Low Free Triiodothyronine as a More Sensitive Predictor of Survival Than Total Testosterone among Dialysis Men

BACKGROUND

Some endocrine disorders, previously considered benign, may be related to a poorer prognosis for patients with renal failure. Both low serum free triiodothyronine (fT3) and low total testosterone (TT) concentrations have been considered as predictors of death in dialysis patients, but the results of studies are inconsistent. In our study, we evaluated the relationships of the serum thyroid hormone levels and the total testosterone levels with survival in male dialysis patients.

METHODS

Forty-eight male dialysis patients, 31 on hemodialysis (HD) and 17 on peritoneal dialysis (PD), aged 61.4 ± 10.0, 59.2 ± 12.2 years, respectively, were included in the study. Serum thyroid hormones and total testosterone were measured.

RESULTS

During the 12-month follow-up, nine all-cause deaths were recorded. The concentrations of fT3 were significantly lower in those who died than in the survivors (p = 0.001). We did not observe any statistically considerable differences between the group of men who died and the rest of the participants in terms of the total serum testosterone concentration (p = 0.350). Total testosterone positively correlated with fT3 (r = 0.463, p = 0.009) in the HD group.

CONCLUSIONS

In the group of male dialysis patients, the serum concentration of fT3 had a better prognostic value in terms of survival than the total testosterone. A linear relationship between the fT3 levels and testosterone levels in men undergoing hemodialysis may confirm the hypothesis that some of the hormonal changes observed in chronic kidney disease (CKD) may have a common cause.

[Diagnostic difficulties of IgG4-related disease - a case report]

IgG4-related disease belongs to the group of immune-mediated diseases. It is a relatively new condition, classified in 2003. It is characterized by involvement of multiple organs, over time causing organ failure. The observed radiological changes are slow growing. As a rule, the course of the disease is subclinical, which means that the diagnosis is often made incidentally, retrospectively and many years after the onset of symptoms. In the initial stage of diagnosis, it is often confused with Sjögren's syndrome, systemic vasculitis, or neoplastic disorders.

A CASE REPORT

We report the case of a female patient who was diagnosed with glomerulonephritis at the age of 34. The patient was qualified for renal replacement therapy with chronic hemodialyses in 2020 due to end-stage renal disease. In the same year, the patient was hospitalized for pneumonia of unknown etiology. After discharge from the hospital, the patient developed fever up to 39oC, chills, and pleural fluid. A suspicion of systemic disease was raised. Computed tomography of the chest showed enlargement of the anterior and middle mediastinum with increased densitization of adipose tissue and enlargement of mediastinal lymph nodes. Antibiotic therapy was introduced, followed by systemic corticosteroids, resulting in clinical improvement and remission of infiltrative lesions in radiological studies. The differential diagnosis excluded neoplastic lesions of the left lung, systemic connective tissue diseases, e.g. systemic lupus erythematosus and systemic vasculitis. Taking into account the whole clinical picture the suspicion of IgG4-related disease was raised. After the treatment, serum IgG4 level was found to be normal at 36.6 mg/ dl, anti-nuclear antibodies (ANA) were negative, rheumatoid factor was not elevated, complement component 4 (C4) was normal, complement component 3 (C3) decreased to 71 mg/dl (n: 90-180 mg/dl). Treatment with prednisone 10 mg/day was maintained. Histopathologic reanalysis of the renal biopsy (from a biopsy performed in 2012) was performed, which showed lymphocytic infiltration in the renal interstitium with segmental vascular loop sclerosis in the glomeruli and the presence of abundant granular IgG4 deposits in the glomerular mesangium by immunofluorescence.

CONCLUSIONS

IgG4-related disease poses great diagnostic difficulty due to its non-specific and long-term course. Patients usually seek help with various specialists many years before the full picture of the disease is presented. It is poorly understood as it is a recently described condition (two decades ago). The classification criteria of IgG4 disease developed in 2019, the growing number of publications and recommendations being developed give hope for better understanding and more efficient diagnosis of the disease.

Noninfectious, Severe Cryoglobulinemic Vasculitis with Renal Involvement - Safety and Efficacy of Long-Term Treatment with Rituximab

Background

The management of nonviral cryoglobulinemic vasculitis (CV) has not been established yet. Randomized control trials are challenging to perform because of the rarity of the disease. The most promising biological therapy is rituximab (RTX), an anti-CD 20 monoclonal antibody. The aim of the study was to assess rituximab treatment's safety and effectiveness in patients with severe noninfectious cryoglobulinemic vasculitis.

Materials and Methods

We retrospectively reviewed 8 courses of RTX treatment in three patients with severe noninfectious CV. In 2 patients, the indication for the start of RTX therapy was the relapse of the disease despite the maintenance treatment, for the third patient, it was the first-line therapy.

Results

Clinical, renal, and immunologic efficacy was observed in all evaluable RTX courses. We found a significant decrease of cryoglobulins in the 3-rd month from RTX treatment. However, 5 clinical relapses occurred and two patients experienced severe adverse events (SAEs) after RTX therapy. Patients with SAEs were relatively older and had a longer duration of disease. Lower levels of hemoglobin, C3 component of complement and eGFR as well as higher rheumatoid factor (RF) concentration were observed before RTX treatments complicated with SAEs.

Conclusion

Data from our observation show the efficacy of rituximab in the refractory, nonviral cryoglobulinemic vasculitis with a severe course of the disease. However, the therapy is associated with the risk of SAEs, especially in elderly patients with kidney failure and significant immunologic alterations.

Application of the Molecular Adsorbent Recirculating System in Type 1 Hepatorenal Syndrome in the Course of Alcohol-Related Acute on Chronic Liver Failure

BACKGROUND This study aimed to evaluate the Molecular Adsorbent Recirculating System (MARS) effectiveness in patients with alcohol-related acute-on-chronic liver failure (AoCLF) complicated with type 1 hepatorenal syndrome (HRS). So far, MARS efficacy and safety has been demonstrated in various acute liver failure scenarios. MATERIAL AND METHODS Data from 41 MARS procedures (10 patients with type 1 HRS, in the course of alcohol-related AoCLF were considered for this study. Biochemical tests of blood serum were performed before and after each procedure. The condition of patients was determined before and after the treatment with the use of the model for end-stage liver disease - sodium (MELD-Na) and the stage of encephalopathy severity based on the West Haven criteria. RESULTS During the observation period (20.5±13.9 days), 5 patients died, and the remaining 5 surviving patients were discharged from the hospital. In the group of 10, the 14-day survival, starting from the first MARS treatment, was 90%. The MARS procedure was associated with a 19% reduction in bilirubin (27.5±6.1 versus 22.3±4.0 mg/dL, P<0.001), 37% reduction in ammonia (44.1±22.5 versus 27.6±20.9 P<0.001), 27% reduction in creatinine (1.5±1.0 versus 1.1±0.6 mg/dL, P<0.001) and 14% reduction urea (83.8±36.1 versus 72.1±33.3, P<0.001) in blood serum samples, with stable hemodynamic parameters. In the group of patients discharged from the clinic (n=5), the MARS treatments resulted in an improvement in hepatic encephalopathy (West Haven; P=0.043), as well as a reduction in the MELD-Na score (P=0.015). CONCLUSIONS MARS is a hemodynamically safe method for supporting the function of the liver and the kidneys. Application of the MARS reduces the symptoms of encephalopathy in patients with alcohol-related type 1 HRS.

The incidence of, and relationship between, distal limb and facial asymmetry, and performance in the event horse

Identification of influential conformational traits is an important aspect in choosing the most appropriate horse for a specific discipline with regards to both performance potential and career longevity. Symmetry of bilateral traits, both functional and non-functional, demonstrates the ability of an individual to display their genotypic quality through their phenotype. External trait symmetry has been linked to effective functioning and health of a number of internal organ systems. The identification of a relationship between bilateral trait symmetry and performance in the equine athlete could highlight important conformational indicators of potential future performance. Using Invicta metric callipers and a tape measure, direct measurements of 15 bilateral traits, functional (limb) and non-functional (facial), were obtained from 18 advanced event horses (AdE) and 15 event horses proven incapable of reaching advanced level (NIE). Tests of difference were performed to determine differences in asymmetry between the two populations for individual traits and for identification of the mean total asymmetry (MTA) of the two populations. The AdE group demonstrated statistically lower asymmetry for a number of functional (metacarpal length and width, P≤0.05; fore proximal phalanx length, P≤0.05) and non-functional (nostril length, P≤0.001; pinna length, P≤0.05) traits. Furthermore, the AdE group demonstrated significantly lower MTA (P≤0.001) than the NIE. Where significance was not identified, all but one functional trait still demonstrated a trend for lower asymmetry in the AdE group. From the results, it is suggested that asymmetry levels have future potential to be used as an indicator of performance potential. The size of the mean asymmetry values being considered, further imply that the differences between the performance of the two groups cannot be as a result of limb biomechanics alone and that other more intricate biological disruptions, for example neurological development, may also be reflected by the trait asymmetries.

[Acute renal failure in the course of renal-ocular syndrome]

Acute tubulointerstitial nephritis with uveitis is described as TINU syndrome. This syndrome, known as a renal-ocular disease, is a rare problem. Until now there have been described 200 cases of TINU all over the world. The most frequent morbidity concerns girls and young women although it may occur at any age. Etiology of this syndrom is unknown. Diagnosis is often difficult as in approximately 65% of cases, ocular symptoms occur later than tubulointerstitial nephritis. General symptoms (fever, weight loss, weakening, fatigue) are frequently nonspecific. There are no randomized studies dealing with treatment of TINU syndrome. Glucocoticosteroids and immunosuppressive drugs are mainly administered. The prospects are generally good, particularly among young children. However, in some patients chronic renal failure develops. Uveitis is treated locally with steroids. The prospects are good as well but inflammation process returns. A study of TINU syndrome has a general purpose of reminding of this disease which is often forgotten by doctors and the problems connected with diagnostics and treatment.

[Acute renal injury in the course of renal-ocular syndrome - case report]

Renal-ocular syndrome is a rare cause of tubulointerstitial renal diseases. A case of 52 years old woman with acute renal injury in the course of acute tubulointerstitial nephritis and uveitis (TINU syndrome) is presented. For diagnosis of kidney disease a kidney biopsy and renal tubular function tests were used. Progression of the renal disease was the cause of the general intensive steroid treatment inclusion. In a short time after treatment initiation, a significant improvement of renal function was observed. Until the time of handing over the article (5 months), no relapse of the disease was noticed. The aim of the study was to present the case of TINU, which is a rarely recognized syndrome as a cause of acute kidney injury and to describe a treatment method.