A high peritoneal large pore fluid flux causes hypoalbuminaemia and is a risk factor for death in peritoneal dialysis patients

BACKGROUND

Hypoalbuminaemia is common in peritoneal dialysis (PD) patients and has an associated high mortality. An excess morbidity and mortality has previously been found in patients with high peritoneal transport. A high peritoneal large pore fluid flux (Jv(L)) results in increased peritoneal loss of protein that possibly contributes to patient morbidity. Alternatively, hypoalbuminaemia and high transport status could be just a marker of capillary pathology associated with atherosclerotic comorbidity.

METHODS

Peritoneal dialysis capacity computer modelling of peritoneal transport, based on Rippe's three-pore model, was performed to measure Jv(L) in 155 incident PD patients 2-4 weeks after PD initiation. Patient clinical and biochemical status was determined -6, -3, -1, 1 and 6 months after PD initiation, and every 6 months thereafter. Jv(L) was redetermined in prevalent patients 2 and 4 years after PD initiation.

RESULTS

Jv(L) was 0.106+/-0.056 ml/min/1.73 m(2) (median 0.094, interquartile range 0.068-0.128). It was correlated to age*** (*P<0.05; **P<0.01; ***P<0.001) (20-30 years 0.079+/-0.04; 70 years 0.121+/-0.071), but not to gender. No correlation to diabetic or preexisting renal replacement therapy was seen, but patients with atherosclerosis had higher Jv(L) (0.123+/-0.06 vs 0.100+/-0.056*) as had patients with other systemic disease (0.121+/-0.68 vs 0.100+/-0.051*). Jv(L) was positively correlated to area parameter (r = 0.41***), and negatively correlated to plasma albumin (-0.36***). Patients were divided into three equal groups: group 1, Jv(L) <0.075 ml/min/1.73 m(2); group 2, 0.075-0.11; group 3: >0.11. There was no difference between the groups in p-albumin prior to PD. Immediately after PD start, differences between the three groups appeared (1 month p-albumin: (micromol/l) group 1, 548+/-83; group 2, 533+/-86; group 3, 497+/-78**), and persisted for up to 6 years. No significant change in Jv(L) was seen at 2 and 4 years. Patients with significant albuminuria also had hypoalbuminaemia (<1 g/day: 546+/-81 mumol/l; >2 g/day: 503+/-54 micromol/l). Intermittent PD ameliorated the effect of Jv(L) on albumin losses and clearance. Mortality was increased significantly with raised Jv(L), independently of age (2 year mortality: group 1, 10%, group 3, 32%*). There was no overall effect on technique survival, but hypoalbuminaemic group 3 patients had a higher failure rate.

CONCLUSION

Jv(L) is related to hypoalbuminaemia and mortality after PD initiation. A high Jv(L) seems to be a marker of preexisting vascular pathology, and to cause hypoalbuminaemia after PD initiation. It is suggested that peritoneal albumin loss can have an identical pathogenic effect as urinary albumin loss, by causing an iatrogenic "nephrotic" syndrome.

Is there a correlation between degree of viremia and liver histology in chronic hepatitis C?

OBJECTIVE

To determine the correlation between degree of histological liver damage and serum HCV RNA level in patients of chronic hepatitis C, in order to evaluate the usefulness of HCV RNA estimation as an alternate to liver biopsy.

METHODS

This non-interventional descriptive study, was carried out at the department of Pathology, Army Medical College, Rawalpindi, Pakistan between April and September 2002. Core needle liver biopsies of fifty five patients of chronic hepatitis C were evaluated according to Knodell's histological activity index system. The patients were categorized into four subgroups depending upon the grade and stage of disease according to Desmet's classification, and into three groups according to degree of viremia.

RESULTS

Five patients had mild viremia, 43 moderate and 7 had severe viremia. Seven patients had minimal disease, 9 mild, 22 moderate and 17 had severe chronic hepatitis. Eight patients had no fibrosis, 20 had fibrous portal expansion, 19 bridging fibrosis, and 8 patients had cirrhosis. No significant correlation was found between serum HCV RNA levels and grade or stage of the disease, with correlation coefficients of rs = -.054 and rs = .034 respectively. Moreover, no individual component of the HAI correlated with serum HCV RNA levels.

CONCLUSION

Serum HCV RNA level does not determine the degree of hepatic injury precisely and liver biopsy is necessary to accurately evaluate the extent of liver damage.

Morphological study of liver biopsy in Thalassaemia major

OBJECTIVE

To see the morphological changes in liver in transfusion dependent Thalassaemia major children undergoing bone marrow transplantation.

METHODS

This retrospective cross-sectional survey was conducted at Pathology department of Army Medical College and Paediatric department of Military Hospital, Rawalpindi from Jul 2000 to Aug 2003. Liver biopsies were done in 40 thalassaemic major children and histological changes including Knodell Histological activity index (HAI); grade, stage and score along with degree of haemosiderosis were noted. Serum ALT levels, ferritin assays and screening for HBsAg and Anti- HCV antibody were also carried out in these cases.

RESULTS

Forty children 1.5-10.5 years of age (mean 6.1 years) with a male to female ratio of 1.2:1 were included in the study. According to Knodell HAI scoring, 24 (60%) cases had Knodell HAI score between 13/22 to 18/22 and 18 patients (45%) in grade 9-12/18. Six children had fully developed cirrhotic changes whereas 22 and 12 patients showed stage 3 and 1 respectively. Twenty eight (70%) patients had grade 3-4 haemosiderosis. HBsAg was positive in 6 and anti- HCV antibody in 14 patients. Serum ferritin and ALT levels were markedly raised in most of the patients.

CONCLUSION

Seventy percent patients had moderate to severe haemosiderosis and high Knodell HAI score was found in children with severe haemosiderosis, raised ALT and Ferritin levels and with positive serology for HBsAg and anti- HCV antibody. Liver biopsy is useful in thalassaemic children to assess the stage of liver disease and selection of suitable cases for bone marrow transplantation (BMT).

Comparison of optimal malarial test with light microscopy for the diagnosis of malaria

OBJECTIVE

To evaluate the efficacy of a parasite lactate dehydrogenase-based immunochromatographic antigen detection assay (optimal) against conventional light microscopy in the diagnosis of malaria at Military Hospital, Rawalpindi and Department of Pathology Army Medical College Rawalpindi from August to October 2002 in patients reporting sick with history suggestive of malaria.

METHODS

The blood samples were collected from 215 patients reporting with symptoms suggestive of malaria. Thick and thin blood films were prepared, stained with Leishman's stain and examined by light microscopy for the presence of malarial parasites. Parasitaemia was estimated on all positive slides. All samples were tested for presence of malarial parasite by optimal dipstick method according to the manufacturer's instructions.

RESULTS

A total of 215 cases were studied. Malarial parasites were visualized in 98 (45.5%) cases with light microscopy. Optimal test revealed 93 (43.2%) of these samples as positive. Microscopy showed 61 out of 98 positive cases to be P. vivax and 37 P. falciparum. The Optimal dipstick method revealed that 58 out of 93 were positive for P. vivax and 35 positive for P. falciparum. These results demonstrated that Optimal had sensitivities of 95% and 94.5% for P. vivax and P. falciparum respectively. It has 100% specificity for both malarial species, when compared to conventional microscopy.

CONCLUSION

Optimal test showed excellent correlation with microscopy in the diagnosis of P. vivax and P. falciparum. It is expensive but it has an advantage of being simple, rapid and effective test in the diagnosis of malaria especially where well trained microscopists are not available or work load is too high.

Efficacy of bronchial wash cytology and its correlation with biopsy in lung tumours

OBJECTIVE

To evaluate bronchial wash cytology with histology in our set up.

METHODS

Seventy three specimens were obtained by flexible fiberoptic bronchoscope at pulmonology department of Military Hospital Rawalpindi. All the preserved samples were processed under standard conditions. The slides were stained with Papanicolaou and Haematoxylin and Eosin stains.

RESULTS

A total of 73 patients were studied. The age range was 21 to 80 years. Male to female ratio was 8:1. Complete cytological and biopsy consensus was found in 55 (77.4%) cases. Cytology revealed 24 cases as malignant and nine as atypical/suspicious. Benign and inadequate were 29 and 2 respectively. Histopathology of these cases confirmed 24 (32.9%) as malignant and 29 (39.8%) as benign. True positive alongwith suspicious/atypical were 33 and true negative cases were 29. False positive was one case only whereas false negative cases were eight. The bronchial wash cytology showed sensitivity (80.5%), specificity (96.6%) and accuracy (87.3%). Positive predictive value and negative predictive value were 97% and 78.4% respectively. The commonest types of tumours were squamous cell carcinoma and small cell carcinoma.

CONCLUSION

It is concluded that bronchial wash cytology is a valuable tool and yields almost same information as biopsy. It is useful in patients with evidence of obstruction or risk of haemorrhage.

The effect of special training for quinacrine sterilization (QS) in Faisalabad, Pakistan: a report on an 1833-women subset of 11,000 cases

OBJECTIVE

To determine the impact of retrained clinicians on the efficacy of transcervical quinacrine sterilization.

METHOD

Retraining of clinicians in the accepted insertion technique was conducted in 1996. From 1 January 1997 through 2001, they performed 1089 quinacrine sterilizations in 11 MCH clinics of the Mother & Child Welfare Association at Faisalabad, Pakistan. Of these, 885 women had a recorded follow-up visit (81.4%) by 31 December 2001.

RESULT

Reported pregnancy failures declined after retraining from 5.4% (SE 2.3) for one year of use to 1.1% (SE 0.4) for 5 years of use. The rates at 4 years of use showed the expected increase in failures for women 30 years old or younger of 1.5% (SE 0.7) compared to 0.9% (SE 0.4) for those over 30; a lower rate of 0.8% (SE 0.4) for breastfeeding subjects and 2.2% (SE 1.1) for mothers not breastfeeding; but rates were similar for uterine length and post insertion traumatic bleeding.

CONCLUSION

Quinacrine sterilization appears safe with acceptable efficacy.

An autopsy study of hypertrophic cardiomyopathy

OBJECTIVE

To see the pathological features of this disease in our set up and to emphasise the importance of morphological examination in making the diagnosis of hypertrophic cardiomyopathy (HCM) especially in cases of sudden cardiac death.

METHODS

A retrospective, descriptive study of 15 autopsies of this particular disease was carried out at the Armed Forces Institute of Pathology (AFI) Rawalpindi during the period from 1990 to 1995. The hearts along with blood vessels were fixed in 10% formalin and were dissected according to the modified Virchow's method for eliciting the gross appearance of cardiac chambers and valves. Representative sections were taken for histological examination.

RESULTS

All the cases were young adult males. The age range was from 17-34 years (mean, 26-6 years). Ten cases died suddenly and five cases had an evidence of moderate to severe exertion preceding their death. Symmetrical as well as asymmetrical hypertrophy was noted in this study. The thickness of inter ventricular septum (mean 20 mm) and left ventricular wall (mean 22.5 mm) was increased. All the specimens revealed disarray of hypertrophic myocardial fibres and patchy interstitial fibroses.

CONCLUSION

Sudden death is usually the first manifestation of disease. The hearts showed asymmetric as well as concentric hypertrophy. Myofibre hypertrophy and disarray was an important pathological findings in our cases. While carrying out post-mortem examination of a case of sudden cardiac death one should also keep in mind the possibility of this disease.

[Gallbladder polyps]

Polyps in the gall bladder are detected in 4-5% of the population and most of them are benign. However, they can be premalignant and the prognosis for gall bladder carcinoma is still poor. As with other cancers, treatment at an early stage is therefore, considered essential to improve the prognosis. Because of the very low morbidity after laparoscopic cholecystectomy we recommend laparoscopic cholecystectomy when a polyp in the gall bladder is detected by ultrasonography. A wait and see attitude with repeated ultrasonography twice a year may be chosen, if there are contra-indications to laparoscopic cholecystectomy. If the lesion increases in size, cholecystectomy should be performed.

Study of water quality of Hudiara drain, India-Pakistan

This paper examines the extent of pollution in Hudiara drain water due to untreated industrial and sewage waste of India and Pakistan. Ninety-nine surface water samples from the Pakistani side of the Hudiara drain were collected during September 1997, and April and June 1998. The analytical results of the Hudiara drain samples point out the industrial and sewage inputs from India and Pakistan. Higher values of biochemical oxygen demand (BOD), chemical oxygen demand(COD), total organic carbon(TOC), and trace metals in drain samples from the Indo-Pak border clearly indicate the Indian industrial and sewage pollution. Large variations in the levels of various measured parameters (COD, BOD, TOC, pH, total soluble substances, and trace metals) were observed along the Hudiara drain in the Pakistani vicinity. These variations were due to different types of industrial effluents and small village drains. The study showed that suspended solids(SS), COD, and fecal coliform (FC) were the major pollutants. Accordingly, the most feasible alternative is to convert the drainage network to a sedimentation and temporary storage reservoir. If disinfected, the runoff water can be used for restricted irrigation. Groundwater samples taken from the drain's surrounding area have also been analyzed. Thirty percent of the samples are not fit for drinking purposes due to NO3-N, Se and FC counts as prescribed by World Health Organization (WHO) guidelines. A trilinear diagram clearly indicates the influence of surface water of the Hudiara drain on ground water; moreover, higher values of nitrate and FC clearly indicate the seepage from the Hudiara drain.

MT1-MMP and MMP-2 mRNA expression in human ovarian tumors: possible implications for the role of desmoplastic fibroblasts

Expression of activated MMP-2 (72 kDa type IV collagenase) is highly associated with the malignant phenotype in adenocarcinomas, but predominant expression of the mRNA appears to be in stromal cells. MT1-MMP (membrane type 1-matrix metalloproteinase) is implicated in tumor-epithelial cell surface activation of latent pro-MMP-2, indicating a mechanism for tumor-stromal interaction in invasion. We determined the relative mRNA distribution of these MMPs in human ovarian tumors with a view to analyzing potential variations in the epithelial-mesenchymal interactions dictating ovarian tumor cell spread. In situ hybridization using 35S-labeled riboprobes was used to analyze 33 human ovarian tumors and mouse xenografts of human ovarian (DOV 13, SKOV3) and breast (MCF 7) tumor cell lines known to express MT1-MMP and MMP-2. MMP-2 mRNA was expressed in 31 of 33 and MT1-MMP mRNA was expressed in 29 of 33 tumor cases. MMP-2 mRNA was predominantly expressed in desmoplastic fibroblasts and in the subepithelial stroma. MT1-MMP mRNA showed some colocalization with MMP-2 in stromal cells. Neoplastic epithelial cell labeling for MT1-MMP mRNA was present in borderline and malignant tumors but not in benign tumors, and was invariably less than stromal labeling. Xenografts of DOV 13, SKOV 3, and MCF 7 cells showed some stromal localization of MMP-2 mRNA and weak labeling of DOV 13 cells. There was variable labeling for MT1-MMP mRNA in the neoplastic cells only. The colocalization of MT1-MMP and MMP-2 mRNAs in ovarian carcinoma stroma supports the view that MT1-MMP is closely associated with MMP-2 expression and function. It suggests that either additional mechanisms are involved in regulating MMP-2 activation at the tumor cell surface, or more intriguingly, that desmoplastic fibroblasts may be the primary mediators of extracellular matrix remodeling with respect to this system.

Matrix metalloproteinase-2 and tissue inhibitor of metalloproteinase-2 expression and synthetic matrix metalloproteinase-2 inhibitor binding in ovarian carcinomas and tumor cell lines

Enhanced matrix metalloproteinase-2 (MMP-2/72-kd type IV collagenase) action correlates with invasion in neoplasia. MMP-2 is inhibited in vivo by tissue inhibitors of metalloproteinases (TIMPs)-TIMP-1 and, especially, TIMP-2. A synthetic, biotinylated inhibitor specific for activated MMP-2 in solution phase, and immunohistochemistry were used to detect MMP-2 and TIMP-2 expression in cell lines and ovarian tumors and to analyze the surface-binding capacity of the inhibitors, which are potential therapeutic agents. Characterization of novel monoclonal antibodies to MMP-2 and TIMP-2 is described together with immunocytochemical staining of 83 paraffin-embedded ovarian tumors (67 malignant, 7 borderline, 9 benign) and 9 cell lines. Synthetic MMP-2 inhibitor binding under controlled conditions was visualized by immunofluorescence and avidin-biotin complex immunoperoxidase methods in cell lines and cryostat sections of ovarian tumors. MMP-2 and TIMP-2 showed heterogenous immunoreactivity, with enhanced staining on high-grade tumors, specifically at the invasive front and in vascular invasion. TIMP-2 immunoreactivity was maximal in malignant cell cytoplasm and less intense in desmoplastic fibroblasts. One monoclonal antibody to MMP-2 showed membrane immunoreactivity, apically polarized in benign and low-grade tumors but depolarized and strong in 37 of 44 cases of high-grade invasive tumors. Eleven of eighteen ovarian carcinomas and six of nine cell lines showed membrane localization of the synthetic inhibitor. Maximal binding occurred in the ovarian cell line OVCA 432 and the breast cell lines MCF 7 and MDA MB 435, all of which were immunoreactive for MMP-2. Cell lines propagated on type I collagen showed no enhancement in inhibitor binding. This study demonstrates cell surface binding of a synthetic MMP-2 inhibitor and provides new evidence of MMP-2 and TIMP-2 immunoreactivity in ovarian carcinomas and cell lines.

MDM2 overexpression is rare in ovarian carcinoma irrespective of TP53 mutation status

Somatic mutations in TP53 are seen in many human cancers. In addition, the protein product of the wild-type TP53 can be sequestered by the protein MDM2 (murine double minute 2). This protein is commonly overexpressed in human sarcomas and gliomas, usually as a result of gene amplification. In this study, 43 ovarian carcinomas (OCs) were analysed for aberrations in the TP53 gene by immunohistochemistry (IHC), loss of heterozygosity (LOH) or mutation analysis. The MDM2 gene and its product was studied by Southern blotting and IHC. Over 50% of the OCs studied showed mutations in TP53 by either direct sequencing (19/36, 53%), positive IHC (23,43, 53%) or both, whereas 0/32 had amplification of MDM2 and only 1/37 tumours had positive IHC using the anti-MDM2 antibody IF-2. The solitary example of positive IHC in this series was seen in a mixed müllerian tumour with sarcomatous differentiation and was not accompanied by MDM2 DNA amplification. These results support previous data showing that around 50% of OCs have mutations in TP53 and in addition, suggest that MDM2 is not amplified in OC, but the presence of sarcomatous features in mixed müllerian tumours may result in positive immunohistochemistry with IF-2.