Clinical Features, Outcomes, and Response to Corticosteroid Treatment of Acute Tubulointerstitial Nephritis: A Single-Centre Retrospective Cohort Study in the Czech Republic

INTRODUCTION

Acute tubulointerstitial nephritis (ATIN) is a well-recognized cause of acute kidney injury (AKI) due to the tubulointerstitial inflammation. The aim of this study was to explore the clinical features, outcomes, and responses to corticosteroid treatment in patients with ATIN.

METHODS

Patients with biopsy-proven ATIN, who were diagnosed between 1994 and 2016 at the Department of Nephrology, Charles University, First Faculty of Medicine, and General University Hospital in Prague, were included in the study. Patient demographics, the aetiological and clinical features, the treatment given, and the outcome at 1 year of follow-up were extracted from patient records.

RESULTS

A total of 103 ATIN patients were analysed, of which 68 had been treated with corticosteroids. There was no significant difference in the median serum creatinine 280 (169-569) µmol/L in the conservatively managed group versus 374 (249-558) µmol/L in the corticosteroid-treated group, p = 0.18, and dependence on dialysis treatment at baseline at the time of biopsy (10.3 vs. 8.6%). During the 1 year of follow-up, those ATIN patients who had been treated with corticosteroids did better and showed greater improvement in kidney function, determined as serum creatinine difference from baseline and from 1 month over 1-year period (p = 0.001).

CONCLUSIONS

This single-centre retrospective cohort study supports the beneficial role of the administration of corticosteroid therapy in the management of ATIN.

Unveiling the Unexpected: Why Doctors Should Look beyond the Lungs when Predicting COVID-19 Mortality

INTRODUCTION

The main objective of this study was to identify the best combination of admission day parameters for predicting COVID-19 mortality in hospitalized patients. Furthermore, we sought to compare the predictive capacity of pulmonary parameters to that of renal parameters for mortality from COVID-19.

METHODS

In this retrospective study, all patients admitted to a tertiary hospital between September 1st, 2020, and December 31st, 2020, who were clinically symptomatic and tested positive for COVID-19, were included. We gathered extensive data on patient admissions, including laboratory results, comorbidities, chest X-ray (CXR) images, and SpO2 levels, to determine their role in predicting mortality. Experienced radiologists evaluated the CXR images and assigned a score from 0 to 18 based on the severity of COVID-19 pneumonia. Further, we categorized patients into two independent groups based on their renal function using the RIFLE and KDIGO criteria to define the acute kidney injury (AKI) and chronic kidney disease (CKD) groups. The first group ("AKI&CKD") was subdivided into six subgroups: normal renal function (A); CKD grade 2+3a (B); AKI-DROP (C); CKD grade 3b (D); AKI-RISE (E); and grade 4 + 5 CKD (F). The second group was based only on estimated glomerular filtration rate (eGFR) at the admission, and thus it was divided into four grades: grade 1, grade 2+3a, grade 3b, and grade 4 + 5.

RESULTS

The cohort comprised 619 patients. Patients who died during hospitalization had a significantly higher mean radiological score compared to those who survived, with a p value <0.01. Moreover, we observed that the risk for mortality was significantly increased as renal function deteriorated, as evidenced by the AKI&CKD and eGFR groups (p < 0.001 for each group). Regarding mortality prediction, the area under the curve (AUC) for renal parameters (AKI&CKD group, eGFR group, and age) was found to be superior to that of pulmonary parameters (age, radiological score, SpO2, CRP, and D-dimer) with an AUC of 0.8068 versus 0.7667. However, when renal and pulmonary parameters were combined, the AUC increased to 0.8813. Optimal parameter combinations for predicting mortality from COVID-19 were identified for three medical settings: Emergency Medical Service (EMS), the Emergency Department, and the Internal Medicine Floor. The AUC for these settings was 0.7874, 0.8614, and 0.8813, respectively.

CONCLUSIONS

Our study demonstrated that selected renal parameters are superior to pulmonary parameters in predicting COVID-19 mortality for patients requiring hospitalization. When combining both renal and pulmonary factors, the predictive ability of mortality significantly improved. Additionally, we identified the optimal combination of factors for mortality prediction in three distinct settings: EMS, Emergency Department, and Internal Medicine Floor.

Presence of retinopathy and incident kidney and cardiovascular events in type 2 diabetes with normoalbuminuria - A post-hoc analysis of the PRIORITY randomized clinical trial

AIMS

Baseline diabetic retinopathy (DR) and risk of development of microalbuminuria, kidney function decline, and cardiovascular events (CVEs) in type 2 diabetes.

METHODS

Post-hoc analysis of the PRIORITY study including 1758 persons with type 2 diabetes and normoalbuminuria followed for a median of 2.5 (IQR: 2.0-3.0) years. DR diagnosis included non-proliferative and proliferative abnormalities, macular oedema, or prior laser treatment. Cox models were fitted to investigate baseline DR presence with development of persistent microalbuminuria (urinary albumin-creatinine ratio > 30 mg/g); chronic kidney disease (CKD) G3 (eGFR <60 ml/min/1.73m²); and CVE. Models were adjusted for relevant risk factors.

RESULTS

At baseline, 304 (17.3 %) had DR. Compared to persons without DR, they were older (mean ± SD: 62.7 ± 7.7 vs 61.4 ± 8.3 years, p = 0.019), had longer diabetes duration (17.9 ± 8.4 vs. 10.6 ± 7.0 years, p < 0.001), and higher HbA_1c (62 ± 13 vs. 56 ± 12 mmol/mol, p < 0.001). The adjusted hazard ratios of DR at baseline for development of microalbuminuria (n = 197), CKD (n = 166), and CVE (n = 64) were: 1.50 (95%CI: 1.07, 2.11), 0.87 (95%CI: 0.56, 1.34), and 2.61 (95%CI: 1.44, 4.72), compared to without DR.

CONCLUSIONS

Presence of DR in normoalbuminuric type 2 diabetes was associated with an increased risk of developing microalbuminuria and CVE, but not with kidney function decline.

A case report: Acute kidney injury with progression to chronicity in an eldery woman

Acute renal failure in elderly patients can be caused by a wide spectrum of diseases that usually have a cause outside the kidney. The most common causes include renal impairment as part of ANCA vasculitis, another category includes clonal plasmatic cell disease with light chain cast nephropathy; and there also exists an increasing number of drug-induced tubulointerstial damage. We present a case of iatrogenic less common form of acute failure in a 73-year-old woman, who did not suffer from any serious disease until then. Although the biopsy helped to determine the cause of the failure and thus affect subsequent therapy, the function did not return to the previous state and the patient progressed to CKD G3bA1 with serum creatinine values of around 170-140 μmol/l.

Can Renal Parameters Predict the Mortality of Hospitalized COVID-19 Patients?

Introduction

Our study aimed to analyze whether renal parameters can predict mortality from COVID-19 disease in hospitalized patients.

Methods

This retrospective cohort includes all adult patients with confirmed COVID-19 disease who were consecutively admitted to the tertiary hospital during the 4-month period (September 1 to December 31, 2020). We analyzed their basic laboratory values, urinalysis, comorbidities, length of hospitalization, and survival. The RIFLE and KDIGO criteria were used for AKI and CKD grading, respectively. To display renal function evolution and the severity of renal damage, we subdivided patients further into 6 groups as follows: group 1 (normal renal function), group 2 (CKD grades 2 + 3a), group 3 (AKI-DROP defined as whose s-Cr level dropped by >33.3% during the hospitalization), group 4 (CKD 3b), group 5 (CKD 4 + 5), and group 6 (AKI-RISE defined as whose s-Cr level was elevated by ≥50% within 7 days or by ≥26.5 μmol/L within 48 h during hospitalization). Then, we used eGFR on admission independently of renal damage to check whether it can predict mortality. Only 4 groups were used: group I − normal renal function (eGFR > 1.5 mL/s), group II − mild renal involvement (eGFR 0.75–1.5), group III − moderate (eGFR 0.5–0.75), and group IV − severe (GFR <0.5).

Results

A total of 680 patients were included in our cohort; among them, 244 patients displayed normal renal function, 207 patients fulfilled AKI, and 229 patients suffered from CKD. In total, a significantly higher mortality rate was found in the AKI and the CKD groups versus normal renal function − 37.2% and 32.3% versus 9.4%, respectively (p < 0.001). In addition, the groups 1–6 divided by severity of renal damage reported mortality of 9.4%, 21.2%, 24.1%, 48.7%, 62.8%, and 55.1%, respectively (p < 0.001). The mean hospitalization duration of alive patients with normal renal findings was 9.5 days, while it was 12.1 days in patients with any renal damage (p < 0.001). When all patients were compared according to eGFR on admission, the mortality was as follows: group I (normal) 9.8%, group II (mild) 22.1%, group III (moderate) 40.9%, and group IV (severe) 50.5%, respectively (p < 0.001). It was a significantly better mortality predictor than CRP on admission (AUC 0.7053 vs. 0.6053).

Conclusions

Mortality in patients with abnormal renal function was 3 times higher compared to patients with normal renal function. Also, patients with renal damage had a worse and longer hospitalization course. Lastly, eGFR on admission, independently of renal damage type, was an excellent tool for predicting mortality. Further, the change in s-Cr levels during hospitalization reflected the mortality prognosis.

Expert opinion on the cooperation of diabetologists and internists with nephrologists in the care of patients with chronic kidney diseases

Chronic kidney disease (CKD) affects 10% of the population of developed countries and significantly affects the population health. In addition to the well-known renoprotection tools slowing down the progression of CKD, SGLT2 inhibitors have been newly introduced into clinical practice based on the results of extensive studies, both in diabetics and non-diabetics. This expert opinion discusses the classification of CKD, current renoprotection options, and the recent role of SGLT2 inhibitors in the care of patients with CKD.

A Matched Case-Control Study of Noncholesterol Sterols and Fatty Acids in Chronic Hemodialysis Patients

Dyslipidemia is common among patients on hemodialysis, but its etiology is not fully understood. Although changes in cholesterol homeostasis and fatty acid metabolism play an important role during dialysis, the interaction of these metabolic pathways has yet to be studied in sufficient detail. In this study, we enrolled 26 patients on maintenance hemodialysis treatment (high-volume hemodiafiltration, HV HDF) without statin therapy (17 men/9 women) and an age/gender-matched group of 26 individuals without signs of nephropathy. The HV-HDF group exhibited more frequent signs of cardiovascular disease, disturbed saccharide metabolism, and altered lipoprotein profiles, manifesting in lower HDL-C, and raised concentrations of IDL-C and apoB-48 (all p < 0.01). HV-HDF patients had higher levels of campesterol (p < 0.01) and β-sitosterol (p = 0.06), both surrogate markers of cholesterol absorption and unchanged lathosterol concentrations. Fatty acid (FA) profiles were changed mostly in cholesteryl esters, with a higher content of saturated and n-3 polyunsaturated fatty acids (PUFA) in the HV-HDF group. However, n-6 PUFA in cholesteryl esters were less abundant (p < 0.001) in the HV-HDF group. Hemodialysis during end-stage kidney disease induces changes associated with higher absorption of cholesterol and disturbed lipoprotein metabolism. Changes in fatty acid metabolism reflect the combined effect of renal insufficiency and its comorbidities, mostly insulin resistance.

A mutation in the SAA1 promoter causes hereditary amyloid A amyloidosis

Amyloid A amyloidosis is a serious clinical condition resulting from the systemic deposition of amyloid A originating from serum amyloid A proteins with the kidneys being the most commonly and earliest affected organ. Previously described amyloid A amyloidosis is linked to increased production and deposition of serum amyloid A proteins secondary to inflammatory conditions arising from infectious, metabolic, or genetic causes. Here we describe a family with primary amyloid A amyloidosis due to a chr11:18287683 T>C (human genome version19) mutation in the SAA1 promoter linked to the amyloidogenic SAA1.1 haplotype. This condition leads to a doubling of the basal SAA1 promoter activity and sustained elevation of serum amyloid A levels that segregated in an autosomal dominant pattern in 12 genetically affected and in none of six genetically unaffected relatives, yielding a statistically significant logarithm of odds (LOD) score over 5. Affected individuals developed proteinuria, chronic kidney disease and systemic deposition of amyloid composed specifically of the SAA1.1 isoform. Tocilizumab (a monoclonal antibody against the interleukin-6 receptor) had a beneficial effect when prescribed early in the disease course. Idiopathic forms represent a significant and increasing proportion (15-20%) of all diagnosed cases of amyloid A amyloidosis. Thus, genetic screening of the SAA1 promoter should be pursued in individuals with amyloid A amyloidosis and no systemic inflammation, especially if there is a positive family history.

Obstructive Jaundice Secondary to Pancreatic Head Metastasis of Malignant Amelanotic Melanoma as the First Clinical Manifestation

Malignant melanoma is commonly known for its high probability of metastasizing to distant organs. Metastases to gastrointestinal tract are well documented, but resulting jaundice is only scarcely seen. We present a case of histologically verified metastasis of amelanotic melanoma to the head of pancreas infiltrating the common bile duct and consequently causing obstructive jaundice which constituted its first clinical manifestation. Multidisciplinary approach is essential in patients with malignant melanoma since early detection of the melanoma or its metastases may improve patients' clinical outcome, especially owing to the use of targeted biological treatment without any delay.

A roadmap for optimizing chronic kidney disease patient care and patient-oriented research in the Eastern European nephrology community

Chronic kidney disease (CKD) is a major health problem because of its high prevalence, associated complications and high treatment costs. Several aspects of CKD differ significantly in the Eastern European nephrology community compared with Western Europe because of different geographic, socio-economic, infrastructure, cultural and educational features. The two most frequent aetiologies of CKD, DM and hypertension, and many other predisposing factors, are more frequent in the Eastern region, resulting in more prevalent CKD Stages 3-5. Interventions may minimize the potential drawbacks of the high prevalence of CKD in Eastern Europe, which include several options at various stages of the disease, such as raising public, medical personnel and healthcare authorities awareness; early detection by screening high-risk populations; preventing progression and CKD-related complications by training health professionals and patients; promoting transplantation or home dialysis as the preferred modality; disseminating and implementing guidelines and guided therapy and encouraging/supporting country-specific observational research as well as international collaborative projects. Specific ways to significantly impact CKD-related problems in every region of Europe through education, science and networking are collaboration with non-nephrology European societies who have a common interest in CKD and its associated complications, representation through an advisory role within nephrology via national nephrology societies, contributing to the training of local nephrologists and stimulating patient-oriented research. The latter is mandatory to identify country-specific kidney disease-related priorities. Active involvement of patients in this research via collaboration with the European Kidney Patient Federation or national patient federations is imperative to ensure that projects reflect specific patient needs.

Early detection of diabetic kidney disease by urinary proteomics and subsequent intervention with spironolactone to delay progression (PRIORITY): a prospective observational study and embedded randomised placebo-controlled trial

BACKGROUND

Microalbuminuria is an early sign of kidney disease in people with diabetes and indicates increased risk of cardiovascular disease. We tested whether a urinary proteomic risk classifier (CKD273) score was associated with development of microalbuminuria and whether progression to microalbuminuria could be prevented with the mineralocorticoid receptor antagonist spironolactone.

METHODS

In this multicentre, prospective, observational study with embedded randomised controlled trial (PRIORITY), we recruited people with type 2 diabetes, normal urinary albumin excretion, and preserved renal function from 15 specialist centres in ten European countries. All participants (observational cohort) were tested with the CKD273 classifier and classified as high risk (CKD273 classifier score >0·154) or low risk (≤0·154). Participants who were classified as high risk were entered into a randomised controlled trial and randomly assigned (1:1), by use of an interactive web-response system, to receive spironolactone 25 mg once daily or matched placebo (trial cohort). The primary endpoint was development of confirmed microalbuminuria in all individuals with available data (observational cohort). Secondary endpoints included reduction in incidence of microalbuminuria with spironolactone (trial cohort, intention-to-treat population) and association between CKD273 risk score and measures of impaired renal function based on estimated glomerular filtration rate (eGFR; observational cohort). Adverse events (particularly gynaecomastia and hyperkalaemia) and serious adverse events were recorded for the intention-to-treat population (trial cohort). This study is registered with the EU Clinical Trials Register (EudraCT 20120-004523-4) and ClinicalTrials.gov (NCT02040441) and is completed.

FINDINGS

Between March 25, 2014, and Sept 30, 2018, we enrolled and followed-up 1775 participants (observational cohort), 1559 (88%) of 1775 participants had a low-risk urinary proteomic pattern and 216 (12%) had a high-risk pattern, of whom 209 were included in the trial cohort and assigned to spironolactone (n=102) or placebo (n=107). The overall median follow-up time was 2·51 years (IQR 2·0-3·0). Progression to microalbuminuria was seen in 61 (28%) of 216 high-risk participants and 139 (9%) of 1559 low-risk participants (hazard ratio [HR] 2·48, 95% CI 1·80-3·42; p<0·0001, after adjustment for baseline variables of age, sex, HbA_1c, systolic blood pressure, retinopathy, urine albumin-to-creatinine ratio [UACR], and eGFR). Development of impaired renal function (eGFR <60 mL/min per 1·73 m²) was seen in 48 (26%) of 184 high-risk participants and 119 (8%) of 1423 low-risk participants (HR 3·50; 95% CI 2·50-4·90, after adjustment for baseline variables). A 30% decrease in eGFR from baseline (post-hoc endpoint) was seen in 42 (19%) of 216 high-risk participants and 62 (4%) of 1559 low-risk participants (HR 5·15, 95% CI 3·41-7·76; p<0·0001, after adjustment for basline eGFR and UACR). In the intention-to-treat trial cohort, development of microalbuminuria was seen in 35 (33%) of 107 in the placebo group and 26 (25%) of 102 in the spironolactone group (HR 0·81, 95% CI 0·49-1·34; p=0·41). In the safety analysis (intention-to-treat trial cohort), events of plasma potassium concentrations of more than 5·5 mmol/L were seen in 13 (13%) of 102 participants in the spironolactone group and four (4%) of 107 participants in the placebo group, and gynaecomastia was seen in three (3%) participants in the spironolactone group and none in the placebo group. One patient died in the placebo group due to a cardiac event (considered possibly related to study drug) and one patient died in the spironolactone group due to cancer, deemed unrelated to study drug.

INTERPRETATION

In people with type 2 diabetes and normoalbuminuria, a high-risk score from the urinary proteomic classifier CKD273 was associated with an increased risk of progression to microalbuminuria over a median of 2·5 years, independent of clinical characteristics. However, spironolactone did not prevent progression to microalbuminuria in high-risk patients.

FUNDING

European Union Seventh Framework Programme.

Nephrology and Public Policy Committee propositions to stimulate research collaboration in adults and children in Europe

The strengths and the limitations of research activities currently present in Europe are explored in order to outline how to proceed in the near future. Epidemiological and clinical research and public policy in Europe are generally considered to be comprehensive and successful, and the European Renal Association – European Dialysis and Transplant Association (ERA-EDTA) is playing a key role in the field of nephrology research. The Nephrology and Public Policy Committee (NPPC) aims to improve the current situation and translation into public policy by planning eight research topics to be supported in the coming 5 years by ERA-EDTA.

Loss of bone mineral density and trabecular bone score in elderly hemodialysis patients: a 2-year follow-up, prospective, single-centre study

BACKGROUND

Low bone mineral density (BMD) and trabecular bone score (TBS) are established risk factors for fractures even in hemodialysis population and they seem to be significantly lower in comparison with general population. The aim of our study was to describe 2-year loss of BMD and TBS and their predictors in hemodialysis patients.

METHODS

From 59 non-selected patients (mean age 67.6 ± 13.1 years) from one dialysis centre, treated with hemodiafiltration (HDF), clinical and laboratory characteristics were obtained and densitometry examinations (with BMD and TBS results) were performed initially and at the end of 2-year follow-up.

RESULTS

Two-year decrease in BMD of lumbar spine reached 4.1% (ns), of proximal femur 9.1% (p = 0.004), and of femoral neck 1.3% (ns). In the co-educated cohort, BMD decrease in all the sites correlated significantly with age and only the change of BMD of lumbar spine was negatively associated with serum calcium (r = - 0.39; p = 0.04) and dialysis vintage (r = - 0.387; p = 0.062), no other predictors of BMD loss were identified. Some predictors of BMD loss were identified with regard to gender. TBS decrease was 0.05 (3.9%; p = 0.03), and similarly, it was not predicted by any of selected parameters. No differences in BMD changes or TBS were observed between the patients with and without fractures.

CONCLUSIONS

In patients with HDF, significant BMD and TBS annual losses were observed, and they were associated only with age and (in BMD of lumbar spine) with serum calcium and dialysis vintage.

Dyslipidemia in patients with chronic kidney disease: etiology and management

The worldwide population is burdened with chronic kidney disease (CKD) from 10-13 %. Patients with CKD subsequently die to cardiovascular disease (CVD) and their complications. In the Czech population, in 2016, the number of patients with end stage renal disease (ESRD) on regular dialytic treatment was 6 739, or 674/1 000 000 inhabitants. Overall mortality in regular dialysis treatment patients was 18.4 % in 2016, of which 43 % died of cardiovascular complications. In view of this fact, a number of expert groups are concerned, among other things, with the problems of lipid metabolism disorders, with the aim of finding a common predictive marker (preferably also therapeutically qualifiable) to stratify patients dialyzed or potentially indicating hypolipidemic therapy. The aim of possible interventions is to minimize cardiovascular risk and subsequent complications resulting from cardiovascular disease (CVD), thus improving the quality of life of regular dialysis treatment patients.

Importance of breath tests for the evaluation liver function in patients with chronic kidney disease

Breath tests for the evaluation liver metabolic function are a non-invasive diagnostic method with high sensitivity and specificity. Up today, the issue of liver damage in patients with chronic kidney disease has not been investigated sufficiently, although it might have significant clinical consequences. The following article describes the principles of breath tests, experiences with breath tests in patients with chronic kidney disease (CKD) and the results of our pilot study with methacetin breath tests in patients with CKD and in regular peritoneal dialysis treatment.

Crystalopathy - underestimated entity in nephrology

Crystal is a solid particle with a geometric shape because its atoms, ions, or molecules are arranged in a regular ordered structure. However, in case of accidental order of the particles, we are talking about the amorphous substances which can also form crystallike particles. Crystallopathy is a disease that involves crystals of crystallike particulate matter in the pathogenesis of tissue injury. Generally, several predominant pathophysiological mechanisms are involved in the formation of crystallopathies: necroinflammation, chronic remodeling of tissues leading to their atrophy and scarring, and obstruction of ducts, cavities or vessels by larger crystalline masses or stones. The basic distribution of crystallopathies in nephrology is as follows: renovascular crystallopathy (type 1), tubular crystallopathy (type 2), and finally urolithiasis (type 3) (tab. 1). Nowadays, the issue of crystallopathies in general medicine is omitted frequently not only among a wide range of professionals in the field of internal medicine but also in the field of specialists - nephrologists, urologist etc. One of the possible reasons may be the complexity and difficulty of grasping a wideranging topic, so it is our intention to provide an overview of the latest findings and possible approaches to this problem.

What are the blood pressure targets for patients with chronic kidney disease?

Cardiovascular (CV) diseases remain the main reason for mortality and morbidity among patients with or without chronic kidney disease (CKD) and hypertension represents one of their risk factor. Despite the lack of definitive evidence that intensive blood pressure (BP) lowering improves kidney function outcomes, we agree with the recommendation of target BP.

Hepatorenal syndrome - update 2020

Hepatorenal syndrome (HRS) is a serious complication in patients with advanced liver cirrhosis and ascites occurring simultaneously. According to current diagnostic criteria it is considered as one of the less common forms of acute kidney injury (AKI), referred to as HRS-AKI. As a result of the revision of the diagnostic criteria, there was a significant shift in the diagnosis of AKI in patients with liver cirrhosis, allowing early initiation of adequate measures and appropriate treatment. The following article describes the issue of AKI in liver cirrhosis in a wider context, the diagnostic criteria and algorithm of HRS-AKI treatment.

Current status of dietary measures in patients with advanced-stage chronic renal failure

For patients with advanced chronic kidney disease (CKD) appropriately chosen and timely initiated dietary measures, as a complement to drug therapy, may slow the progression of the disease and delay the need for dialysis treatment. According to the results, dietary protein restriction may play a very important in management of such a patient. The effect of low protein diet is given by the early initiation and well cooperation of patients. The low protein diet with supplementation of ketoanalogues of amino acids is an attractive intervention to help maintain good nutritional status of patients and also have a positive role in calcium phosphate metabolism. Depending on the level of CKD´s progression it should not be forgotten either the fluid balance and the limitation of the intake of salt and phosphorus in the diet which may also have an unfortunate effect on the course of the disease.

The ERA-EDTA today and tomorrow: a progress document by the ERA-EDTA Council

Scientific societies are increasingly seen as central to the advancement of information sharing and collaboration among scientists and clinical investigators for the progress of medical research and the promotion of education, professional competence, integrity and quality studies. To more effectively serve the practicing nephrologists and investigators dedicated to renal science, the Council of the European Renal Association and European Dialysis and Transplantation Association (ERA-EDTA) reorganized and integrated the various activities of the society into two branches, the Clinical Nephrology Governance branch and the Renal Science branch. New affordable initiatives to promote research, education and professional development and to advocate for the recognition of chronic kidney disease as a major public health issue at the European level will be put in place and/or potentiated in the new organizational frame. Educational initiatives will be espoused to Continuous Professional Development and, starting from 2019, 14 Education & Continuous Professional Development courses will be held covering the full range of knowledge areas of modern nephrology. Consolidation and development is the short- and medium-term mantra of the ERA-EDTA. The society has a rich portfolio of successful activities and brilliant, creative scientists among its members. Integrating the various activities of the ERA-EDTA and treasuring the expertise and wisdom of its most accomplished members will facilitate collaborative research, education and its public impact at large.

Lipid Metabolism in Patients with End-Stage Renal Disease: A Five Year Follow-up Study

BACKGROUND

Patients with end-stage renal disease (ESRD) exhibit high morbidity as well as mortality for atherosclerotic cardiovascular diseases (CVD). Therefore, we investigated differences in individual lipoprotein classes and subclasses in ESRD patients under chronic high volume hemodiafiltration (HV-HDF) in comparison with a control group. We also assessed the prognosis of these patients and analyzed these parameters after 5 years follow-up.

METHODS

57 patients and 50 controls were enrolled. We analysed high density (HDL) and low density (LDL) lipoprotein subfractions using the Quantimetrix Lipoprint(R) system. Subfractions were correlated with selected clinical-biochemical parameters including risk factors for atherosclerotic CVD at the beginning of and after 5 years follow-up.

RESULTS

Fourteen patients survived the 5-year follow-up. Follow-up results revealed a shift toward smaller HDL subfractions. In lipoproteins carrying apolipoprotein B, there was a shift of cholesterol from very low density (VLDL) to intermediate density (IDL) lipoproteins and LDLs. Hypolipidaemic therapy did not influence lipoprotein profiles in HV-HDF patients.

CONCLUSION

1. HV-HDF patients exhibit specific lipid profiles with elevated triacylglycerol, low HDL and LDL and higher content of cholesterol in remnant particles (VLDL and IDL) at the expense of large LDL. HDL subfractions were linked to the number of risk factors for CVD in the control group only. 2. Baseline lipoprotein profiles did not differ between survivors and non-survivors. Non-survivors had higher CRP and lower HDL-C. 3. During the 5 year follow-up period, cholesterol in HDL particles and lipoproteins carrying apolipoprotein B redistributed in survivors towards smaller particles, thus resembling the profile of control patients.

Bioptically Proven "Anticoagulation-Related Nephropathy" Induced by Dual Antiplatelet Therapy

Anticoagulation-related nephropathy (ARN) is a significant and underdiagnosed complication in patients who receive anticoagulation therapy. It is characterized by acute kidney injury in the setting of excessive anticoagulation defined as an international normalized ratio > 3.0 in patients treated with warfarin. A definitive diagnosis is made by renal biopsy showing acute tubular necrosis with obstruction of the tubuli by red blood cell casts. However, the evidence shows that ARN can occur during treatment with novel oral anticoagulants as well. Although it has been suggested that antiplatelet therapy, such as aspirin, might contribute to coagulopathy (and therefore the hypothetical risk of ARN), there are no reports of ARN induced by antiplatelet therapy according to our knowledge. It is also reported that glomerular lesions (i.e., kidney disease) represent a risk factor for ARN. We present a case of an 82-year-old man who developed biopsy-proven ARN after the administration of dual antiplatelet therapy with no previous anticoagulation treatment and normal coagulation tests.

Characteristics of high- and low-risk individuals in the PRIORITY study: urinary proteomics and mineralocorticoid receptor antagonism for prevention of diabetic nephropathy in Type 2 diabetes

AIM

To compare clinical baseline data in individuals with Type 2 diabetes and normoalbuminuria, who are at high or low risk of diabetic kidney disease based on the urinary proteomics classifier CKD273.

METHODS

We conducted a prospective, randomized, double-blind, placebo-controlled international multicentre clinical trial and observational study in participants with Type 2 diabetes and normoalbuminuria, stratified into high- or low-risk groups based on CKD273 score. Clinical baseline data for the whole cohort and stratified by risk groups are reported. The associations between CKD273 and traditional risk factors for diabetic kidney disease were evaluated using univariate and logistic regression analysis.

RESULTS

A total of 1777 participants from 15 centres were included, with 12.3% of these having a high-risk proteomic pattern. Participants in the high-risk group (n=218), were more likely to be men, were older, had longer diabetes duration, a lower estimated GFR and a higher urinary albumin:creatinine ratio than those in the low-risk group (n=1559, P<0.02). Numerical differences were small and univariate regression analyses showed weak associations (R² < 0.04) of CKD273 with each baseline variable. In a logistic regression model including clinical variables known to be associated with diabetic kidney disease, estimated GFR, gender, log urinary albumin:creatinine ratio and use of renin-angiotensin system-blocking agents remained significant determinants of the CKD273 high-risk group: area under the curve 0.72 (95% CI 0.68-0.75; P<0.01).

CONCLUSIONS

In this population of individuals with Type 2 diabetes and normoalbuminuria, traditional diabetic kidney disease risk factors differed slightly between participants at high risk and those at low risk of diabetic kidney disease, based on CKD273. These data suggest that CKD273 may provide additional prognostic information over and above the variables routinely available in the clinic. Testing the added value will be subject to our ongoing study. (European Union Clinical Trials Register: EudraCT 2012-000452-34 and Clinicaltrials.gov: NCT02040441).

Predictors of bone fractures in a single-centre cohort of hemodialysis patients: a 2-year follow-up study

PURPOSE

Bone involvement represents one of the complications of end-stage chronic kidney disease, with fractures being its major risk. The aim of our study was to assess the frequency and predictors of low-trauma fractures in a cohort of maintenance hemodialysis patients followed-up on for 2 years.

METHODS

59 patients (67.6 ± 13.1 years, 43 males) treated with hemodiafiltration underwent initially laboratory (markers of calcium-phosphate metabolism and bone turnover markers) and densitometry examination with TBS assessment (Lunar Prodigy, TBS software 2.1.2). During 24-month follow-up, the frequency of low-trauma fractures was assessed and possible predictors of increased fracture risk were identified using product-moment correlation matrices.

RESULTS

Altogether 7 (11.9%) low-trauma fractures were observed. In the whole group, age (P = 0.047), T-score in proximal femur (P = 0.04), low vitamin D, low BMI (P = 0.03 for both), and higher FRAX for major osteoporotic fracture (P = 0.01) were connected with fractures, but in multi-variate analysis only BMI remained significantly negatively associated with fractures (P = 0.047). TBS and bone turnover markers failed to predict fractures. However, women with fractures had significantly lower serum phosphate (P = 0.03) and higher parathyroid hormone (P = 0.04). Parameters of hip structure analysis significantly correlated with FRAX, but not with fractures.

CONCLUSIONS

In a group of hemodialysis patients from one centre, T-score in proximal femur, low vitamin D, low BMI, and high FRAX for major osteoporotic fracture were associated with low-trauma fractures, however, in multi-variate analysis only low BMI remained a significant predictor of fracture risk.

The ERA-EDTA today and tomorrow: a progress document by the ERA-EDTA Council

Scientific societies are increasingly seen as central to the advancement of information sharing and collaboration among scientists and clinical investigators for the progress of medical research and the promotion of education, professional competence, integrity and quality studies. To more effectively serve the practicing nephrologists and investigators dedicated to renal science, the Council of the European Renal Association and European Dialysis and Transplantation Association (ERA-EDTA) reorganized and integrated the various activities of the society into two branches, the Clinical Nephrology Governance branch and the Renal Science branch. New affordable initiatives to promote research, education and professional development and to advocate for the recognition of chronic kidney disease as a major public health issue at the European level will be put in place and/or potentiated in the new organizational frame. Educational initiatives will be espoused to Continuous Professional Development and, starting from 2019, 14 Education & Continuous Professional Development courses will be held covering the full range of knowledge areas of modern nephrology. Consolidation and development is the short- and medium-term mantra of the ERA-EDTA. The society has a rich portfolio of successful activities and brilliant, creative scientists among its members. Integrating the various activities of the ERA-EDTA and treasuring the expertise and wisdom of its most accomplished members will facilitate collaborative research, education and its public impact at large.

Transient elastography - role in the assessment of the liver disease development

Transient elastography, an examination based on the liver stiffness measurement, is a method validated for the non-invasive liver fibrosis staging. This method was recently successfully introduced into routine clinical practice. In accordance with the global- wide screening of viral hepatitis (chronic viral hepatitis type B and type C) and with the increasing effectiveness of antiviral therapy, as well as with the increasing prevalence of non-alcoholic fatty liver disease (NAFLD), the part of population requiring the care of hepatologists is certain to increase. Now more than ever we need a non-invasive, fast, safe, inexpensive and reliable method for evaluating patients with chronic liver disease. A new area of ​​use of elastography appears to be used to measure the stiffness of the spleen as a prediction of the presence of esophageal varices or the stiffness (or rather fibrosis) of transplanted kidneys. The aim of this review is to provide a comprehensive view of transient elastography, its principles, advantages and pitfalls, including its use in everyday clinical practice. Key words: cirrhosis - fibrosis - renal allograft - transient elastography.

Association of kidney fibrosis with urinary peptides: a path towards non-invasive liquid biopsies?

Chronic kidney disease (CKD) is a prevalent cause of morbidity and mortality worldwide. A hallmark of CKD progression is renal fibrosis characterized by excessive accumulation of extracellular matrix (ECM) proteins. In this study, we aimed to investigate the correlation of the urinary proteome classifier CKD273 and individual urinary peptides with the degree of fibrosis. In total, 42 kidney biopsies and urine samples were examined. The percentage of fibrosis per total tissue area was assessed in Masson trichrome stained kidney tissues. The urinary proteome was analysed by capillary electrophoresis coupled to mass spectrometry. CKD273 displayed a significant and positive correlation with the degree of fibrosis (Rho = 0.430, P = 0.0044), while the routinely used parameters (glomerular filtration rate, urine albumin-to-creatinine ratio and urine protein-to-creatinine ratio) did not (Rho = -0.222; -0.137; -0.070 and P = 0.16; 0.39; 0.66, respectively). We identified seven fibrosis-associated peptides displaying a significant and negative correlation with the degree of fibrosis. All peptides were collagen fragments, suggesting that these may be causally related to the observed accumulation of ECM in the kidneys. CKD273 and specific peptides are significantly associated with kidney fibrosis; such an association could not be detected by other biomarkers for CKD. These non-invasive fibrosis-related biomarkers can potentially be implemented in future trials.

Complete genome analysis of two new bacteriophages isolated from impetigo strains of Staphylococcus aureus

Exfoliative toxin A (ETA)-coding temperate bacteriophages are leading contributors to the toxic phenotype of impetigo strains of Staphylococcus aureus. Two distinct eta gene-positive bacteriophages isolated from S. aureus strains which recently caused massive outbreaks of pemphigus neonatorum in Czech maternity hospitals were characterized. The phages, designated ϕB166 and ϕB236, were able to transfer the eta gene into a prophageless S. aureus strain which afterwards converted into an ETA producer. Complete phage genome sequences were determined, and a comparative analysis of five designed genomic regions revealed major variances between them. They differed in the genome size, number of open reading frames, genome architecture, and virion protein patterns. Their high mutual sequence similarity was detected only in the terminal regions of the genome. When compared with the so far described eta phage genomes, noticeable differences were found. Thus, both phages represent two new lineages of as yet not characterized bacteriophages of the Siphoviridae family having impact on pathogenicity of impetigo strains of S. aureus.

Extended follow-up of the CYCLOFA-LUNE trial comparing two sequential induction and maintenance treatment regimens for proliferative lupus nephritis based either on cyclophosphamide or on cyclosporine A

Objective To evaluate the extended follow-up of the CYCLOFA-LUNE trial, a randomized prospective trial comparing two sequential induction and maintenance treatment regimens for proliferative lupus nephritis based either on cyclophosphamide (CPH) or cyclosporine A (CyA). Patients and methods Data for kidney function and adverse events were collected by a cross-sectional survey for 38 of 40 patients initially randomized in the CYCLOFA-LUNE trial. Results The median follow-up time was 7.7 years (range 5.0-10.3). Rates of renal impairment and end-stage renal disease, adverse events (death, cardiovascular event, tumor, premature menopause) did not differ between the CPH and CyA group, nor did mean serum creatinine, 24 h proteinuria and SLICC damage score at last follow-up. Most patients in both groups were still treated with glucocorticoids, other immunosuppressant agents and blood pressure lowering drugs. Conclusion An immunosuppressive regimen based on CyA achieved similar clinical results to that based on CPH in the very long term.

Renal Effects of DPP-4 Inhibitors: A Focus on Microalbuminuria

Incretin-based therapies represent one of the most promising options in type 2 diabetes treatment owing to their good effectiveness with low risk of hypoglycemia and no weight gain. Other numerous potential beneficial effects of incretin-based therapies have been suggested based mostly on experimental and small clinical studies including its beta-cell- and vasculo-protective actions. One of the recently emerged interesting features of dipeptidyl peptidase-4 (DPP-4) inhibitors is its possible protective effect on the diabetic kidney disease. Here, we review the renal effects of DPP-4 inhibitors with special focus on its influence on the onset and progression of microalbuminuria, as presence of microalbuminuria represents an important early sign of kidney damage and is also associated with increased risk of hypoglycemia and cardiovascular complications. Mechanisms underlying possible nephroprotective properties of DPP-4 inhibitors include reduction of oxidative stress and inflammation and improvement of endothelial dysfunction. Effects of DPP-4 inhibitors may be both glucagon-like peptide-1 (GLP-1) dependent and independent. Ongoing prospective studies focused on the nephroprotective effects of DPP-4 inhibitors will further clarify its possible role in the prevention/attenuation of diabetic kidney disease beyond its glucose lowering properties.

Polymorphisms in the vitamin D receptor gene and parathyroid hormone gene in the development and progression of diabetes mellitus and its chronic complications, diabetic nephropathy and non-diabetic renal disease

BACKGROUND

We chose to study polymorphisms of vitamin D receptor gene (VDR) and parathyroid hormone genes (PTH), whose protein products significantly affect calciumphosphate metabolism in kidneys and are implicated in the pathogenesis of diabetes, which may also involve kidney damage.

METHODS

Distribution of genotypes of four polymorphisms in VDR gene, i.e, TaqI (rs731236), BsmI (rs1544410) ApaI (rs7975232), FokI (rs2228570) and two polymorphisms of PTH gene, i.e., DraII (rs6256), BstBI (rs6264), were studied using PCRRFLP. Examined groups consisted of 147 patients with diabetes (DM), 47 patients with nondiabetic renal disease (NDRD), 132 patients with diabetic nephropathy (DN) and 118 healthy subjects.

CONCLUSION

Comparison of DN group and healthy subjects identified statistically significant difference for the FokI polymorphism in VDR gene (P<10-4) and also for the BstBI polymorphism in PTH gene (P=0,023). Differences in DraII polymorphism distribution in PTH gene were statistically significant in each group of patients compared to healthy subjects. In DN patients, the BBFFAATt combination of VDR gene was more frequent than in healthy subjects (P=0,046), and the BbFFAaTt variant was more frequent than in DM2 patients (P=0,018). The BBDD haplotype of PTH gene seems to be a predisposing factor for diabetes itself (P=0,019).

What Is the Quality of Pre-Dialysis Healthcare in the Czech Republic?

<b><i>Aim:</i></b> The PREPARE study (PRE-dialysis healthcare in PAtients initiating Renal rEplacement therapy and its consequences) evaluates the quality of pre-dialysis healthcare in patients commencing dialysis treatment in the Czech Republic. <b><i>Methods:</i></b> 48% of Czech dialysis centers participating in this prospective multicenter observational study provided data on all consecutive patients starting renal replacement therapy during 24 weeks. <b><i>Results:</i></b> 68% out of 303 patients had nephrological pre-dialysis care lasting >6 months (57% diabetics). Peritoneal dialysis (PD) was chosen by 11.2%. 23.6% of patients were receiving erythropoiesis-stimulating agents while the mean hemoglobin level was 98.3 ±15.6 g/l. 36.1% of patients were taking phosphate binders while serum phosphates reached 1.90 ±0.61 mmol/l. 64.4% of patients had a functional arteriovenous fistula or PD catheter. 91.8% of the patients felt they were well informed about hemodialysis and 51.6% about PD. Physicians reported poor compliance of patients in 15.1% of cases, while the patients evaluated their own compliance as 9.4%. <b><i>Conclusions:</i></b> To conclude: (1) better pre-dialysis care and information are needed; (2) higher awareness on PD might increase its low popularity; (3) particular attention should be paid to diabetics due to their higher morbidity, a lower proportion considered for transplantation and a lower proportion referred to nephrologists by diabetologists, and (4) preemptive transplantation should be considered more often.

Contribution of Jan Brod to nephrology

Jan Brod (1912-1985), Professor of Medicine of Charles University, Prague, was one of the outstanding personalities of the Czechoslovak medicine and European nephrology of the 20th century. He was an eminent clinician, teacher and scientist who belonged among the founders of renal medicine in Europe. He grew up in the scientific tradition of Prague and Vienna and he was trained by some outstanding personalities, particularly Paul Wood. He became famous due to his pathophysiological-clinical approach to hypertension, heart and kidney diseases. He was not only interested in renal and cardiac physiology but in the entire clinical nephrology. He was among the first clinicians who started to use creatinine clearance in routine practice. His early work was also performed in the field of acute glomerulonephritis and in interstitial nephritis. Later he was interested in water and electrolytes in heart failure and the pathogenesis of edema, and he published priority data on the hemodynamic pattern in emotional stress. Furthermore, it is for sure that he was one of the first cardionephrologists, too. As early as in 1950, he studied diurnal variation in renal perfusion and urinary output in heart failure and later the effect of the adrenergic blockade on the renal hemodynamics in heart failure. Up to his exile in 1968, he served as the head of the Institute for Cardiovascular Research based in Prague and later on, up to his retirement, as the head of the Department of Nephrology in Hannover. He was a founding member of the International Society of Nephrology and president of its 2nd congress held in Prague in 1963. Throughout his life, Jan Brod remained a political man who voiced his opinions. Despite two exiles, he was always the Czech patriot. He holds a special place in the history of Czechoslovak and European nephrology.

Clinical manifestation and natural history of diabetic nephropathy

The prevalence of diabetes, predominantly of type 2, and the incidence of diabetic nephropathy have dramatically increased worldwide. Diabetic patients constitute the largest proportion of patients with end-stage renal disease (ESRD) requiring dialysis or transplantation; in developed countries, this accounts for up to 50% of ESRD patients, but this proportion has stabilized and possibly somewhat decreased in recent years. Chronic kidney disease in diabetic patients is more heterogeneous than previously thought. The largest proportion suffers from proteinuric diabetic nephropathy with Kimmelstiel-Wilson lesions as the underlying pathology, but reduced glomerular filtration rate in the absence of albuminuria/proteinuria is recognized in an increasing proportion of type 2 diabetic patients. Of particular interest is the recent recognition of vascular lesions in the brain and retina as predictors of nonproteinuric nephropathy with reduced GFR; although currently unproven, such lesions may also be of potential relevance for target blood pressure. Because of the high prevalence of type 2 diabetes in the population, coexisting primary kidney disease and diabetic nephropathy occur in a sizable proportion of type 2 diabetic patients with ESRD. The optimal point to start treatment differs according to target organs. There is no doubt that in proteinuric diabetic patients the earlier the treatment (blood pressure lowering, renin-angiotensin system blockade) is started, the greater is the benefit--at least in patients with proteinuric disease and no major cardiovascular damage. In our opinion, there is no one target blood pressure that fits all patients. Survival of patients with diabetic nephropathy is to a large extent determined by cardiovascular comorbidity. It is currently a matter of debate whether the current definition of type 2 diabetes is appropriate. Some recent findings suggest that minor renal hemodynamic and morphological changes are seen even in (prediabetic) patients who fail to meet the current definition of type 2 diabetes.

Urinary collagen fragments are significantly altered in diabetes: a link to pathophysiology

Background

The pathogenesis of diabetes mellitus (DM) is variable, comprising different inflammatory and immune responses. Proteome analysis holds the promise of delivering insight into the pathophysiological changes associated with diabetes. Recently, we identified and validated urinary proteomics biomarkers for diabetes. Based on these initial findings, we aimed to further validate urinary proteomics biomarkers specific for diabetes in general, and particularity associated with either type 1 (T1D) or type 2 diabetes (T2D).

Methodology/Principal Findings

Therefore, the low-molecular-weight urinary proteome of 902 subjects from 10 different centers, 315 controls and 587 patients with T1D (n = 299) or T2D (n = 288), was analyzed using capillary-electrophoresis mass-spectrometry. The 261 urinary biomarkers (100 were sequenced) previously discovered in 205 subjects were validated in an additional 697 subjects to distinguish DM subjects (n = 382) from control subjects (n = 315) with 94% (95% CI: 92–95) accuracy in this study. To identify biomarkers that differentiate T1D from T2D, a subset of normoalbuminuric patients with T1D (n = 68) and T2D (n = 42) was employed, enabling identification of 131 biomarker candidates (40 were sequenced) differentially regulated between T1D and T2D. These biomarkers distinguished T1D from T2D in an independent validation set of normoalbuminuric patients (n = 108) with 88% (95% CI: 81–94%) accuracy, and in patients with impaired renal function (n = 369) with 85% (95% CI: 81–88%) accuracy. Specific collagen fragments were associated with diabetes and type of diabetes indicating changes in collagen turnover and extracellular matrix as one hallmark of the molecular pathophysiology of diabetes. Additional biomarkers including inflammatory processes and pro-thrombotic alterations were observed.

Conclusions/Significance

These findings, based on the largest proteomic study performed to date on subjects with DM, validate the previously described biomarkers for DM, and pinpoint differences in the urinary proteome of T1D and T2D, indicating significant differences in extracellular matrix remodeling.

Cyclosporine A or intravenous cyclophosphamide for lupus nephritis: the Cyclofa-Lune study

Intravenous cyclophosphamide is considered to be the standard of care for the treatment of proliferative lupus nephritis. However, its use is limited by potentially severe toxic effects. Cyclosporine A has been suggested to be an efficient and safe treatment alternative to cyclophosphamide. Forty patients with clinically active proliferative lupus nephritis were randomly assigned to one of two sequential induction and maintenance treatment regimens based either on cyclophosphamide or Cyclosporine A. The primary outcomes were remission (defined as normal urinary sediment, proteinuria <0.3 g/24 h, and stable s-creatinine) and response to therapy (defined as stable s-creatinine, 50% reduction in proteinuria, and either normalization of urinary sediment or significant improvement in C3) at the end of induction and maintenance phase. Secondary outcomes were incidence of adverse events, and relapse-free survival. At the end of the induction phase, 24% of the 21 patients treated by cyclophosphamide achieved remission, and 52% achieved response, as compared with 26% and 43%, respectively of the 19 patients treated by the Cyclosporine A. At the end of the maintenance phase, 14% of patients in cyclophosphamide group, and 37% in Cyclosporine A group had remission, and 38% and 58% respectively response. Treatment with Cyclosporine A was associated with transient increase in blood pressure and reversible decrease in glomerular filtration rate. There was no significant difference in median relapse-free survival. In conclusion, Cyclosporine A was as effective as cyclophosphamide in the trial of sequential induction and maintenance treatment in patients with proliferative lupus nephritis and preserved renal function.(ClinicalTrials.gov identifier: NCT00976300)

Salmonella enterica serovar Typhimurium typing by prophage-specific PCR

Recent data from microarray analysis have shown that integrated prophages are the most frequent sources of genomic variation between different strains of Salmonella enterica serovar Typhimurium (S. Typhimurium). This led us to hypothesize that PCR detection of the integrated prophages might be an efficient typing tool that could be used as an alternative to PFGE. In this study, we optimized four triplex PCRs specific for 12 target sequences of mostly prophage origin, and tested them in 102 field strains. The same set of strains was also characterized by PFGE. Among the strains, 22 different multiplex PCR, and 25 different PFGE profiles, were identified. Despite the fact that the PFGE was slightly more discriminatory, multiplex PCR typing, owing to its simplicity and potential of simple data sharing between laboratories, represents an interesting user-friendly alternative to PFGE typing of S. Typhimurium.

[Epidemiology of diabetic nephropathy]

The epidemiology of diabetic nephropathy (DN) should be approached from two angles: a) incidence of diabetic nephropathy in patients with diabetes, and b) epidemiology of chronic renal failure (CHRF) in diabetic patients. According to data from different sources, DN affects, in all its stages, about one third of patients irrespective of the type of diabetes they suffer from, with the peak rate of incidence after 15 years of duration of the illness. It is estimated that the rate of DN prevalence is 4-8% of patients monitored in diabetes centres. In addition, a significant portion of diabetics, especially the type 2 diabetic patients, are affected by the non-diabetic type nephropathy of primarily atherosclerotic etiology. Currently, DN is the principal cause of CHRF in advanced industrial countries (Western Europe, USA,Japan). A similar trend has been recorded in the Czech Republic which has one of the highest incidences of DN among the former Eastern Block countries. Most affected patients are type 2 diabetes patients. The cause of the above increase is the growing prevalence and incidence of type 2 diabetes, and, primarily, better care for type 2 diabetes patients who live long enough to develop severe macro and microvascular complications including DN. The principal factors influencing the risk of a diabetic patient developing DN are long-term monitoring ofglycaemia, control of hypertension, genetic (ethnic) factors, age and sex. Metabolic control has an effect on the risk of diabetic nephropathy developing in type 1 and 2 diabetes, yet it is blood pressure control which is critical for the progression of chronic renal insufficiency in DN patients. In view of the high number of diabetic patients with CHRF which, in addition, associates with their high polymorbidity and extensive demands put on medical and nursing care which is not directly associated with CHRF therapy, we have to do with a serious medical and economic problem.

An unusual cause of renal amyloidosis secondary to gout: the first description of familial occurrence

BACKGROUND

AA amyloidosis caused by the chronic inflammation accompanying gouty arthritis is extremely rare and familial occurrence has not been described so far.

CASE REPORT

We present the case of two brothers (47 and 44 years old) with 7- and 10-year history of hyperuricaemia and chronic tophaceous gout with polyarticular involvement. The enzymatic assay performed in their erythrocytes proved the partial hypoxanthine-guanine phosphoribosyl transferase deficiency (Kelley-Seegmiller syndrome), the genetic defect of purine metabolism. Later on they developed proteinuria and chronic renal insufficiency /CRI/. Renal biopsy disclosed the combination of AA amyloidosis and gouty nephropathy in both the cases. Despite the standard treatment the older brother progressed to chronic renal failure. On the contrary, the younger one being longterm treated with oral colchicin have stabilized CRI.

CONCLUSIONS

Only several cases of AA renal amyloidosis until recently, secondary to gout have been reported. Our case represents the first report of familial occurrence of this extremely rare disease.

Cloning, biochemical properties, and distribution of mycobacterial haloalkane dehalogenases

Haloalkane dehalogenases are enzymes that catalyze the cleavage of the carbon-halogen bond by a hydrolytic mechanism. Genomes of Mycobacterium tuberculosis and M. bovis contain at least two open reading frames coding for the polypeptides showing a high sequence similarity with biochemically characterized haloalkane dehalogenases. We describe here the cloning of the haloalkane dehalogenase genes dmbA and dmbB from M. bovis 5033/66 and demonstrate the dehalogenase activity of their translation products. Both of these genes are widely distributed among species of the M. tuberculosis complex, including M. bovis, M. bovis BCG, M. africanum, M. caprae, M. microti, and M. pinnipedii, as shown by the PCR screening of 48 isolates from various hosts. DmbA and DmbB proteins were heterologously expressed in Escherichia coli and purified to homogeneity. The DmbB protein had to be expressed in a fusion with thioredoxin to obtain a soluble protein sample. The temperature optimum of DmbA and DmbB proteins determined with 1,2-dibromoethane is 45 degrees C. The melting temperature assessed by circular dichroism spectroscopy of DmbA is 47 degrees C and DmbB is 57 degrees C. The pH optimum of DmbA depends on composition of a buffer with maximal activity at 9.0. DmbB had a single pH optimum at pH 6.5. Mycobacteria are currently the only genus known to carry more than one haloalkane dehalogenase gene, although putative haloalkane dehalogenases can be inferred in more then 20 different bacterial species by comparative genomics. The evolution and distribution of haloalkane dehalogenases among mycobacteria is discussed.

Cystatin C as a Marker of Residual Renal Function during Continuous Hemodiafiltration

BACKGROUND

The level of residual renal function (RRF) has an important impact on follow-up in critically ill patients with renal failure. There is currently no clear marker of RRF.

METHODS

Cystatin C (cysC) concentrations were measured before and during the first 48 h of CVVHDF in 33 mechanically ventilated patients suffering from renal failure. Samples were drawn both from the ports proximal and distal to the filter. Each of the two control groups consisted of 10 patients.

RESULTS

The levels of cysC were significantly higher in the group where diuresis (Vu) remained low or decreased after 48 h of treatment (n = 21, Vu median 380 (80-935) ml/24 h, cysC range 4.44-3.42 mg/l) than in the group where Vu increased to the level of 1.5 ml.kg(-1).h(-1) or higher after 48 h of treatment (n = 12, Vu 4,570 (4,000-5,130) ml/24 h, cysC 3.17-2.46 mg/l, p < 0.01). Creatinine clearance taken before treatment was not different between the groups. Significant correlation between cysC levels and Vu was found (r = -0.44, p < 0.0001). CysC levels were significantly higher in non-survivors than in survivors (3.54 +/- 1.38 vs. 3.07 +/- 1.24, p < 0.03).

CONCLUSION

The levels of cysC are inversely related to Vu. High levels of cysC are associated with low residual diuresis, longer duration of CVVHDF and higher intensive care unit mortality in patients treated with CVVHDF.