1029 FABRY DISEASE: A RARE CAUSE TO REMEMBER WHEN FACING ACUTE KIDNEY INJURY IN YOUNG

Introduction

Anderson-Fabry disease (FD) is a rare X-linked hereditary disease caused by mutations in the alpha-galactosidase A (GLA) gene, a lysosomal hydrolase that catabolizes lipids. GLA deficency leads to a progressive accumulation of undegraded glycosphingolipids, mainly Globotriaosylceramide (GB3), within lysosomes of cells (epithelial and endothelial cells, neurons, cardiomyocytes and renal cells), leading to cellular dysfunction. The incidence of FD is 1:117.000 but in patients with end stage renal disease (ESRD), incidence is higher, ranging from 0.04% up to 1.16% in male dialysis patients. Classical form of the disease shows renal, cardiac and cerebrovascular involvements usually. Cardiac involvement includes hypertrophic cardiomyopathy, arrhythmias such as complete heart block, valve dysfunction and myocardial infarction. Renal manifestations include proteinuria, progressive loss of renal function with chronic kidney disease (CKD) that leads to ESRD. The diagnosis of FD can be very difficult and often is delayed due to subtle clinical manifestations, but an early diagnosis is crucial to start enzyme replacement therapy (ERT), based on recombinant human GLA, as soon as possible.

Clinical Case

we describe the case of a 36-years-old male admitted to the Emergency Room of our hospital due to asthenia, nausea, dysphagia, anuria and loss of weight. At physical examination, apical systolic murmur and a bilateral ankle edema. Blood pressure was 195/100 mmHg, heart rate 125 beats per minute, peripheral oxygen saturation 100%. Blood test showed Hemoglobin 8 g/dL, Blood Urea 422 mg/dL, Creatinine 20 mg/dL, Na+ 135 mEq/L, K+ 4 mEq/L, Phosphorus 9 mg/dL. Arterial blood gas analysis showed metabolic and lactic acidosis. The diagnosis of acute kidney injury (AKI) was made, and a dialytic treatment was scheduled. During dialytic session, the patient had a syncope. EKG showed a complete left bundle branch block (LBBB) with advanced atrio-ventricular block (2:1, complete). An echocardiogram highlighted a severe myocardial hypertrophy (septal wall 25 mm) involving also the right ventricle with “ground glass” aspect of the posterolateral, posterior and inferior septum, with minimal pericardial effusion. Heart MRI scan confirmed LV myocardial hypertrophy with circumferential aspect (interventricular septum 26.6 mm), mild decrease in left ventricular ejection fraction (47%) and myocardial hypointensity area in the FSE sequences. Renal ultrasound showed bilateral cortical hyperecogenity, small cortico-medullary border, initial reduction of kidney volume and diffuse perirenal edema.

In consideration of the high probability of a storage disease, we performed genetic testing for FD and Gaucher disease, peri-umbilical fat biopsy for Amyloid Disease and a renal biopsy. The genetic test resulted positive for typical mutation of FD and renal biopsy documented ESRD secondary to glycosphingolipid storage disease ceramid type from FD.

Conclusion

Differential diagnosis of AKI in a young male should include FD, as suggested by the clinical case reported, and nephrologist should screen young patients for α-GLA enzyme deficiency (diagnostic for FD) possibly coupled with renal biopsy in uncertain cases.

1141 CARDIAC METASTASIS

Introduction: in medical literature, studies on cardiac metastases are few and discordant and their actual incidence is underestimated. Autoptic examination shows evidence of cardiac metastases in about 9% of all the patients affected by malignant tumor. Each malignant tumor can metastasize to the heart (incidence varying from 2.3% to 18.3%); nevertheless, formation of cardiac metastases is more frequently associated with primitive neoplasms such as pleural mesothelioma (48.4%), melanoma (27.8%), adenocarcinoma as well as lung and kidney carcinomas.

Clinical case: patient aged 66, former smoker, no further cardiovascular disease risk factors, no occurrences of heart disease in his past medical history. In 2008 surgical excision of melanoma skin cancer, negative sentinel lymph node. In 2014 cancer relapse, final cycle of chemotherapy treatment completed in July. In October 2014 evidence of liver and adrenal gland metastases. In November 2014 evidence of bone metastases. As the CT scan showed evidence of pleural and pericardial effusion, the patient was requested to undergo cardiac examination and an echocardiogram test in preparation for further chemotherapy treatment. During the medical examination the patient presented with symptoms of marked asthenia, dyspnea under moderate effort (NYHA II), palpitations. BP: 100/60 mmHg. ECG: low voltages, sinus tachycardia, incomplete RBBB, inverted T waves in V1 – V4, III. Home Therapy: Furosemide 25 mg, Cortisone 25 mg, Tramadolo Cloridrato 50 mg, Albumina. The findings of the echocardiogram test showed: enlarged and hyperkinetic left ventricle, abundant circumferential pericardial effusion measuring up to 2,3 cm. Evidence of hyperechogenic areas in the epicardium, myocardium and at the level of mitral valve flaps (figure 1 and 2). In December 2014 hospital admission due to worsening of clinical symptoms, onset of ascites, hyperpotassemia, anemization (Hb 8.6g/dL). During the 72 hours following hospitalisation: STEMI, acute kidney failure, respiratory failure, metabolic acidosis, death. The autoptic examination showed evidence of undifferentiated large cell neoplasm with formation of metastases in the myocardium, mitral valve apparatus and coronary tree.

Conclusions

echocardiography should always be included in the clinical examinations which patients affected by neoplasm are required to undergo. Serial evaluations allow to identify the occurrence of pericardial effusion and/or heart involvement even in the absence of clinical suspicion. Identifying such anomalies may have important therapeutic implications.

Role of Physical Activity in Bone-Muscle Crosstalk: Biological Aspects and Clinical Implications

Bone and muscle tissues influence each other through the integration of mechanical and biochemical signals, giving rise to bone-muscle crosstalk. They are also known to secrete osteokines, myokines, and cytokines into the circulation, influencing the biological and pathological activities in local and distant organs and cells. In this regard, even osteoporosis and sarcopenia, which were initially thought to be two independent diseases, have recently been defined under the term "osteosarcopenia", to indicate a synergistic condition of low bone mass with muscle atrophy and hypofunction. Undoubtedly, osteosarcopenia is a major public health concern, being associated with high rates of morbidity and mortality. The best current defence against osteosarcopenia is prevention based on a healthy lifestyle and regular exercise. The most appropriate type, intensity, duration, and frequency of exercise to positively influence osteosarcopenia are not yet known. However, combined programmes of progressive resistance exercises, weight-bearing impact exercises, and challenging balance/mobility activities currently appear to be the most effective in optimising musculoskeletal health and function. Based on this evidence, the aim of our review was to summarize the current knowledge about the role of exercise in bone-muscle crosstalk, highlighting how it may represent an effective alternative strategy to prevent and/or counteract the onset of osteosarcopenia.

PTX3 Effects on Osteogenic Differentiation in Osteoporosis: An In Vitro Study

Pentraxin 3 (PTX3) is a glycoprotein belonging to the humoral arm of innate immunity that participates in the body’s defence mechanisms against infectious diseases. It has recently been defined as a multifunctional protein, given its involvement in numerous physiological and pathological processes, as well as in the pathogenesis of age-related diseases such as osteoporosis. Based on this evidence, the aim of our study was to investigate the possible role of PTX3 in both the osteoblastic differentiation and calcification process: to this end, primary osteoblast cultures from control and osteoporotic patients were incubated with human recombinant PTX3 (hrPTX3) for 72 h. Standard osteinduction treatment, consisting of β-glycerophosphate, dexamethasone and ascorbic acid, was used as control. Our results showed that treatment with hrPTX3, as well as with the osteogenic cocktail, induced cell differentiation towards the osteoblastic lineage. We also observed that the treatment not only promoted an increase in cell proliferation, but also the formation of calcification-like structures, especially in primary cultures from osteoporotic patients. In conclusion, the results reported here suggest the involvement of PTX3 in osteogenic differentiation, highlighting its osteoinductive capacity, like the standard osteoinduction treatment. Therefore, this study opens new and exciting perspectives about the possible role of PTX3 as biomarker and therapeutic agent for osteoporosis.

Low-density-lipoprotein peak particle size in a Mediterranean population

BACKGROUND

The predominance of small, dense low-density lipoprotein (LDL) particles ('LDL phenotype B') has been associated with a three-fold increased risk of myocardial infarction, but the feasibility of the identification of small, dense LDL as independent predictors of coronary artery disease risk in population studies remains questioned. Design We evaluated the LDL peak particle size and its relation with other established risk factors for coronary heart disease in a group of 156 randomized subjects living on the Mediterranean island of Ustica (71 males and 85 women, range of age 20-69 years), representing approximately 30% of the total population.

RESULTS

The prevalence of LDL phenotype B subjects was low (approximately 15% in both men and women) and there was a clear trend for both genders in reducing the LDL peak particle size with age. Moreover, LDL phenotype B subjects had higher BMI values, prevalence of diabetes and plasma triglyceride (TG) levels and lower plasma HDL-C concentrations in comparison with LDL phenotype A individuals; in a multivariate analysis, plasma TG levels were the only variable independently associated with LDL peak particle size.

CONCLUSIONS

In this population, which appears to be somewhat protected by premature coronary artery disease, a low prevalence of the LDL pattern B was found in both men and women, and plasma TG could have a key role in regulating the LDL peak particle size. The follow up, still ongoing, will provide useful information on the predictive role of LDL peak particle size on cardiovascular risk, at least in a low-risk population.

ApoE polymorphism in a small Mediterranean island: relationships with plasma lipids, lipoproteins and LDL particle size

Polymorphisms of apoE gene are able to modulate lipoprotein metabolism at different steps and to influence LDL-cholesterol (LDL-C) levels and also other lipoproteins features. Population studies documented large differences in the frequency of apoE alleles which could be even related to the prevalence of cardiovascular disease. In this study we evaluated the apoE genotypes and allele frequency in 576 subjects living in a small island in the Tyrrhenian Sea and the relative contribution of apoE polymorphism on plasma lipid and lipoprotein profile, including LDL particle size. We found a cumulative frequency of 0.073, 0.866 and 0.061 for epsilon2, epsilon3 and epsilon4 alleles respectively. Moreover epsilon3 subjects had only triglyceride levels significantly lower and LDL-C and lipoprotein (a) (Lp(a)) levels higher than epsilon2 carriers. LDL-particle size was significant smaller in epsilon2 subjects than both epsilon3 and epsilon4 carriers, but the difference disappeared when data were adjusted for triglycerides. In conclusion we have provided further evidence of a low prevalence of epsilon4 allele in a Mediterranean population which may represent a genetic protective factor of these populations. Environmental factors, such as diet, occurring in this area may have attenuated the influence of this gene on plasma lipoproteins.

Distribution of risk factors, plasma lipids, lipoproteins and dyslipidemias in a small Mediterranean island: the Ustica Project

BACKGROUND AND AIM

The populations of the Mediterranean area have a low incidence of cardiovascular disease (CHD). The aims of this paper are: 1) to present demographic data of the population of Ustica, a small island in the southern part of the Tyrrhenian sea that has reduced communications with the mainland and a diet presumably rich in fish; and 2) to evaluate the distribution of risk factors, plasma lipids, lipoproteins and dyslipidemias in this population.

METHODS AND RESULTS

We invited all of the free-living resident population aged more than 14 years (about 800 individuals) to participate in the study; 576 responded, for a participation rate of about 73%. The distribution of cardiovascular risk factors, plasma lipids, lipoproteins and dyslipidemias were evaluated in all of the subjects. More than 60% of the population was out of the normal weight range. Total and low-density lipoprotein cholesterol levels were respectively 207.4 +/- 46.7 and 141.7 +/- 42.4 mg/dL, and similar in males and females. Lipoprotein (a) (Lp[a]) levels presented the classical "skewed" distribution and, among the apolipoprotein(a) isoforms, there was a clear predominance of intermediate-sized kringle IV repeats. Overall, 43% of the subjects had a lipid disorder: the prevalence of hypercholesterolemia was 22.8% (3.2% with severe hypercholesterolemia terolemia > or = 300 mg/dL); low high-density lipoprotein cholesterol levels were found in 22.5%; the so-called lipid triad in 2.1%; and high Lp(a) levels in 6.2%. Large familial clusters were found for some lipid disorders.

CONCLUSIONS

A large prevalence of body weight disturbances and high frequency of dyslipidemias are the main characteristics of this population. Ongoing data and future longitudinal studies will better clarify the relative influence of each parameter on CHD risk and total mortality.

The combined implant of an endourethral prosthesis and artificial sphincter in post-operative urethral strictures involving the external sphincter

— Urethral strictures still represent one of the most difficult urological pathologies to treat. This report deals with two cases of post-operative urethral strictures involving the external sphincter treated with a combined implant of an endourethral prosthesis and an artificial sphincter AMS-800. Two years after the implant, the urodynamic equilibrium is satisfactory. The relatively high cost of the treatment requires really favourable results in particularly motivated subjects.

Pharmacocavernosometry as a functional diagnostic test of venous leakage

During 1994, 20 patients underwent pharmacocavernosometry because of suspected venous leakage. Only two patients showed evident signs of this syndrome. However, in another 10 patients, who did not show cavernosometric signs of venous leakage, cavernosography manifested opacity of the pudendal veins. Therapy for the two above-mentioned cases was surgical ligation of the crural vessels and of the dorsal vein. Short-term results have been substantially satisfactory. Analysing these cases and taking into account the latest bibliographic references, a prevalently functional pathogenesis of venous leakage can be proposed. Pharmacocavernosometry, as a functional diagnostic exam, although limited, could be the best test presently available to diagnose this syndrome. Cavernosography, being a more anatomic exam, could appear much less significant. The therapy to be proposed is surgery, on its own or supported by pharmacoprosthesis.

Priapism: Our Experience and a Literature Review

The series of cases which was taken into consideration, although statistically irrelevant, is in line with the most recently acquired bibliographic knowledge on the subject. It shows that, because of its growing incidence, priapism is a remarkably interesting syndrome; in addition, it shows the need to define diagnostic and therapeutic procedures which, taking the physiology of erection into consideration, allow both the morbid syndrome to be cured and its development foreseen.

Clonal variation in paramecium. II. A comparison of stable and unstable clones of the same serotype

Paramecium generally expresses only one antigen on its surface from among an array of antigens. This mutual exclusion of antigens now has been shown in certain instances to be illusory. Unstable clones which will give rise to subclones with new serotypes possess several antigens. Unstable clones, even though they manifest only one serotype, continually manufacture an antigen other than the surface antigen characteristic of the serotype.