Is there long-term value of pathology scoring in immunoglobulin A nephropathy? A validation study of the Oxford Classification for IgA Nephropathy (VALIGA) update

Background

It is unknown whether renal pathology lesions in immunoglobulin A nephropathy (IgAN) correlate with renal outcomes over decades of follow-up.

Methods

In 1130 patients of the original Validation Study of the Oxford Classification for IgA Nephropathy (VALIGA) cohort, we studied the relationship between the MEST score (mesangial hypercellularity, M; endocapillary hypercellularity, E; segmental glomerulosclerosis, S; tubular atrophy/interstitial fibrosis, T), crescents (C) and other histological lesions with both a combined renal endpoint [50% estimated glomerular filtration rate (eGFR) loss or kidney failure] and the rate of eGFR decline over a follow-up period extending to 35 years [median 7 years (interquartile range 4.1–10.8)].

Results

In this extended analysis, M1, S1 and T1–T2 lesions as well as the whole MEST score were independently related with the combined endpoint (P < 0.01), and there was no effect modification by age for these associations, suggesting that they may be valid in children and in adults as well. Only T lesions were associated with the rate of eGFR loss in the whole cohort, whereas C showed this association only in patients not treated with immunosuppression. In separate prognostic analyses, the whole set of pathology lesions provided a gain in discrimination power over the clinical variables alone, which was similar at 5 years (+2.0%) and for the whole follow-up (+1.8%). A similar benefit was observed for risk reclassification analyses (+2.7% and +2.4%).

Conclusion

Long-term follow-up analyses of the VALIGA cohort showed that the independent relationship between kidney biopsy findings and the risk of progression towards kidney failure in IgAN remains unchanged across all age groups and decades after the renal biopsy.

Post-traumatic hydrocephalus

BACKGROUND

Surgical treatment of ventricular dilatation following severe head trauma (GCS <8) remains controversial due to the difficulty to distinguish brain atrophy-related ventriculomegaly from active, symptomatic ventricular dilatation. Consequently, the reported incidence of post-traumatic hydrocephalus in literature varies greatly from 0.7-29%. The presence of ventricular dilatation following severe head trauma should be considered and demands investigation, based also on satisfactory results obtained with cerebrospinal fluid (CSP) shunting,

METHODS

Ninety-eight patients with post-traumatic hydrocephalus undergoing CSF shunting were selected for this study among 4,044 patients with severe head trauma treated from 1972 to 1999 at the Department of Neurosurgery at the City Hospital of Verona. Patients included 82 (84%) males and 16 (16%) women, ranging from one month to 83 years (mean age; 39 years). In 24 (24%) cases, the brain trauma lesion was single, while in 74 (76%) cases the patient suffered multiple cranio-cerebral lesions. The total number of lesions was 230 including 214 (93%) supratentorial and 16 (7%) posterior cranial fossa (PCF) lesions. Seventy-nine operations were performed on 59 (60%) patients. The onset of hydrocephalus was immediate after trauma in 14 (14%) cases, whereas a delayed onset was observed within 30 days in 44 (45%) cases, between one-four months in 30 (31%) cases and between four-six months in 10 (10%) cases. Of the 98 patients in this study, 15 were treated with an external CSF shunt and 83 underwent internal CSF shunting.

RESULTS

Long-term results of the 15 patients with external shunts demonstrated good recovery in 13% while 87% of cases resulted in death. In the 83 cases of internal shunts, despite severe preoperative conditions (75% in coma or persistent coma), the results were as follows: good recovery in 37 (45%) patients, partial disability in nine (11%), persistent coma in 29 (35%) and death in seven (8%) cases.

CONCLUSIONS

Post-traumatic hydrocephalus is a complication that must always be considered in cases of severe head trauma (GCS <8) in young patients presenting added neurological deficits, ceased clinical improvement (ceased improvement after initial improvement), increased hypertonia, surgical flap tension or CSF accumulation. The results of this study suggest the necessity to treat post-traumatic ventricular dilatation with aggressive surgery and CSF shunting, based on favorable outcome seen even in coma and persistent coma patients.

[Scabies in a dalysis unit. Mystery and prejudice]

BACKGROUND

Pruritus is one of the most common symptoms of uremia. The etiology of uremic pruritus is steel incompletely known. Scabies may be a cause of itching in these patients.

METHODS

Retrospective analysis of beginning and developing of a scabies outbreak in a Dialysis Unit with 160 patients.

RESULTS

Sixteen cases of scabies were observed in the Dialysis Unit from April 1998 and January 1999: in 6 of them the scarification was positive. In 10 the scarification was negative, but itching disappeared after treatment with benzyl benzoate 20%. Many courses were necessary (max 6). Prophylaxis (treatment with benzyl benzoate 20% for 3 days and lingery cleaning) was applied to approximately 400 people. No cases were observed among health care workers of the Dialysis Unit.

CONCLUSIONS

In a Dialysis Unit the diagnosis of scabies is difficult because the patients often have generalized itching; moreover some of them are affected by neuropathy that may make the infestation of scabies more difficult to identify. The most important factor to limitate the outbreak seems to be the prophylaxis of people who take care of patients (health-care workers, family members and car-drivers). It seems also necessary to repeat the treatments many times. The most exposed patients seemed to be those with diminished independence, diabetes and malnutrition.

Role of surgery in gliomas of cerebral hemispheres in adults

Current neurological opinion favours the extensive surgical removal of supratentorial glioma, when feasible, without injury to normal structures. Several recent studies relate the extent of surgical resection to the length and quality of survival. Better surgical results due to microsurgical techniques and operative facilities suggest the re-evaluation of the role of surgery in the overall management of glial tumours.

Procarbazine and high-dose tamoxifen as a second-line regimen in recurrent high-grade gliomas: a phase II study

PURPOSE

A phase II study was conducted in patients with high-grade gliomas that recurred after surgery plus radiotherapy and a first-line nitrosourea-based regimen. Our aim was to investigate the efficacy of procarbazine (PCB) combined with high-dose tamoxifen in relation to tumor control, toxicity, and time to progression (TTP).

PATIENTS AND METHODS

Fifty-three patients were treated with procarbazine in repeated 30-day courses at 100 mg/m2/d plus tamoxifen 100 mg/d, with a 30-day interval between courses. Thirty-four patients had been pretreated with a first-line nitrosourea-based chemotherapy regimen (group A), and 19 patients had also been pretreated with a second-line chemotherapy regimen consisting of carboplatin and teniposide (group B). Twenty-one of the patients had also been procarbazine pretreated, whereas the remaining 32 patients were not procarbazine pretreated.

RESULTS

The response was assessed in 51 patients, 28 of whom had glioblastoma multiforme (GBM) and 23 of whom had anaplastic astrocytoma (AA). There were two complete responses (CR) (4%) and 13 partial responses (PR) (25.5%). The overall response rate (CR + PR) was 29.5% (SE, 6.4; 95% confidence interval [CI], 23 to 35.8). Seventeen patients (32%) had stable disease (SE, 6.2; 95% CI, 21 to 33.6). The median TTP was 13 weeks for patients with GBM and 33 weeks for patients with AA (P = .006). The median survival time (MST) was 27 weeks for patients with GBM and 57 weeks for those with AA (P = .006).

CONCLUSION

Combined PCB and tamoxifen as a second-line regimen gave a reasonably high response rate in patients with heavily pretreated high-grade gliomas. However, although it resulted in an improvement in the patients' quality of life and/or performance status, it was not followed by an increased TTP or MST.

Optimizing sodium balance in hemodialysis

this paper develops and tests a mathematical model for Na+ kinetics applied to standard hemodialysis. The volume of distribution of exchangeable Na+, dialyzer surface area, blood and dialysis fluid flow rate, target weight loss, treatment duration and the Na+ diffusibility constant are taken into account. The model is used to compute the optimal hour by hour dialysis fluid Na+ concentration required to achieve the prescribed end-dialysis natremia and maintain a constant end-dialysis body Na+ pool, while providing a nearly uniform removal of Na+ over dialysis. The model was preliminary tested on 10 consecutive dialyses in a single patient using special dialyzer which generates a part of ultrafiltrate uncontaminated by dialysate.

[Evolution of the serum aluminum values in the Piedmont dialysis population. Dialysis Centers of the Piedmont]

The authors have evaluated the evolution of values of serum aluminium concentration (Als) in the whole pool of patients undergoing RDT in Piedmont in the years 1982-1990. We have compared the data of the Piedmont Regional Registry of Dialysis and Transplantation at the end of 1990 to those obtained in 1982, 1986 and 1989. A progressive reduction has been observed in the percentage of patients with Als > 100 micrograms/l, who were 13.5% of the pool in 1982 and 7.5% in 1986 and finally decreased to 1.5% in 1990. This is yet more evident for patients dialyzing at home as in 1982 43% of them had a Als > 100 micrograms/l, whereas in 1986 only 8.2% did and in 1990 this percentage had decreased to 3.6%. The values of Als (distinguished by type of treatment of chronic renal failure) show end confirm the improvement of the situation of aluminium accumulation, specially as regards bicarbonate HD where the percentage of patients with Als > 100 micrograms/l decreases from 10.5% in 1986 to 1.7% in 1990. These data point out the efficacy of prevention and control programs regarding aluminium pathology performed in the last years in Piedmont. This has led to a reduction of the severe accumulation syndromes observed in the first years of '80 and has allowed the nephrologist to prepare more correct therapeutic prescriptions.

Risk factors for cerebral glioma in adults: a case-control study in an Italian population

A case-control study on risk factors for cerebral tumors was conducted on an adult Italian population by the four Neurosurgical Departments of the Veneto Region, i.e. Padua, Treviso, Verona and Vicenza. The study recruited 195 cases of histologically-confirmed cerebral glioma. One hospital control was selected for each case. Cases and controls were matched for age, sex, data of hospitalization and residence. Information on both cases and controls was obtained from a relative. Uninvolved interviewers administered a structured questionnaire including items on the subject's education, occupation, lifestyle, medical history, exposure to radiation for diagnosis or therapy, head trauma and blood group and the medical history of family members. The series of cerebral tumors was first considered as an indistinct set: none of the risk factors examined showed a statistically significant association. A positive association was found with blood group A (OR = 6) when low-grade astrocytomas (n = 41) were considered separately. As for the malignant astrocytomas (n = 132), there was a suggestive but not statistically significant association with the presence of CNS tumors among first- and second-degree relatives (OR = 7.0). On the whole, this study yielded no clear and meaningful association for the various risk factors analyzed.

[The organizational problems of the hospitals of the Nord Italia Transplant Program (NITp) engaged in the activities of organ retrieval for transplantation. The Collaborative Group of Resuscitation Anesthetists]

If the quality of results of organ transplantation in NITp is highly satisfactory, the same cannot be said for the number of transplants performed, which only cover 20-25% of the requirement. To understand the causes of organ shortage, a study group of Anaesthesiologists and Transplant Coordinators from the North Italy Transplant Program (NITp) investigated, through a questionnaire addressed to the Heads of 103 Intensive Care Units (ICU) in 92 Hospitals in the NITp area, some of the organizational problems linked to donor identification and treatment and to organ retrieval. The questionnaire took into consideration the number of possible donors identified in 1990, those retrieved and the causes for non retrieving organs and examined a number of variables linked both to retrieval and to ICUs and Hospitals organization. The results show that potential donors were 461: 143 (31%) were used, 138 (30%) were lost due to family opposition to organ donation, 192 (20%) for clinical reasons and 88 (19%) for organizational reasons. The latter figure represents 5% of non retrieval in the most active ICUs and increases to 50% in the Hospitals that had procured no donors in 1990. The main obstacles for ICUs to procure organ donors are: convey the Medical-Legal Committee, carry out of complicated administrative procedures, availability of round the clock specialized equipment for neurological assessment (especially for ICU outside Neurosurgical and Neurological departments), inadequate number of medical and nursing staff, most of all at night, and finally the difficulty in the management of non-traumatic cerebrovascular patients.

Production of tumor necrosis factor-alpha in patients on hemodiafiltration

The systemic production of tumor necrosis factor (TNF)-alpha was evaluated in uremic patients before and after hemodiafiltration (HDF) and paired filtration dialysis (PFD) and in the interdialytic period. Both HDF and PFD were performed using polysulfone dialyzers with either standard or ultrapure dialysis fluid. TNF-alpha was quantitated by using a specific biological assay based on its cytotoxic effect on a TNF-sensitive human melanoma cell line SK-MEL-109. Postdialytic mean plasma TNF-alpha levels decreased, albeit not significantly, in regard to predialytic values. These results differ from those obtained in patients on HDF using other high-permeability membranes such as polymethylmethacrylate and polyacrylonitrile (AN 69) as recently described by us. Of interest, the adoption of ultrapure dialysis fluid resulted in a marked reduction in the interdialytic production of TNF-alpha. These results suggest that the enhanced production of TNF-alpha in patients dialyzed with high-permeability membranes is mainly dependent upon the bacteriological purity of dialysis fluid.

[Role of tumor necrosis factor in hemodiafiltration]

The Authors review the mechanisms involved in the production of cytokines during substitutive extracorporeal treatment with particular reference to microbial contamination and possibility of backfiltration of bacterial constituents more likely to occur with high permeability membranes. Recent and on-going studies from our laboratory support the contention that patients treated with high permeability membranes may be chronically stimulated. Use of "ultrapure" solution indeed brings about a marked reduction in predialytic plasma levels of tumor necrosis factor (TNF) in regard to what observed when standard solutions are adopted.

[Role of paired filtration dialysis in substitutive treatment]

The Authors have evaluated the possibilities of use of the PFD in the regular dialysis treatment. At first they have studied in 8 patients the advantages offered by this technique in terms of depuration of small molecules and of tolerance in comparison with HD and HDF. Subsequently, they have compared the performances obtained in HF in a second group of 7 patients with the results observed in PFD executed by using 2 dialyzers on line and, in a second phase, in parallel, extending the comparison parameters to a higher molecular weight solute such as the beta 2-M. The results obtained indicate the PFD as a technique which can offer (compared to HD) a better tolerance and higher depurative performances, which on their turn can eventually allow a reduction of the length of the treatment. Moreover the possibility of executing the PFD with 2 polysulfone dialyzers on line and in parallel, increasing the UF to 13.5 and 15 L, renders this technique competitive with the HF also for its capacity of removing the beta 2-M.

Spontaneous spinal haematomas

A series of 10 surgically treated "spontaneous" spinal haematomas (7 cases with epidural, 3 with intramedullary location), is presented. Symptomatology was rarely acute. Clinical onset was mostly dominated by spinal or radicular pain, followed by severe motor deficit. Surgical outcome was satisfactory in the majority of cases. Age, duration of symptoms, haematoma site and size appeared to have no influence on final outcome. This was significantly correlated only with the preoperative neurological condition.

Management of associated primary cerebral neoplasms and vascular malformations: 2. Intracranial arterio-venous malformations

3 cases of primary cerebral tumours associated to intracranial arterio-venous malformations are reported. The presenting symptoms were caused by the AVM in 2 patients, by the tumour in 1 patient. In 2 cases the lesions were coexistent, while in one case the tumour was diagnosed 30 months after resection of the AVM. The tumour was a glioma in 2 cases, a pituitary adenoma in 1 case. The AVM was located in the right hemisphere in 2 patients, and was always ipsilateral to the tumour. Surgical treatment was undertaken in all patients, and consisted of resection of the tumour and AVM in 2 cases, and only resection of the tumour in 1 case. As regards outcome, one patient survived with a mild deficit, and 2 patients died from the natural evolution of the malignant tumour. It is concluded that the management of associated AVMs and brain tumours should be decided in the individual patient according to various considerations, owing to the variability of each lesion and to the relatively benign prognosis of an arterio-venous malformation.

Management of associated primary cerebral neoplasms and vascular malformations: 1. Intracranial aneurysms

18 patients harbouring a primary cerebral tumour associated with one or more intracranial aneurysms are presented. Initial symptoms were caused in 10 cases by the tumour, in 8 cases by aneurysmal rupture. In 2 cases the tumour was discovered years after the exclusion of the aneurysm. The tumour was supratentorial in 14 cases, and was more commonly a meningioma (44% of cases) or glioma (38% of cases). A total of 25 aneurysms were observed in the 18 patients: 8 had ruptured and 17 were incidental. The aneurysms were more commonly on the internal carotid artery (40%). Surgical treatment was undertaken in 13 patients, and consisted of: a) tumour resection plus aneurysmal exclusion in 6 patients, b) only tumour resection in 5 patients with incidental aneurysms, and c) only exclusion of the aneurysm in 2 patients later developing malignant gliomas. Rupture of incidental aneurysms was never observed. The prognosis was linked mainly to the nature of the tumour in cases with malignant tumours, and to the evolution of subarachnoid haemorrhage in patients with ruptured aneurysms. As a whole, a satisfactory recovery was observed in 7 patients, and death occurred in 11 patients, mainly due to progressive evolution of the malignant tumour (in 6 cases) or to fatal aneurysmal rebleeding (in 3 cases). It is concluded that tumours associated with aneurysms should be operated on at the same time whenever possible, and decisions regarding exclusion of incidental aneurysms should be balanced against the risks of the procedure.

In vitro analysis of BCNU-sensitivity in human malignant gliomas. II. Cross-resistance studies with cisplatinum and nitrosoureas

With the use of the Human Brain Tumor Stem Cell Assay (HBTSCA) in a cross-resistance study, four early (3-4) culture passages of human malignant gliomas (glioblastoma multiforme) were tested for in vitro chemosensitivity with three of the most effective single agents for brain tumor chemotherapy: BCNU, CCNU and cisplatinum (DDP). The shapes of the dose-response curves indicated complete cross-resistance between BCNU and CCNU, i.e. two chloroethyl-nitrosoureas sharing a common alkylating-carbamoylating activity, with no evident cross-resistance between the two nitrosoureas and the DDP, a DNA binder with a putatively different antitumor action. Probably because of differences in drug delivery kinetics or in the cytotoxic mechanism, DDP might play a role in the treatment of nitrosourea-resistant gliomas.

Intracranial hematomas following aneurysmal rupture: experience with 309 cases

Three hundred and nine consecutive cases of intracranial hematomas due to aneurysmal rupture--representing 34% of the total number of patients with aneurysms observed in a 12-year period--were evaluated; of these, 211 were submitted to computed tomography scan. Hematomas were present on admission in 71% of patients and occurred at rebleeding in 29%. Ruptured middle cerebral artery aneurysms caused an intracranial hematoma more frequently than aneurysms in other locations. Ventricular hematomas were frequently observed--especially at rebleeding--in cases with anterior communicating artery aneurysms. Basal ganglia hematomas were detected in eight cases with internal carotid bifurcation aneurysms and in three with middle cerebral artery aneurysms. Subdural hematomas were observed in 32 cases, mainly due to ruptured middle-cerebral-artery and internal-carotid-artery aneurysms. As for clinical evolution, a rapid deterioration was observed in 39% of cases and a chronic course in 46%; a subacute deterioration was far less frequent. Delayed deterioration from vasospasm was observed in 8% of cases, and appeared to be related to the amount of subarachnoid bleeding associated with the hematoma. One hundred and forty-two patients were submitted to surgical treatment (evacuation of hematoma together with exclusion of aneurysm); deep coma, poor medical condition, stabilized neurological disability, or combinations of these factors accounted for the high number of patients not operated upon. Regardless of treatment, 24% of patients showed good results and 58% died. Presence of a large hematoma, ventricular hemorrhage, and shift of the ventricles represented significant risk factors, associated with a poor prognosis. A comparison between two groups of patients admitted within 3 days of hemorrhage--47 operated on early, and 149 with delayed treatment--showed that better results were achieved by early operations, especially for cases in Hunt's grades IV and V.

In vitro analysis of BCNU-sensitivity in human malignant gliomas. I. A model study with alkylating, cross-linking and carbamoylating agents in anaplastic astrocytomas of pediatric age

Like all chloroethyl-nitrosoureas of major clinical use, 1,3 bis-(2-chloroethyl)-1-nitrosourea (BCNU) - which is one of the most effective chemotherapeutic agents for CNS malignancies - biologically degrades into active alkylating and carbamoylating moieties. Using a human brain tumor stem cell assay, we analyzed a series of anaplastic astrocytomas of pediatric age, characterized by different degrees of BCNU-resistance. Early (2-4) passage cultures from these tumors were treated in vitro with model drugs for alkylation (BCNU, CHLZ (2-[3-(2-chloroethyl)-3-nitrosoureido]-2-deoxy-D-glucopyranose), ENU (N-ethyl-N-nitrosourea), cross-linking (BCNU, CHLZ) and carbamoylation BHCNU (1,3 bis (trans-4-hydrocyclohexyl)-1-nitrosourea): dose-schedules were compatible with clinically achievable levels. Results of chemosensitivity tests confirmed that - as previously reported in malignant gliomas of the adult - cellular resistance to BCNU was closely related to the cross-linking activity of alkylating species. However, in pediatric gliomas the levels of cell kill after treatment with the purely carbamoylating agent BHCNU, even at the highest doses tested, were lower than expected.

Cerebral vasospasm after head injury

Cerebral vasospasm occurs frequently after head injury. Correlation between neurological deterioration and vasospasm has been reported previously, but delayed neurological deterioration secondary to vasospasm in head injury is a rare occurrence. We report the case of a 57-year-old man who, after a motorcycle accident, developed an acute subdural hematoma and a thick subarachnoid deposition of blood in the left sylvian-insular cistern. After surgical evacuation of the hematoma, the patient improved until the 10th postoperative day, when he developed aphasia and a right hemiparesis. Angiography demonstrated multitapering spasm, and a computed tomographic (CT) scan showed persistence of the cisternal deposition of blood. Despite therapy with hypervolemia, the patient improved only slightly. The association of head injury with substantial subarachnoid hemorrhage producing vasospasm has been considered rarely. Delayed posttraumatic vasospasm secondary to blood degradation products seems to play some role in the vasospasm after head injury. CT scanning may be useful in predicting vasospasm in such patients, and digital subtraction angiography might be useful in demonstrating it.

Posterior inferior cerebellar artery aneurysm in the fourth ventricle: acute surgical treatment

A case of an aneurysm of the posterior inferior cerebellar artery lying in the fourth ventricle is reported. The patient was surgically treated within a few hours after the onset of the subarachnoid hemorrhage by a microsurgical technique using direct exclusion of the aneurysm by a clip. The patient recovered completely following the operation.

Cerebral arteriovenous malformations in children (56 cases)

A survey of 56 patients aged less than or equal to 16 years, admitted (1954-1979) for cerebral arteriovenous malformations, is presented. The clinical manifestation was mostly related to hemorrhage, less frequently to epilepsy or to a cerebral 'steal' syndrome. The most frequent site was the parietal lobe, with supply from the middle cerebral artery. Deep malformations were not uncommon and most lesions were of medium or large size. 38 patients were operated upon, and 18 were given treatment other than surgical (including radiotherapy). 23 malformations were completely excised, in 4 patients only a partial excision could be carried out, and in 10 patients surgery consisted of occlusion (clipping or coagulation) of feeding vessels. In 1 patient, surgery had to be limited to removal of an intracerebral hematoma. The immediate and long-term results of treatment are much better in the surgical than in the nonsurgical group.

Intracranial aneurysms of childhood

15 cases of cerebral aneurysms in children between 8 and 15 years of age, all operated upon in a 20-year span (1956--1976), are reported. 7 of them were the carriers of large aneurysms (3 'giant'). Surgical mortality was limited to 2 patients with aneurysms of the middle cerebral artery and large intracerebral hematomas. All other patients are in satisfactory conditions, with a follow-up ranging from 2 to 22 years. A direct approach to the aneurysm was used in all but 3 cases. Certain features of cerebral aneurysms in children are discussed pertinently to this series.