Outcomes of transperineal and transrectal ultrasound-guided prostate biopsy

OBJECTIVE

To compare the clinical outcomes and pathological findings of transperineal ultrasound-guided prostate biopsy (TPUSPB) and transrectal ultrasound-guided prostate biopsy (TRUSPB) in a secondary referral hospital.

METHODS

This was a retrospective study of 100 TPUSPBs and 100 TRUSPBs performed in our centre. Pre-biopsy patient parameters (eg, patient age, clinical staging, serum prostate-specific antigen [PSA] level, prostate size, and PSA density), as well as pathological results and 30-day complication and readmission rates, were retrieved from the patients' medical records and compared between the two groups.

RESULTS

One hundred TPUSPBs performed from January 2018 to May 2018 and 100 TRUSPBs performed from January 2016 to April 2016 were included for analysis. Mean age did not significantly differ between the groups. The TPUSPB group had a higher mean PSA level, smaller prostate size, and higher PSA density, compared with the TRUSPB group. The overall prostate cancer detection rate was similar between the TPUSPB and TRUSPB groups (35% vs 25%, P=0.123). There were no significant differences between the groups in prostate cancer detection rates after stratification according to PSA density and clinical staging. With respect to complications, no patients developed fever in the TPUSPB group, while 4% of patients in the TRUSPB group had fever and required at least 1-week admission for intravenous antibiotic administration.

CONCLUSION

For prostate biopsy, TPUSPB is safer, with no infection complications, and has similar prostate cancer detection rate compared with TRUSPB.

Role of C-reactive protein in the pathogenesis of acute kidney injury

Acute kidney injury (AKI) is characterized by both non-inflammatory and inflammatory process, and accumulating evidence has demonstrated that inflammation plays a key role in the pathogenesis and progression of AKI. C-reactive protein (CRP), an acute reactant produced by liver and many inflammatory cells, acts not only as an inflammation biomarker, but also as a pathogenic factor for AKI. Indeed, increased concentration of CRP is associated with poor outcome of varied etiologically related AKI patients. In recent years, the role of CRP is gradually recognized as an active participant in the pathogenesis and progression of AKI by exacerbating local inflammation, impairing the proliferation of damaged tubular epithelial cells and promoting fibrosis of injured renal tissue.

Outcome Evaluation of a Short-Term Hospitalization and Community Support Program for People Who Abuse Ketamine

Ketamine is a popular recreational drug among young people in Hong Kong. Long-term abuse of ketamine can lead to acute urological and medical issues, which often require immediate care at emergency rooms. Many patients require short-term hospitalization for medical management. This opens a brief time window, within which mental health professionals could engage young people who abuses ketamine in psychosocial, functional, and lifestyle interventions. The Crisis Accommodation Program (CAP) is a short-term hospitalization and community support program that addresses the health care needs of young people who abuse ketamine. During short-term hospitalization, the patient participates in a range of cognitive and psychosocial assessments, motivational interviewing, emotions management, and lifestyle re-design interventions. Upon discharge, social work professionals of non-government agencies continue to work with the patients on their action plans in the community. This evaluation study uses a quasi-experimental non-equivalent group design, in which the outcomes of the treatment group (n = 84) are compared with a comparison group (n = 34) who have a history of ketamine abuse but who have not joined the treatment program. The results confirm that the treatment group showed significant increases in motivation for treatment, reduction in drug use, improvement in cognitive screening tests, healthy lifestyle scores, and self-efficacy in avoidance of drugs over 13 weeks. When compared with the comparison group, the treatment group had significant decreases in anxiety and treatment needs and had moved from pre-contemplation to the contemplation or preparation stage. However, there were no significant changes in outcome measures covering lifestyle or self-efficacy in drug avoidance. Overall, the CAP is effective in reducing drug use, anxiety, and helping patients to move from pre-contemplation to the contemplation or preparation stage of change. The study results suggest that health care professionals can successfully engage young people who abuse ketamine to participate in a package of psychosocial interventions, motivational interviewing, and lifestyle re-design during their hospital stay for management of urological problems. The CAP also highlights the importance of collaboration between hospitals and community social services in the management of addiction.

Tetramethylpyrazine suppresses angiotensin II-induced soluble epoxide hydrolase expression in coronary endothelium via anti-ER stress mechanism

Activation of soluble epoxide hydrolase (sEH) is associated with endothelial dysfunction in hypertension, though the underlying mechanisms are inadequately understood and the role of endoplasmic reticulum (ER) stress is yet to be studied in detail. Tetramethylpyrazine (TMP), a major bioactive ingredient of Chinese herb Chuanxiong, is well-known for its cardiovascular benefits. Nevertheless, whether TMP may protect vascular endothelium from ER stress and whether regulation of sEH is involved remain unknown. This study aimed at investigating the role of ER stress in angiotensin-II (Ang-II)-induced sEH dysregulation and elucidating the significance of ER stress regulation in the vasoprotective effect of TMP. Porcine primary coronary artery endothelial cells (PCECs) were used for western blot, ELISA, and reverse-transcription PCR analysis. Porcine coronary arteries were assessed in a myograph for endothelial dilator function. Ang-II induced expression of ER stress molecules in PCECs meanwhile enhanced sEH expression and decreased 11,12-EET. Exposure of PCECs to the chemical ER stress inducer tunicamycin also increased sEH expression. Inhibition of ER stress suppressed sEH upregulation, resulting in an increase of 11,12-EET. The impairment of endothelium-dependent vasorelaxation induced by Ang-II or tunicamycin was ameliorated by inhibitors of ER stress or sEH. TMP showed comparable inhibitory effect to ER stress inhibitors on the expression of ER stress molecules, the dysregulation of sEH/EET, and the impairment of endothelial dilator function. We demonstrated that ER stress mediates Ang-II-induced sEH upregulation in coronary endothelium. TMP has potent anti-ER stress capacity through which TMP normalizes sEH expression and confers protective effect against Ang-II on endothelial function of coronary arteries.

Activation of PERK branch of ER stress mediates homocysteine-induced BKCa channel dysfunction in coronary artery via FoxO3a-dependent regulation of atrogin-1

The molecular mechanism of endoplasmic reticulum (ER) stress in vascular pathophysiology remains inadequately understood. We studied the role of ER stress in homocysteine-induced impairment of coronary dilator function, with uncovering the molecular basis of the effect of ER stress on smooth muscle large-conductance Ca²⁺-activated K⁺ (BK_Ca) channels. The vasodilatory function of BK_Ca channels was studied in a myograph using endothelium-denuded porcine small coronary arteries. Primary cultured porcine coronary artery smooth muscle cells were used for mRNA and protein measurements and current recording of BK_Ca channels. Homocysteine inhibited vasorelaxant response to the BK_Cachannel opener NS1619, lowered BK_Ca β1 subunit protein level and suppressed BK_Ca current. Inhibition of ER stress restored BK_Ca β1 protein level and NS1619-evoked vasorelaxation. Selective blockade of the PKR-like ER kinase (PERK) yielded similarly efficient restoration of BK_Ca β1, preserving BK_Ca current and BK_Ca-mediated vasorelaxation. The restoration of BK_Ca β1 by PERK inhibition was associated with reduced atrogin-1 expression and decreased nuclear localization of forkhead box O transcription factor 3a (FoxO3a). Silencing of atrogin-1 prevented homocysteine-induced BK_Ca β1 loss and silencing of FoxO3a prevented atrogin-1 upregulation induced by homocysteine, accompanied by preservation of BK_Ca β1 protein level and BK_Ca current. ER stress mediates homocysteine-induced BK_Ca channel inhibition in coronary arteries. Activation of FoxO3a by PERK branch underlies the ER stress-mediated BK_Ca inhibition through a mechanism involving ubiquitin ligase-enhanced degradation of the channel β1 subunit.

Photoselective vaporisation prostatectomy using a GreenLight High Performance System for patients with bleeding tendency

OBJECTIVES

To report the results of a modified vaporisation incision technique using a GreenLight High Performance System in the treatment of benign prostatic disease in men receiving anticoagulants.

DESIGN

Case series.

SETTING

Regional hospital, Hong Kong.

PATIENTS

From January 2007 to April 2010, 48 patients with a bleeding tendency or on oral anticoagulants who underwent photoselective vaporisation prostatectomy with a GreenLight High Performance System in the North District Hospital were studied. Data collected prospectively were analysed to determine perioperative and postoperative outcomes, including uroflowmetry parameters, serum prostate-specific antigen level, prostate volume, and complications at 1, 3, 6, and 12 months post-surgery.

RESULTS

The patients' mean age was 76 (standard deviation, 7; range 62-94) years. The mean follow-up period was 13 (standard deviation, 9) months. Thirty-six (75%) patients had urinary retention prior to surgery. Bleeding tendencies were due to receipt of aspirin (n=36), two antiplatelet agents (n=6), warfarin (n=4) and clopidogrel (n=1), and to thrombocytopaenia (n=1). Preoperative transrectal ultrasonography showed a mean prostate size of 58 (standard deviation, 30; range, 18-154) mL. Of the patients, 81% were discharged without a catheter and their mean hospital stay was 3 days. Five patients were readmitted for secondary haemorrhage, two had a drop of more than 10 g/L in their haemoglobin level, but only one received a blood transfusion. Mean uroflowmetry parameters, namely, peak flow rate and residual volume, were 8.7 mL/s and 199 mL preoperatively and 14.7 mL/s and 50 mL 1 year after the operation.

CONCLUSION

With an ageing population in which patients with various co-morbidities receive anticoagulant/antiplatelet therapy, photoselective vaporisation prostatectomy using a GreenLight High Performance System is a safe treatment option.

Increased α-synuclein phosphorylation and nitration in the aging primate substantia nigra

Post-translational modifications of α-synuclein occur in the brain of patients affected by Parkinson's disease and other α-synucleinopathies, as indicated by the accumulation of Lewy inclusions containing phosphorylated (at serine 129) and nitrated α-synuclein. Here we found that phospho-Ser 129 and nitrated α-synuclein are also formed within dopaminergic neurons of the monkey substantia nigra as a result of normal aging. Dopaminergic cell bodies immunoreactive for phospho-Ser 129 and nitrated α-synuclein were rarely seen in adult mature animals but became significantly more frequent in the substantia nigra of old primates. Dual labeling with antibodies against phospho-Ser 129 and nitrated α-synuclein revealed only limited colocalization and mostly stained distinct sub-populations of dopaminergic neurons. Age-related elevations of modified protein paralleled an increase in the number of neurons immunoreactive for unmodified α-synuclein, supporting a relationship between higher levels of normal protein and enhanced phosphorylation/nitration. Other mechanisms were also identified that likely contribute to α-synuclein modifications. In particular, increased expression of Polo-like kinase 2 within neurons of older animals could contribute to phospho-Ser 129 α-synuclein production. Data also indicate that a pro-oxidant environment characterizes older neurons and favors α-synuclein nitration. Aging is an unequivocal risk factor for human α-synucleinopathies. These findings are consistent with a mechanistic link between aging, α-synuclein abnormalities and enhanced vulnerability to neurodegenerative processes.

Refractory thrombotic thrombocytopenic purpura and membranoproliferative glomerulonephritis successfully treated with rituximab: a case associated with hepatitis C virus infection

Plasmapheresis remains the main treatment modality for patients with thrombotic thrombocytopenic purpura. We report a patient who had simultaneous onset of membranoproliferative glomerulonephritis and thrombotic thrombocytopenic purpura. She did not improve after 48 plasmapheresis sessions. A 6-week course of weekly intravenous doses of rituximab was then given. This achieved complete remission of her nephrotic syndrome and improvement in her renal function, so plasmapheresis was ceased. She had a low ADAMTS13 antigen level and a positive ADAMTS13 antibody, both of which reverted to normal after treatment with rituximab. This coincided with a rise in her hepatitis C virus RNA and liver transaminases. Liver biopsies did not reveal active fibrosis. Her hepatitis C virus RNA titre dropped afterwards, and she had no relapses of her thrombotic thrombocytopenic purpura and nephrotic syndrome, for more than 2 years after remission. The simultaneous onset and successful outcomes of both the membranoproliferative glomerulonephritis and thrombotic thrombocytopenic purpura illustrate the usefulness of rituximab. We discuss its use and risks, in the context of chronic hepatitis C infection.

The prevalence of cardiovascular risk factors in male patients who have lower urinary tract symptoms

OBJECTIVES

To assess the prevalence of cardiovascular risk factors in men presenting with lower urinary tract symptoms, and their possible correlation with the severity of such symptoms.

DESIGN

Retrospective cohort study.

SETTING

Specialty clinic, Hong Kong.

PATIENTS

A total of 617 men presenting with lower urinary tract symptoms between April 2005 and October 2006.

MAIN OUTCOME MEASURES

Presence of cardiovascular risk factors inferred from the prior and current medical and social history as well as physical examination and investigative findings, among patients with International Prostatic Symptom Scores of different severity.

RESULTS

Of 617 patients, 268 (43%) had known hypertension and 318 (52%) had a history of smoking. According to the World Health Organization criteria for Asian populations, 396 (64%) patients were considered to be overweight (body mass index > or =23 kg/m(2)). A total of 178 (29%) patients were either known to have or were diagnosed to have dysglycaemia during workup. For dyslipidaemia and hyperuricaemia, the corresponding figures were 331 (54%) and 191 (31%). In total, 264 (43%) patients were newly diagnosed as having dysglycaemia, dyslipidaemia, or hyperuricaemia. Logistic regression indicated that only hyperuricaemia and a smoking history were significant predictors of moderate-to-severe lower urinary tract symptoms (International Prostatic Symptom Score > or =8), with respective adjusted odds ratios of 2.20 (95% confidence interval, 1.12-4.31; P=0.022) and 2.11 (1.24-3.57, P=0.006). Patients with moderate-to-severe International Prostatic Symptom Scores had a statistically higher chance of having at least one cardiovascular risk factor during assessment (P=0.001).

CONCLUSIONS

Cardiovascular risk factors were prevalent in male patients who had lower urinary tract symptoms; a large portion of these cardiovascular risk factors were not recognised until their urological consultations. Patients with moderate-to-severe lower urinary tract symptoms (International Prostatic Symptom Score > or =8) had statistically higher chances of having more cardiovascular risk factors.

Prevalence of subclinical infection and transmission of severe acute respiratory syndrome (SARS) in a residential care home for the elderly

OBJECTIVE

To ascertain the prevalence of subclinical severe acute respiratory syndrome-coronavirus (SARS-CoV) infection and study the transmission of SARS-CoV in a local outbreak at a residential care home for the elderly.

DESIGN

Cross-sectional study.

SETTING

A residential care home for the elderly in Hong Kong with a local outbreak of SARS.

PARTICIPANTS

Residents and staff in the residential care home who had contact with three patients with SARS (residents A and B, and staff C).

MAIN OUTCOME MEASURES

Blood samples were tested for total antibodies to SARS-CoV by immunofluorescence antibody test. The transmission of SARS was elucidated based on information from standardised questionnaires, and records of investigation and surveillance by the Department of Health.

RESULTS

Among the 90 eligible residents, three died, one moved out, and 19 refused to participate. Of the 32 eligible staff, six refused to participate. None of the remaining 93 participants tested positive for antibody to SARS-CoV. Based on the chronological order, resident A might have transmitted infection to resident B and staff C. Sitting close to the bathroom doorway while resident A took a shower was the only contact of resident B with resident A. The only opportunity for staff C to have contact with body fluids/excreta of resident A was in the handling of rubbish from the resident's room.

CONCLUSION

Subclinical SARS-CoV infection was rare in a residential care home for the elderly with an outbreak of SARS. Nonetheless the close working and living conditions for staff and residents in such a home may facilitate transmission of SARS despite vigilant precautionary measures.

Factors associated with poorly-controlled hypertension in continuous ambulatory peritoneal dialysis patients

INTRODUCTION

Hypertension is highly prevalent among continuous ambulatory peritoneal dialysis (CAPD) patients and is a major risk factor for cardiovascular complications. This study examines the risk factors associated with poorly-controlled hypertension in CAPD.

METHODS

We performed a cross-sectional study of 66 stable adult CAPD patients to evaluate their hypertension control over a period of three to four months and their associations with other clinical and laboratory parameters.

RESULTS

The mean age of the patients was 56.7 (plus or minus 1.27) years. Their mean systolic and diastolic blood pressure were 139 (plus or minus 2.59) mmHg and 77 (plus or minus 1.35) mmHg respectively; 71 percent of them were on antihypertensive drugs. Thirty (45.5 percent) patients had high blood pressure greater than 140/90mmHg. Compared with patients with normal blood pressure, patients with high blood pressure received significantly more antihypertensive drugs (p-value equals 0.034) and were more likely to be clinically overloaded (p-value less than 0.001). Multivariate analysis showed that systolic blood pressure was predicted by volume expansion (p-value less than 0.001) while diastolic blood pressure was negatively predicted by age (p-value equals to 0.004). In addition, volume overload was predicted positively by dialysate/plasma creatinine (p-value equals 0.011) and negatively by serum albumin (p-value less than 0.001).

CONCLUSION

Clinically-apparent volume overload was associated with poor systolic blood pressure control despite aggressive antihypertensive drug therapy. This finding underlines the importance of fluid control and could provide an explanation of the poor outcome observed in patients with high peritoneal transport.

The effects of acute sleep deprivation on performance of medical residents in a regional hospital: prospective study

OBJECTIVE

To evaluate the effects of acute sleep deprivation on the level of perceived occupational stress and cognitive functioning in a group of medical residents.

DESIGN

Prospective study.

SETTING

Regional hospital, Hong Kong.

PARTICIPANTS

Twenty-one residents who had regular in-hospital on-call duties.

MAIN OUTCOME MEASURES

From January to April 2002, participants were asked to complete the Raven Advanced Progressive Matrices (sets I and II) and Occupational Stress Inventory-Revised tests at the beginning of an on-call day. They then repeated the tests towards the end of their on-call duties on their next on-call day, at a mean (standard deviation) interval of 8.9 (2.3) days. Occupational Stress Inventory-Revised test scores were transformed into T-scores to provide information about an individual's scores relative to the scores of participants in a normative sample.

RESULTS

The group slept for a mean (standard deviation) of 2.9 (1.0) hours during 29.3 (3.8) hours of on-call duties. Before the on-call duties, participants' mean T-scores for the Occupational Stress Inventory-Revised test ranged from 50.6 to 54.5 for the Occupational Role Questionnaire, 52.0 to 57.0 for the Personal Strain Questionnaire, and 37.3 to 52.3 for the Personal Resources Questionnaire. After on-call duties, apart from a slight increase in Role Insufficiency T-scores (50.6 [5.9] versus 52.1 [6.0]; P=0.044), there was no significant change in all other scales of the Occupational Stress Inventory-Revised test. The scores of the Raven Advanced Progressive Matrices test remained stable after the on-call duties (11.3 [1.2] versus 11.5 [0.8], P=0.129 for set I; 29.9 [5.5] versus 30.2 [6.3], P=0.2 for set II).

CONCLUSION

Acute sleep deprivation among medical residents was not associated with any significant changes in both cognitive functioning and level of stress perceived.

A retrospective study on efficacy of proton-pump inhibitor-based triple therapy for eradication of Helicobacter pylori in patients with chronic renal failure

OBJECTIVE

The efficacy of short-course triple eradication therapy has been documented in patients with Helicobacter pylori infection and normal renal function. We have evaluated a one-week proton-pump inhibitor-based triple therapy for Helicobacter pylori eradication in a retrospective review of patients with chronic renal failure.

METHODS

We studied 25 patients (mean age 65.1 +/- 2.4 years) with creatinine clearance <30 ml/min/1.73 m2 or serum creatinine level >200 micromol/L (13 on dialysis), who had Helicobacter pylori infection, documented by histological examination or rapid urease test, together with either peptic ulcer disease or severe gastritis. The combination of Omeprazole 20 mg BID or Lansoprazole 30 mg BID, amoxicillin 1 gm BID and clarithromycin 500 mg BID was given for one week, in addition to therapy for peptic ulcers. All patients were re-endoscoped four weeks later.

RESULTS

All but one patient (96%) had successful eradication. On repeat endoscopy, all 13 patients with peptic ulcers had healed ulcers. For the 12 gastritis patients, three became normal and nine had persistent gastritis. For patients not on dialysis, the serum creatinine level and creatinine clearance remained stable at two weeks after treatment (303 +/- 37 vs. 330 +/- 36 micromol/l, p=ns; 23.6 +/- 3.4 vs. 26.0 +/- 3.9 ml/min/1.73 m2, p=ns, respectively).

CONCLUSION

The short course triple therapy was highly efficacious for Helicobacter pylori eradication in patients with chronic renal failure, with no adverse effect on renal function.

Two liters of polyethylene glycol-electrolyte lavage solution versus sodium phosphate as bowel cleansing regimen for colonoscopy: a prospective randomized controlled trial

BACKGROUND AND STUDY AIMS

As a bowel cleansing agent for colonoscopy, sodium phosphate (NaP) has been reported to have equal effectiveness and better patient tolerance in comparison with 4 l polyethylene glycol-electrolyte lavage (PEG-EL) solution. Poor patient tolerance is frequently associated with a large amount of fluid consumed, and better patient tolerance might therefore be expected if the volume of PEG-EL solution could be reduced. This study aimed to compare 2 l PEG-EL solution with NaP in relation to patients' tolerance and its effectiveness as a bowel cleansing agent.

PATIENTS AND METHODS

Two hundred consecutive patients admitted to the day-procedure ward for elective colonoscopy were prospectively randomized to receive either a 2-l PEG-EL solution or a 90-ml oral NaP regimen. Patients with a history of congestive heart failure, impaired renal function (creatinine > 1.5 mg/dl), or previous colectomy were excluded from the study. The patients completed a questionnaire to assess their tolerance of bowel preparation before the colonoscopy. Endoscopists, who were blinded to the type of regimen that had been used, scored the adequacy of bowel preparation from the rectum to cecum using a defined endoscopic score.

RESULTS

Two hundred patients were included in this randomized trial. Nine patients were excluded, due to either an incomplete questionnaire (two in the PEG-EL group, one in the NaP group) or inability to complete the bowel preparation regimen (four in the PEG-EL group and two in the NaP group). The demographic data were comparable in the two groups. There were no differences between the two groups with regard to willingness to repeat the regimen, ease of consumption, acceptability of the bowel preparation regimen, or the endoscopists' satisfaction with the quality of bowel preparation. The NaP group had a better mean endoscopic score at the cecum compared with the PEG-EL group (1.47 +/- 1.15 vs. 1.05 +/- 0.76; P = 0.007).

CONCLUSIONS

The effectiveness and patient tolerance of the 2-l PEG-EL solution is comparable with that of oral NaP. The 2-l PEG-EL solution is therefore an effective alternative as a bowel-cleansing agent for colonoscopy.

Primary hyperoxaluria: a rare but important cause of nephrolithiasis

We report on a middle-aged man with end-stage renal failure apparently secondary to recurrent renal stones. He developed systemic oxalosis soon after commencing dialysis. The diagnosis of primary hyperoxaluria type 1 was supported by the finding of high dialysate glycolate excretion. The patient subsequently received an isolated cadaveric renal transplant, but the outcome was a rapid recurrence of oxalosis and early graft failure. Although isolated liver or renal transplantation in addition to various adjuvant measures may be considered in the early stage, combined liver-kidney transplantation remains the only definitive therapy for a patient with end-stage renal failure and systemic oxalosis due to hyperoxaluria type 1. This case illustrates the possible late presentation of primary hyperoxaluria type 1 and the poor outcome with isolated renal transplantation after the development of systemic oxalosis. One should thus have a high index of suspicion in patients with recurrent renal stones of this rare, but nevertheless important, entity.

Prospective study on renal outcome of IgA nephropathy superimposed on diabetic glomerulosclerosis in type 2 diabetic patients

BACKGROUND AND METHODS

In order to examine the clinical outcome of IgA nephropathy (IgAN) superimposed on diabetic glomerulosclerosis in type 2 patients we studied 36 Chinese patients (26 men, 10 women), who were recruited for renal biopsy when they had proteinuria of more than 1 g/day. Twenty-seven had isolated diabetic glomerulosclerosis and nine had IgAN superimposed on diabetic glomerulosclerosis (combined). Renal function was assessed by serial serum creatinine, 24-h urine protein and creatinine measurements. Patient survival rate, incidence of end-stage renal disease (ESRD), blood pressure, and glycaemic control status were determined.

RESULTS

The age at the time of renal biopsy was younger for the combined group when compared with the diabetic glomerulosclerosis group (44+/-3.6 vs 58+/-2.1 years, P=0.006). The duration of diabetes was, however, similar for the two groups (8.0+/-2.3 vs 6.7+/-1.2 years, P=NS). After a mean follow-up of 31.6+/-15.3 months, 15 patients (one in the combined group and 14 in the diabetic glomerulosclerosis group) developed ESRD. Nine patients (all in the diabetic glomerulosclerosis group) died during follow-up. With similar glycaemic and blood pressure control, the two groups had comparable rate of decline of creatinine clearance (CrCl) (-0.73+/-0.26 vs -0.73+/- 0.18 ml/min/1.73 m(2)/month, P=NS), final serum creatinine (363+/-134 vs 426+/-52 micromol/l, P=NS) and proteinuria levels (4.3+/-0.9 vs 4.4+/-0.6 g/day, P=NS), as well as CrCl (44.1+/-19.0 vs 33.4+/-6.9 ml/min/ 1.73 m(2), P=NS).

CONCLUSION

It is concluded that the superimposed IgAN does not significantly alter the medium-term clinical outcome of patients with diabetic glomerulosclerosis.

Randomized prospective study of the effect of increased dialytic dose on nutritional and clinical outcome in continuous ambulatory peritoneal dialysis patients

Cohort studies have shown that greater urea (Kt/V) and creatinine clearances (CCr) were associated with better survival in patients on continuous ambulatory peritoneal dialysis (CAPD). The possibility of improved patient outcome with increased dialytic dose remains unknown. We prospectively studied over 1 year the effects of an extra 2-L bag on the outcome of 82 patients undergoing three daily 2-L exchanges for at least 12 months. At 1 year, 36 patients were undergoing 6-L exchanges, whereas 30 patients underwent 8-L exchanges. The increased dialytic dose resulted in increased total weekly Kt/V (TKt/V; 1.82 to 2.02), whereas total weekly CCr (TCCr) was maintained (63.2 to 61.9 L/1.73 m(2)). Control patients had reduced solute clearances (TKt/V, 1.87 to 1.67; TCCr, 64.8 to 54.6 L/1.73 m(2)). The fourth bag exchange resulted in a significant increase in net ultrafiltration (0.83 to 1.51 L/d), whereas the control group also had greater ultrafiltration (0.68 to 1.01 L/d) after 1 year. Although the normalized protein equivalent of nitrogen appearance (nPNA) was stable in the controls, the patients using 8-L exchanges achieved a greater nPNA (1.10 to 1.24 g/kg/d). There was no associated change in serum albumin levels (3.79 to 3.48 g/dL). The hospitalization rate increased in the controls (0.9 to 1.8 admissions/12 mon), whereas it was unchanged in the patients using 8-L exchanges. In conclusion, a 33% increase in dialytic prescription led to increased peritoneal and total clearances. Despite achieving increased nPNA (13%), the serum albumin level was unchanged. However, the increased hospitalization rate observed in the controls was avoided in the group using 8-L exchanges.

A retrospective study of seven cases of Candida parapsilosis peritonitis in CAPD patients: the therapeutic implications

BACKGROUND

Candida peritonitis accounts for the majority of fungal peritonitis in continuous ambulatory peritoneal dialysis (CAPD), but the Candida species were not routinely subtyped in previous studies. The clinical course and the outcome of Candida parapsilosis peritonitis remain unclear.

OBJECTIVE

To study the clinical course and outcome of C. parapsilosis peritonitis in CAPD patients.

SETTING

Peritoneal dialysis unit in a regional hospital.

PATIENTS AND DESIGN

A retrospective study on seven cases of C. parapsilosis peritonitis occurring in a single center over 3 years.

RESULTS

The 7 patients included 4 males and 3 females. Their mean age was 62 +/- 11.5 years. Two (29%) were diabetic. Three (43%) had a history of preceding peritonitis and 5 (71 %) had received broad spectrum antibiotic within the previous 1 month. All presented with cloudy dialysate, abdominal pain, and fever. The mean dialysate white cell count was 300 +/- 168/mm3 with a predominance of neutrophils (81.4% +/- 13.1%). The mean time from onset of symptoms to diagnosis was 5.7 +/- 3.1 days. All had been treated with immediate catheter removal within 24 hours of diagnosis and antifungal therapy, including oral fluconazole, intravenous (IV) amphotericin, or their sequential combination. Environmental samplings were negative for C. parapsilosis. The overall complication rate was exceptionally high (71%), with three (43%) complicated by abscess formation requiring surgical drainage, one peritoneal adhesion (14%), and one mortality (14%). In the end, only two (29%) could resume CAPD.

CONCLUSIONS

The outcome of this study group appeared worse than those previously described in the literature, and the optimal treatment for this group of patients remains unclear.

Successful treatment of IgA nephropathy in association with low-grade B-cell lymphoma of the mucosa-associated lymphoid tissue type

Kidney and the urogenital tract are among the various mucosal sites involved in mucosa-associated lymphoid tissue (MALT) lymphoma. We report a case with simultaneous onset of crescentic immunoglobulin (Ig) A nephropathy and gastrointestinal low-grade B-cell lymphoma of the MALT type with kidney infiltration. M-component of IgM lambda was detected in the serum, and the renal biopsy specimen showed monotypic lambda light chain staining in the lymphoma cells but not the glomeruli. The heavy proteinuria and impaired creatinine clearance returned to normal, and microscopic hematuria disappeared 20 months after treatment with chlorambucil as single-agent chemotherapy. This coincided with a complete resolution of the gastric and renal lymphoma infiltration. The close association of both the onset and successful outcome of the two entities thus support their possible causal relationship, and we discuss the possibility of an association of the disturbance of the MALT by the lymphoma cells with the pathogenesis of IgA nephropathy.

Clinical profile of patients with late-onset SLE: not a benign subgroup

The onset of systemic lupus erythematosus (SLE) in later life has been associated with a benign clinical course and better prognosis compared with those with earlier onset. However, different reported studies have failed to agree on a distinct pattern of presentation. We retrospectively studied the clinical profile of a predominantly Chinese lupus population to review the behaviour of late-onset patients. Cumulative clinical features and laboratory findings in 102 patients with SLE were collected. Late-onset patients tended to have a less marked female predominance, a more insidious onset at presentation (P < 0.001), a decreased incidence of cutaneous lesions (P < 0.05), an increased occurrence of serositis (P = 0.004) and a lower cumulative number of SLE manifestations (P = 0.022) compared with the early-onset group. The incidences of all major organ involvement as well as the requirement of immunosuppressive therapies were similar in the two groups. Thus, in this study, late-onset SLE patients had a different clinical profile from the early-onset group, but did not constitute a benign subgroup of the lupus population.

Recombinant human erythropoietin (rHuEPO) therapy has no effect on peritoneal transport in CAPD patients: a short-term study

While theoretically the vasoconstriction associated with the rise in hemoglobin (Hb) level may potentially alter peritoneal transport characteristics, the effect of recombinant human erythropoietin (rHuEPO) therapy on peritoneal transport in continuous ambulatory peritoneal dialysis (CAPD) patients remains unclear. We have therefore performed a prospective study on the short-term effect of rHuEPO on the peritoneal transport characteristics in terms of the change in corrected dialysate/plasma creatinine (D/Pcr) in the fast peritoneal equilibration test (PET). Eight consecutive CAPD patients started on rHuEPO had fast PETs performed before and 4 to 6 months after the initiation of rHuEPO therapy. Another 8 CAPD patients with stable Hb levels not receiving rHuEPO served as a control group. All patients (study and control) had been on CAPD therapy for more than 3 months upon enrollment, and none had peritonitis during the study period. Patients receiving rHuEPO showed significant increase in Hb level, while the Hb levels of those in the control group remained unchanged. Neither the study nor the control group patients showed significant change in the corrected D/Pcr value over a mean observation period of 5.25 +/- 0.89 months. While rHuEPO appears to be effective in increasing the Hb level in CAPD patients, there is no significant impact on the corrected D/Pcr in the fast PET test observed in this short-term study.

Clinical predictors of non-diabetic renal disease in patients with non-insulin dependent diabetes mellitus

BACKGROUND

Several studies had suggested that non-diabetic renal disease (NDRD) was common among non-insulin dependent diabetes mellitus (NIDDM) patients with renal involvement.

METHODS

We prospectively studied the prevalence of NDRD among a Chinese NIDDM population. Renal biopsy specimens were evaluated with light-, immunohistological and electron-microscopy. The cohort consisted of 51 patients who had NIDDM and proteinuria > 1 g/24 h.

RESULTS

Patients with both isolated diabetic nephropathy (DN, n = 34) and NDRD (n = 17) had comparable duration of DM, creatinine clearance, serum creatinine, albumin and glycosylated haemoglobin levels, as well as incidences of retinopathy, neuropathy and hypertension. Significantly more patients with NDRD had microscopic haematuria (P = 0.043) or non-nephrotic proteinuria (P = 0.004). IgA nephropathy accounted for 59% of the NDRD identified.

CONCLUSIONS

In this study, microscopic haematuria and non-nephrotic proteinuria predicted the presence of NDRD among NIDDM patients presenting with renal disease.

Long-term outcome of adult-onset minimal-change nephropathy

BACKGROUND

Adult-onset minimal-change nephropathy has been associated with a slower response to corticosteroids and a less benign prognosis when compared to children. However, there are few long-term outcome data reported.

METHODS

We have reviewed retrospectively 51 idiopathic adult-onset minimal-change nephropathy patients investigated and treated at a single centre.

RESULTS

Male to female ratio was 1:1.4, mean age at diagnosis was 37 years, and average length of follow-up was 14.1 years. Significant comorbidity was identified in 33%. A raised serum creatinine was found in 55% but returned to normal almost invariably upon remission. At presentation, hypertension was found in 47% of patients, microscopic haematuria in 33%, hypercholesterolaemia and hypertriglyceridaemia in 96%, and hyperuricaemia in 42%. Remission (complete or partial) was achieved by 46, 70 and 92% within 4, 8 and 21 weeks respectively, in patients treated with steroids; steroid resistance was encountered in 8%. The time to remission was positively correlated with age (P = 0.002) and initial albumin level (P = 0.005), and negatively correlated to the number of subsequent relapses (P = 0.029); 33% of patients had a spontaneous remission at some time during the disease course. Patients with multiple relapses were treated with cyclophosphamide and 63% of them had remained in remission after 5 years. Hypertension was present in 25% of patients after an average interval of 11 years. At the time of the final follow-up, only three patients had a raised creatinine and all but three patients were in complete remission.

CONCLUSIONS

Adult-onset minimal-change nephropathy shares the same good long-term outcome as the childhood counterpart, with sustained remission and preserved renal function.

Detection of human parvovirus B19 in early spontaneous abortuses using serology, histology, electron microscopy, in situ hybridization, and the polymerase chain reaction

OBJECTIVE

To determine whether there is an association between parvovirus B19 infection and early spontaneous abortion at less than 20 weeks' gestation.

METHODS

Eighty samples of early spontaneous abortions were analyzed. Each sample was examined histologically for the presence of viral inclusions, and selected cases were analyzed for parvovirus using electron microscopy and in situ hybridization. Polymerase chain reaction DNA amplification for the virus was done in each case. Maternal sera were analyzed for immunoglobulin (Ig) M and IgG parvovirus antibodies and compared with temporally matched controls.

RESULTS

Five cases in the study group had evidence of seroconversion for parvovirus, compared with two controls. Products of conception from two of these five cases were positive for virus by polymerase chain reaction amplification, and only one of these two had a characteristic inclusion of parvovirus histologically. Conversely, five chorionic vesicles from mothers who had not seroconverted had histologic changes suggesting parvovirus infection, but all of these cases were negative for parvovirus using in situ hybridization, polymerase chain reaction, and electron microscopy.

CONCLUSIONS

Parvovirus B19 DNA was found in two of 80 early spontaneous abortuses. Although viral DNA was detected in two cases, there was no clear evidence that the infections caused fetal death. Neither case showed erythroblastosis with large numbers of inclusions, as is seen in hydropic fetuses with parvovirus infection. In addition, in five cases in which parvovirus infection was not documented serologically or by the polymerase chain reaction, there was erythroid nuclear clearing suggestive of parvovirus B19 inclusions. This indicates that histologic evaluation for parvoviral inclusions is not always reliable in early spontaneous abortuses.

Polymerase chain reaction amplification of herpes simplex virus DNA from clinical samples

The polymerase chain reaction was used to amplify herpes simplex virus (HSV) DNA from 79 clinical specimens from the female genital tract, and the results were compared with cell culture. Combining the polymerase chain reaction with visualization of amplified products using a direct gel analysis, HSV DNA was detected in 38 specimens, six of which were negative for virus by cell culture. Hybridization of the amplified products detected HSV in three other specimens. One specimen was positive for HSV by cell culture but negative for viral DNA by polymerase chain reaction. Specimen purification before the polymerase chain reaction improved the detection of viral DNA. Restriction endonuclease cleavage of amplified DNA seen by direct gel analysis, used to differentiate HSV-1 from HSV-2, was correct in each case. The analysis time using the polymerase chain reaction was 8-10 hours, making this technique potentially valuable in the clinical setting of parturition.

Detection of herpes simplex virus using the polymerase chain reaction followed by endonuclease cleavage

The polymerase chain reaction (PCR) was used to amplify herpes simplex virus DNA using a single set of primers that amplify both herpes simplex virus I (HSVI) and II (HSVII). The viruses can be differentiated by a single restriction enzyme cleavage. Virus from dilutions of HSV-infected A549 cell suspensions were amplified and the infectivity endpoints of cell culture were compared with the PCR, and with another direct detection method, the enzyme-linked immunosorbent assay (ELISA). The PCR was capable of detecting virus at a 10(-4) dilution for both HSVI and HSVII, when the corresponding TCID50 endpoints were 10(-5.9) and 10(-5.7), respectively. The ELISA detected virus only down to the 10(-1) dilution. The amplification procedure showed the greatest sensitivity when an initial protease digestion was followed by filtration. The PCR may have use in detection of HSV in clinical situations in which a rapid result is desirable.

Detection of parvovirus by DNA analysis

DNA technology has been used to diagnose parvovirus B19 infection in clinical samples. The tests are specific and can attain a high degree of sensitivity, particularly when using PCR amplification. Over the next few years, DNA technology will become increasingly available and may be among the routine diagnostic tests in the future.