Clinical features and outcomes in patient with antineutrophil cytoplasmic autoantibody-positive glomerulonephritis associated with propylthiouracil treatment in Siriraj Hospital

BACKGROUND

ANCA is detected in several vasculitic diseases, including drug-induced systemic vasculitis: propylthiouracil (PTU), hydralazine, minocycline, penicillamine, allopurinol, procainamide, carbimazole, thiamazole, clozapine and phenytoin. All have been known to induce ANCA positive vasculitis in adult patients.

OBJECTIVE

To study the clinical manifestation, renal pathology and outcome of patients with ANCA positive vasculitis associated with propylthiouracil treatment in Siriraj Hospital.

MATERIAL AND METHOD

Retrospective study in 7patients with Graves' disease who were treated with propylthiouracil and developed ANCA-positive glomerulonephritis between 2000-2008.

RESULTS

Seven cases with Graves' disease who received propylthiouracil whose ages were 43 +/- 14 years. The duration of propylthiouracil treatment was 68.5 +/- 39 months and the doses were 50-150 mg per day. Six cases had P-ANCA and one case had C-ANCA in the serum. Proteinuria ranged from 0.49-2.9 gram per day. Mean serum creatinine was 2.05 mg/dl with creatinine clearance of 44 +/- 35 ml/min. The propylthiouracil was withdrawn in every patient and corticosteroid was administered. Renal remission was found until 1 year of follow-up.

CONCLUSION

ANCA positive glomerulonephritis associated with propylthiouracil is not uncommon. The average onset of glomerulonephritis is 2 years or more. The propylthiouracil dosage was not necessary high. Urinalysis and other glomerulonephritis symptoms should be screened for early diagnosis and appropriate treatment in patients treated with PTU.

Malnutrition-inflammation score associated with atherosclerosis, inflammation and short-term outcome in hemodialysis patients

BACKGROUND

Malnutrition-Inflammation Score (MIS) has been proposed as a new quantitative system for assessment of malnutrition and inflammation, which are common important risk factors for increased morbidity and mortality in maintenance hemodialysis (MHD) patients.

OBJECTIVE

To determine the MIS and related it to the presence of atherosclerosis, and the morbidity and mortality rate.

MATERIAL AND METHOD

The inflammatory and nutritional status in 100 MHD patients was evaluated by serum high-sensitivity C-reactive protein (hs-CRP), Subjective Global Assessment (SGA), and MIS. Atherosclerosis was defined by a history of cardiovascular disease or presence of carotid plaque by B-mode ultrasonography. Twelve-month prospective hospitalization and mortality rates were recorded.

RESULTS

The MIS score was significantly higher in patients with atherosclerosis (5.5 +/- 2.3 vs. 3.0 +/- 1.7, p = 0.003) and modestly correlated with serum ferritin level (r = 0.304, p = 0.03), but did not correlated with hs-CRP. The SGA was not associated with hs-CRP level and atherosclerosis. Over a 12-month follow-up period, 4 patients died and 28 were hospitalized at least once. Compared to the survivor group, MIS in the deceased group was significantly higher (8.0 +/- 1.4 vs. 5.1 +/- 2.3, p = 0.01) while SGA, hs-CRP and other biochemical markers were not significantly different. The Receiver Operating Characteristics Curves for the prediction of 1-year mortality from the MIS score identified the optimal cut-off value of 7.5 with sensitivity of 75% and specificity of 88%. There was no association between MIS or SGA and hospitalization.

CONCLUSION

MIS is a useful tool for the assessment of malnutrition and inflammatory status. It is superior to the conventional SGA as a predictor of short-term outcome in MHD patients.

Efficacy of intradermal hepatitis B vaccination compared to intramuscular vaccination in hemodialysis patients

BACKGROUND

Hepatitis B virus infection remains an important problem in hemodialysis patients. Only 50 to 60% of the patients develop seroconversion (anti-HBs Ab titer > 10 IU/L) after intramuscular hepatitis B vaccination. Small dose intradermal inoculation method of hepatitis B vaccine has been reported to be effective as well as economical, and could provide rapid seroconvesion of immunity. The aim of the present study was to compare the efficacy of intradermal hepatitis B vaccination with intramuscular vaccination in hemodialysis patients.

MATERIAL AND METHOD

Fifty one hemodialysis patients were randomly assigned to two groups, 25 patients received a total 7 doses of 10 mmicrog of recombinant hepatitis B vaccine (Engerix B) intradermally every 2 weeks (ID group), whereas 26 patients received 40 microg intramuscularly at 0, 1, 2 and 6 months (IM group). Anti-HBs Ab titer was measured at 2, 3, 4 and 7 months after the first vaccination in both groups. Vaccination responses were classified into 3 subgroups according to anti-HBs Ab titer and these included excellent response (> 1,000 IU/L), good response (10-999 IU/L) and non-response (< 10 IU/L).

RESULTS

The seroconversion rates at 2, 3, 4, and 7 months in the ID group were 56%, 76%, 88%, and 92% compared with 31%, 42%, 65%, and 69% in the IM group, respectively. Only the seroconversion rates at 3 months were significantly higher in the ID group (76% versus 42%, p = 0.03). At 7 months after the first vaccination, good and excellent responders in the ID group were 72% (18/25) and 20% (5/25) compared with 34.5% (9/26) and 34.5% (9/26), respectively (p > 0.05). Only minor side effects were observed.

CONCLUSION

Seven doses of 10 mg intradermal vaccination induced a high seroconversion rate and were comparable with intramuscular regimen. Intradermal vaccination may be helpful for the rapid induction of protective level of antibodies and may be a cost-saving alternative to intramuscular vaccination in hemodilaysis patients.

The relationship between serum concentration of cardiac troponin I in chronic renal failure patients and cardiovascular events

OBJECTIVE

The purpose of this study was to evaluate the relationship between serum cardiac troponin I in asymptomatic chronic renal failure patients and cardiovascular events.

BACKGROUND

Short-term follow-up studies on this subject produced conflicting results.

MATERIAL AND METHOD

A total of 63 asymptomatic patients with chronic renal failure (CRF) with regular hemodialysis were followed for 18 months for cardiac mortality, myocardial infarction events and interventional procedures such as percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG). Serum cTnI and other blood chemistries were measured at the time of the study.

RESULTS

Forty seven chronic dialysis patients (75%) had an elevated level of cTnI concentration more than the 0.08 ng/ml cutoff but only fourteen patients (22%) had and elevated cTnI concentration of more than the AMI cutoff (0.4ng/ml). When using the 0.08 ng/ml cutoff, the NT-proBNP concentrations of the elevated groups were significantly higher than the normal groups. The authors also found that the elevated groups above the AMI cutoff had significantly higher cardiovascular events.

CONCLUSION

Elevated cTnI concentrations are commonly found in chronic renal failure patients. The AMI cutoff level of cTnI (0.4 ng/ml) seem to have a benefit for predicting the cardiovascular events in asymptomatic chronic renal failure patients while the 0.08 ng/ml cutoff doesn't have usefulness for this purpose. Further studies are needed to clarify this hypothesis.

Relationship between hyperhomocysteinemia and atherosclerosis in chronic hemodialysis patients

BACKGROUND

Hyperhomocysteinemia is an independent risk factor of coronary artery heart disease (CAHD) and atherosclerosis in a normal population. However, it is still controversial in end-stage kidney disease patients who underwent long-term dialysis. Carotid intima-media thickness (IMT) is the standard non-invasive measurement of atherosclerosis. The aims of the present study were to determine the homocysteine (Hcy) level, and to evaluate its role as a risk factor of atherosclerosis in hemodialysis (HD) patients.

MATERIAL AND METHOD

Clinical data and blood chemistries were assayed in 62 HD patients. Atherosclerosis was defined by clinical presentations of CAHD, cerebrovascular or peripheral vascular diseases, or carotid plaque by ultrasound. IMT was also measured by ultrasound

RESULTS

Plasma Hcy level in HD patients was significantly higher in HD patients than normal controls (28.3 +/- 8.3 vs 9.7 +/- 2.9 micromol/l, p < 0.001). Older age (p < 0.001), male sex (p = 0.05), longer duration of HD (p = 0.05), and higher plasma Hcy level (p = 0.01) correlated with atherosclerosis by univariate analysis, but plasma Hcy did not show significant correlation by multivariable analysis. There was also correlation between IMT and atherosclerosis in HD patients (p < 0.001) but no correlation was observed between plasma Hcy level and lMT.

CONCLUSION

Hyperhomocysteinemia is not an independent factor in the genesis of atherosclerosis in HD patients. Advanced age plays a major role of hyperhomocysteinemia and IMT is a useful marker of atherosclerosis in these patients.

Effect of fish oil on oxidative stress, lipid profile and renal function in IgA nephropathy

The omega-3 polyunsaturated fatty acids in fish oil have been shown to produce beneficial effects, such as a reduction in blood pressure, proteinuria, lipid levels and inflammation. Aggregated immunoglobulin A obtained from IgA nephropathy patients induced greater oxygen free radicals in polymorphonuclear leukocytes than other glomerulopathy. All of which may affect the course of IgA nephropathy. Twenty-three adult patients with biopsy proven IgA nephropathy, with proteinuria more than 1 g/day, serum creatinine less than 3 mg/dl and blood pressure control less than 130/80 mmHg were given omega-3 polyunsaturated fatty acids (PUFA) in the form of an Omacor capsule 4 g/day equivalent to eicosapentaenoic acid (EPA) 1.88 g and docosahexaenoic acid (DHA) 1.48 g for 6 months. A 3 to 6 month follow-up was planned, with monthly evaluations of the patients. By six months, the serum triglyceride was significantly reduced (143.45 +/- 62.65 vs 91 +/- 42.89 mg/dl, p = 0.002), serum cholesterol was also reduced but not statistically significant (234.16 +/- 56.29 vs 219.76 +/- 51.25 mg/dl, p = 0.07). There was a trend of increased serum high density lipoprotein (HDL)-cholesterol (39.26 +/- 10.56 vs 42.72 +/- 8.37 mg/dl, p = 0.056). Urine beta-2-microglobulin was elevated in IgA patients and decreased statistically significant after 3 months (453 +/- 580 vs 308 +/- 274 microg/24 h, p < 0.001) and 6 months of fish oil therapy (453 +/- 580 vs 142 +/- 182, p < 0.03) while urine N-acetyl-glucosaminidase (NAG) was of no significant difference both before and after fish oil administration (21 +/- 10 vs 22 +/- 10 and 21 +/- 9 U/24 h, p = 0.08). Plasma malondialdehyde (MDA), the end product of oxidative stress was statistically, significantly decreased (1.09 +/- 0.51 vs 0.89 +/- 0.49 nmol/L, p = 0.003). The study did not show any change in blood pressure, proteinuria, or serum creatinine. The authors conclude from the results of this study that patients with idiopathic IgA nephropathy with proteinuria and mildly reduced GFR did not benefit from short-term treatment with 4 g per day of omega-3 PUFA regarding the total protein excretion and glomerular filtration rate (GFR), but the advantage was the improvement in tubular dysfunction, lipid profiles, and oxidative stress.

Circulating N-terminal pro-brain natriuretic peptide and cardiac troponin T in chronic dialysis patients

In the general population, plasma concentrations of cardiac troponin T (cTnT) and N-terminal pro-brain natriuretic peptides (NT-proBNP) are useful as markers of cardiac ischemia and heart failure respectively. Whether these cardiac markers have similar diagnostic potential in chronic dialysis patients are not known. The authors studied the diagnostic value of cTnT and NT-proBNP correlated with the clinical status of 63 chronic renal failure (CRF) patients with chronic dialysis (30 males and 33 females), aged 26 to 77 years (mean +/- SD, 55.9 +/- 12.6 years). Plasma cTnT and NT-proBNP were determined by using Elecsys 2010 (Roche, Switzerland). The authors found that 23.8 per cent of the chronic dialysis patients had cTnT concentrations more than the cut-off (> or = 0.1 ng/ml) and 100 per cent of these patients had NT-proBNP concentrations over the cut-off (> 334 pg/ml). The authors could not demonstrate the statistical difference between males and females for NT-proBNP concentrations as reported in the general population. But cTnT concentrations in females were significantly less than males. The authors also found a weak correlation between the two markers, when the circulating cTnT was correlated with NT-proBNP. These results suggested that plasma cTnT in chronic dialysis patients should be a prognostic marker for cardiac ischemia by using the same cut-off as the normal population. However, plasma NT-proBNP concentrations could not be used as a heart failure marker in this group of patients and needed another cut-off value for specific use in chronic dialysis patients. Moreover, the combination of cTnT and NT-proBNP concentrations in these patients may be another choice for detection of both cardiac ischemia and heart failure in the same situation. These combination markers should improve mortality in chronic dialysis patients.

The renin--angiotensin system gene polymorphisms and clinicopathological correlations in IgA nephropathy

Genetic variability in the renin-angiotensin system (RAS) may modify renal responses to injury and disease progression. We examined whether RAS alleles affect severity of IgA nephropathy. These genetic variants include angiotensin I converting enzyme deletion polymorphism in intron 16 (ACE I/D), a point mutation in the angiotensinogen (AGT) gene resulting in a methionine to threonine substitution at residue 235 (M235T) and an angiotensin receptor type I (ATR) A to C transition at bp 1166 (A 1166 C). A total of 53 patients with biopsy-proven IgA nephropathy and 80 normal control subjects were recruited for study. These patients were classified into two groups according to serum creatinine at renal biopsy. Group 1 patients (n = 40) had normal renal function, serum creatinine < or = 1.5 mg/dl and group 2 patients (n = 13) had renal insufficiency with serum creatinine > 1.5 mg/dl. The blood pressure and urinary protein of group 2 patients were higher than group 1 (p < 0.01). The mean scores of histological parameters including mesangial proliferation, glomerular sclerosis (global and segmental), the interstitial fibrosis and crescent formation in group 2 patients were significantly higher than in group 1 patients (p < 0.05). The most frequent genotype in IgA patients was ID (47%) genotype, followed by II (45%) and DD (8%) genotype of ACE gene. The mean serum ACE activity in the DD group was significantly higher than in the II group (p < 0.05) but was not significantly different from that of the ID group. No statistically significant differences were found with respect to allele frequencies between IgA group 1, group 2, or between controls and all IgA patients. Furthermore, no significant difference in AGT alleles, ATR alleles frequencies was detected between groups of IgA patients, although a trend for a higher frequency of DD genotype and AGT-TT genotype were noted in IgA group 2. The combined analysis of the ACE-DD and AGT-TT genotypes did not show any genetic influence on the risk of the disease susceptibility. To resolve the true role of ACE genotype and any dependent effect on progression, larger collaborative studies are required.

Lipoproteins and lipid peroxidation abnormalities in patients with chronic renal disease

Increasing experimental and clinical evidence suggests that lipoproteins and lipid peroxidation can be important modulators in progressive kidney disease. A group of 54 patients with varying degrees of kidney impairment was studied to find the abnormalities in lipoproteins and lipid peroxidation. Lipoproteins and lipid peroxidation products, malondialdehyde (MDA) were measured in the plasma of 54 chronic renal disease patients CGN 33, nephrosclerosis 11, 7CTIN, 1PCKD, unknown 2 and compared with values obtained from 32 healthy controls. The patients were divided into 5 groups according to serum creatinine levels: Group 1 (serum creatinine of 2 mg/dl), group 2 (S. creatinine > 2-4 mg/dl), group 3 (S. creatinine > 4-8 mg/ dl), group 4 (S. creatinine > 8-12 mg/dl), group 5 (S. creatinine > 12 mg/dl). Plasma cholesterol was higher significantly than controls in patients with group 1, 2 and 3 (p < 0.01, < 0.001, < 0.05) respectively while plasma LDL-chol was statistically significantly different from controls only in group 2 patients (p < 0.001). Plasma VLDL-chol, beta-VLDL-chol, triglycerides, ratio of chol/HDL and LDL/ HDL showed high levels in all groups compared with controls but more evident in patients of group 2. Plasma HDL-chol decreased during the progression of renal failure. All groups had significantly elevated plasma malonyldialdehyde (MDA) vs controls (p < 0.001), especially highest value was found in group 2. Triglycerides, beta-VLDL chol, VLDL-chol LDL/HDL, chol/HDL correlated very closely with plasma MDA levels and also with serum creatinine. Patients with chronic renal disease showed lipoprotein abnormalities and accelerated lipid peroxidation. The evidence was more marked in patients with normal to mild renal insufficiency which suggested the role of oxidative stress early in the course of nephron injury.

Analysis of serum urinary proteins in normal and renal diseases by cellulose acetate electrophoresis

A method using dried polyacrylamide gel to concentrate urine samples has been described, tested and used for the purpose of urine protein analysis. Concentrated urine samples from 10 normals and 100 patients with IgM nephropathy and systemic lupus erythematosus (SLE) were analysed by cellulose acetate electrophoresis (CAE). The results demonstrated that the patterns of proteins in the electrophoresis could be used to discriminate the two diseases. The best discriminating power was found in the logarithm of gamma globulin to albumin ratio. In IgM nephropathy the ratio of gamma globulin to albumin is much smaller than the ratio in SLE, indicating that relatively larger gamma globulins were excreted in SLE. In addition, the ratio can be used to discriminate subgroups of patients with IgM nephropathy. Urine from patients with IgM nephropathy with focal and segmental changes showed a significantly higher ratio. The study indicated the usefulness of the technique in discriminating the two common glomerular diseases.