-MePhe-DTrp-Phe-D-Trp-Leu-MPA, in spite of greatly diminished affinity towards the BN-receptor, inhibited SCLC proliferation more effectively than R (6: IC50 = 2 microM, 7: IC50 = 5 microM and R: IC50 = 10 microM). Moreover, 6 inhibited the respiratory activity of SK-MES 1 epithelial type of lung carcinoma cells in proliferating but not in the quiescent state, suggesting that the antiproliferative effect of these compounds is not due to simple cytotoxicity. These short chain analogues of SP might be promising candidates as therapeutic agents in the treatment of SCLC.

A randomized trial of two treatments for mild traumatic brain injury

The purpose of this study was to compare an education-oriented single session treatment (SS) for mild traumatic brain injury (MTBI) to a more extensive assessment, education, and treatment-as-needed intervention (TAN). Participants were 111 adults with MTBI who were recruited from consecutive admissions to two hospital emergency wards. They were randomly assigned to either the SS or TAN modality. The groups did not differ on any demographic, injury-related, or questionnaire variable when first seen within 3 weeks of injury. The groups generally improved a similar amount and did not differ from each other on any symptom-related, functional, or vocational variables 3-4 months after their baseline session. Patient satisfaction ratings with services provided were also similar for the two groups. Brief educational intervention given soon after MTBI appears to be adequate for most MTBI survivors.

A preliminary normative profile of mild traumatic brain injury diagnostic criteria

This study investigated how mild traumatic brain injury (MTBI) diagnostic and related variables present in a large, nonreferred MTBI sample. Participants were 119 adults with MTBI, drawn from consecutive admissions to two hospital emergency wards. Within 3 weeks of injury, they were asked how the 1993 American Congress of Rehabilitation Medicine MTBI diagnostic criteria and related phenomena presented in their particular cases. Results showed that retrograde amnesia was not reported or was generally very brief; retrograde amnesia was not reported unless posttraumatic amnesia was also reported; and the median ratio of posttraumatic amnesia to retrograde amnesia duration, when both were reported, was 300:1. These and other data provide a preliminary normative profile of such MTBI phenomena, and can help with differential diagnosis of MTBI in individual cases.

[Analgesic nephropathy]

Analgesic nephropathy is a slowly progressive disease caused by the chronic abuse of analgesic mixtures containing two analgesic components combined with potentially addictive substances (coffeine and/or codeine). Pathologically, the nephropathy is characterized by renal papillary necrosis with calcification and chronic interstitial nephritis sometimes in association with transitional-cell carcinoma of the uroepithelium. In the early stage, the clinical characteristics are polyuria, sterile pyuria, sometimes renal colic and haematuria. With further progression of the disease, there are the nonspecific symptoms of advanced renal failure. The incidence of classic analgesic nephropathy among Hungarian patients on chronic renal replacement therapy has proven. There is an urgent need for the estimation of analgesic nephropathy among patients with chronic renal disease and among patients with chronic pain presumably regularly taking analgesics in Hungary. As long as analgesic mixtures containing phenacetin or paracetamol and/or nonsteroidal antiinflammatory drugs and addictive substances are available "over-the-counter", analgesic nephropathy will continue to be a problem also in our country.

[Paracetamol-induced tubulointerstitial nephritis in a chronic alcoholic patient]

Hepatic and renal toxicity of paracetamol overdosage is well known like the fact that ethanol enhances the toxicity of the drug. Scanty data report on reversible hepatic and renal failure appearing after therapeutic dose of paracetamol in alcohol-abusers. Renal damage might also occur without gross hepatocellular damage in alcoholics. We report the case of a young alcoholic male whose first renal biopsy disclosed mesangiocapillary glomerulonephritis. One month later he took 1.5 g paracetamol to control the fever caused by upper respiratory tract infection. Soon he got hospitalised due to fever, toxicoderma, elevated liver and renal function test. While liver enzymes returned to normal, macroscopic haematuria, nephrotic range proteinuria oliguria, uraemia developed. A repeated renal biopsy revealed severe interstitial inflammation, tubular atrophy, progression of the vascular changes seen in the first biopsy. Haemodialysis was started and he got steroids (1 mg/kg body-weight) besides aggressive antihypertensive medication. He showed considerable recovery of renal function in some weeks. The case points to the possibility that paracetamol--even in therapeutic dosage--might result in hepatic and renal damage in alcoholics. The sudden deterioration in renal function was due to the acute tubulointerstitial nephritis superimposed on mesangiocapillary glomerulonephritis, provoked by paracetamol. Early diagnosis, immediate withdrawal of the toxic drug, steroid treatment might have kidney and life saving effect.

Relative Stability and Structure of Dihydro-1,2,4-triazines: A Theoretical Study

A brief survey is given on the synthesis and structure elucidation for dihydro-1,2,4-triazines. The relative stability of nine possible dihydro-1,2,4-triazines and three dihydrotriazinium cations is studied at HF, MP2, generalized gradient approximation DFT, and CBS-4 levels of theory. The structural consequences of the inclusion of the electron correlation are also given. We attempt to rationalize the experimental findings using high-quality theoretical results. The quantum chemical calculations support that the most stable isomer is the 2,5-dihydro-1,2,4-triazine and all the other relatively stable isomers have been experimentally identified correctly. Several experimental papers report structures that have been proved to be nonexistent. These structures have energy that is too high according to the best-quality calculations.

[Surgical trauma induced by laparoscopic cholecystectomy]

The objective demonstration of improved postoperative recovery suggests that surgical injury induced by the laparoscopic approach is less intense than that after open surgery. Forty-two patients diagnosed as having noncomplicated gallstones were studied prospectively. They were operated on by laparoscopy (LC, n = 21) or open surgery (OC, n = 21). Both surgical procedures induced significant changes of investigated parameters (acute-phase response, free radical mediated reactions, neutrophil functions). Comparison of the results of the two cholecystectomy techniques showed that laparoscopic cholecystectomy induced a significantly less intense acute-phase response, a more attenuated oxidative stress characterising by free radical mediated reactions and that is less disruptive to neutrophil function. The results and the data from the literature suggest that surgical injury causing by the laparoscopic cholecystectomy is less intense than that after open cholecystectomy, which can explain partially the better clinical outcome following laparoscopic versus open procedure.

[Recurrent significant bacteriuria and progression of IgA nephropathy]

Tubulointerstitial changes seems to be of decisive importance among factors influencing the prognosis of IgA nephropathy. In consequence of decreased protection ability of mucous membranes, in some cases masked urinary tract infections may stand in the background of the tubulointerstitial changes. In this study the connection between urinary tract infections, significant bacteriurias and the progression of IgA nephropathy was retrospectively investigated. The data and the progress of the disease of 19 IgA nephropathy patients with significant bacteriuria (microbiologically identified) were compared to 19 IgA nephropathy patients of similar age, sex and the time of follow-up without bacteriuria. During the follow-up (on the average 8.5 years), the renal function (values of serum creatinine) decreased significantly (p < 0.05) in both groups, but there was no significant difference between the two groups. Neither at start, nor at the end of the follow-up no significant difference was found in the two groups in the prevalence of proteinuria, haematuria, hypertension and between the values of serum parameters. On the basis of these data we assume, that with the help of frequent medical check up and adequate antibiotic treatment the unfavourable effects of urinary tract infections (chronic tubulointerstitial changes) can probably be fended off.

Predictive morphological findings in "zero-hour" biopsies of renal allografts

"Zero-hour" biopsies of 65 donors have been performed since 1994. Donor kidneys were categorized into five groups based on the morphological findings in "zero-hour" biopsies. No morphological abnormalities were found in 38% of the cases (group 1). Arteriosclerosis was present in 31% of donor kidneys (group 2). Specific morphological alterations, i.e. acute tubular necrosis [21.5%], tubulointerstitial nephritis [6.2%] or glomerulonephritis [3.1%] were detectable in the cases remained (group 3-5). During an average of 336 posttransplant days clinical and histological follow up was performed (50 rebiopsies). Statistical data of mismatch (1.4-2.0), average of donor/recipient age (35-42 years), cold and warm ischaemic time (1290 and 66 min) were comparable in all groups. According to our observations: 1. higher creatinin was found in grafts with arteriosclerosis (group 2) (p < 0.05), 2. there were more non-viable grafts and longer period of delayed graft function in acute tubular necrosis (group 3), 3 higher creatinin, rejections with the need of rehemodialysis were observed in four cases of tubulointerstitial nephritis (TIN-group 4). Glomerulonephritis (GN-group 5) grafts had only delayed graft function, however these groups were few for statistical evaluation. Biopsy complication in 1/115 cases was found (rebiopsy induced kidney haemorrhage). In conclusion, "zero-hour" biopsies can be useful and safe tools to predict early graft function. Besides "zero-hour" biopsies help the histological interpretation of consecutive graft rebiopsies.

Paracetamol induced acute interstitial nephritis superimposed on mesangiocapillary glomerulonephritis

We report the case of a young alcoholic male whose first renal biopsy disclosed mesangiocapillary glomerulonephritis. One month later he took 1.5 g paracetamol to control the fever. Soon he got hospitalized due to toxicoderma, elevated liver and renal function tests. While the liver enzymes returned to normal, uremia developed. A repeated renal biopsy revealed severe interstitial inflammation, tubular atrophy. Haemodialysis was started and he got steroids (1 mg/kg body weight). He showed considerable recovery of renal function in some weeks. The case points to the possibility that paracetamol-even in therapeutic dosage-might result in hepatic and renal damage in alcoholics.

Possible role of free radicals generated by pseudohypoxia in the regulation of hepatic glucose output. An in vitro model using rat liver microsomal glucose 6-phosphatase

Hepatic glucose output is decreased by hyperglycaemia through an unknown mechanism. We hypothesize that free radicals generated by hyperglycaemic pseudohypoxia might cause glucose output to decrease by inhibiting glucose 6-phosphatase - a key enzyme of gluconeogenesis. To prove this a model experiment was performed on a microsome fraction of rat liver. One of the characteristic features of pseudohypoxia due to hyperglycaemia is an increase in the ratio of NADH/NAD+, so in the present study the changes in NADH - induced glucose 6-phosphatase activity were investigated as related to the release of inorganic phosphate (Pi) derived from glucose 6-phosphate. After incubation for 50 min, Pi release was significantly reduced by NADH (4.026 +/- 0.189 vs 2.696 +/- 0.429 micromol x l(-1) x mg protein(-1), control vs NADH samples, p < 0.01). The decrease in the activity of glucose 6-phosphatase generated by NADH was prevented by using desferrioxamine, an irreversible ferric chelator, butylated hydroxytoluene and Trolox, two agents which inhibit lipid peroxidation, and reduced glutathione, a non-specific radical scavenger. Superoxide dismutase, catalase and the hydroxyl radical scavenger dimethyl sulphoxide proved to be ineffective. When the above investigations were carried out in the presence of a ferric-EDTA complex the inhibition of glucose 6-phosphatase was found to be inducible by hydrogen peroxide and/or hydroxyl free radicals. These investigations seem to indicate that pseudohypoxia due to hyperglycaemia can inhibit the activity of glucose 6-phosphatase both by lipid peroxidation and by inducing hydrogen peroxide and/or hydroxyl free radicals and thus it may play a part in the glucose-induced decrease of hepatic glucose output.

[Thin glomerular membrane nephropathy. Clinico-pathological observations]

In two nephrology centres between 1983 and 1993 among 1545 kidney biopsies 34 cases of thin basement membrane nephropathy have been diagnosed. All patients had a varying degree of microscopic dysmorph haematuria, occasional slight proteinuria--except two nephrotic children; and normal blood pressure with one exception. 5 children and 7 adults experienced repeated bouts of macroscopic haematuria mainly after exercise or upper respiratory tract infection, one child after tonsillectomy. All patients had normal renal function and retained it during the follow-up period (mean 61 months, 3 months to 22 years), except a 46 year old patient, who was found to have the joint occurrence of light chain gammopathy and hypertension. Seven patients had positive family history for microscopic haematuria, in four family members of three patients renal biopsy disclosed mesangioproliferative glomerulonephritis with thin GBM segments. As a cut off value for thin basement membrane nephropathy we considered 264 nm. The morphometric analysis of the electron micrographs revealed a mean thickness of 210 nm. No differences in basement membrane thickness were measured regarding gender, age or the presence of macroscopic haematuria. The thin basement membrane is considered to be the pathological basis and predisposing alteration leading to haematuria.

Interaction of Silane Coupling Agents with CaCO3

A study of eight silane coupling agents showed very different effect of these compounds on the mechanical properties of PP/CaCO3 composites. The application of aminofunctional silane coupling agents resulted in the reactive coupling of the two inactive components leading to increased strength and decreased deformability. A detailed study of the interaction between CaCO3 and the various coupling agents was carried out in order to find an explanation for the strong coupling effect. The amount of coupling agent creating a monolayer coverage was determined by a dissolution method for each coupling agent. The obtained values changed between 0.3 and 1.0 wt% calculated for the CaCO3 . An attempt was made to determine the orientation of the adsorbed molecules to the filler surface. Most of the coupling agents are oriented perpendicularly to the surface with the exception of a methacryl functional silane compound. Possible interactions between hydrolyzed or condensed silane coupling agents and the filler were studied by Fourier transform infrared spectroscopy using transmitting (FTIR-TS) and diffuse reflectance (DRIFT) modes, as well as gel permeation chromatography (GPC). The results showed that bulky organofunctional groups form a caged, polycyclic, low-molecular-weight structure on the surface, while silanes with smaller groups tend to condense into open, ladder type, high-molecular-weight polysiloxane chains. Polymer/filler adhesion, however, depends primarily on the chemical character of the organofunctional group. Aminofunctional silane coupling agents adhere well to the filler surface and react also with the polymer. In the case of similar functionality the size of the organofunctional group determines the strength of the adhesion.

[The effect of spasmolytics on dilatation of the uterine cervix]

Spasmolytics and spasmoanalgetic mixtures are administered to facilitate dilatation of the cervix during delivery and to shorten the first stage of labour. This medication is used in 70% deliveries at the 1st Dept. of Obstetrics and Gynaecology Masaryk University in Brno. The aim of the study was to analyze the spasmolytic effect on the process of cervix dilatation. The study comprises 108 uncomplicated deliveries (52 deliveries with spasmolytics and 56 deliveries without). We analyzed the effect of spasmolytics on the cervix, process of labour and outcome of delivery. Six kinds of spasmolytics were used, administered from once to four times during labour and most of them (85%) in the latent phase of the first stage of labour. In the group with spasmolytics there was statistically insignificant by prolonged active phase of the first stage of labour (126 vs 104 minutes) and more frequent administration of Oxytocin. Others parameters such as length of the second stage of labour, rate of birth injuries, the 1st minute Apgar score less than 7 and the necessity of neonatal resuscitation did not differ in the two groups.

CONCLUSIONS

The application of spasmolytics did not significantly affect the process of delivery.